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April 27, 2004
Plastic Surgery Gets a New Look
By JAMES GORMAN
VANCOUVER, British Columbia — Cosmetic surgery is getting
a makeover. People want to look younger, rather than different —
to have the face in their mind's eye, not the one in the mirror.
They want quicker, less expensive and less invasive procedures,
and new medical technologies are feeding and increasing the demand.
Along with the incremental improvements come other changes. Surgeons
are seeing the numbers and percentage of men increase, and treating
younger as well as older patients as cosmetic improvement becomes
a lifelong pursuit.
"I think there is a paradigm shift in thinking, right at this
moment," said Dr. V. Leroy Young of St. Louis, chairman of
the emerging trends task force for the American Society for Aesthetic
Plastic Surgery. The group had its annual meeting here this month.
Surgeons, Dr. Young said, are backing off from more aggressive surgeries
and moving toward nips, tucks and injections. Operate early and
often might be the new motto. Traditional cosmetic self-improvement,
in the form of breast enlargement and nose surgery, are still significant,
but surgeons see their field in the process of transformation.
The change, said Dr. Brian Kinney of Los Angeles, a member of the
trends panel, "comes for three or four reasons.""One
is younger people who aren't going to wait," Dr. Kinney said.
"They want to start surgery now. Smaller budgets. They don't
want to spend as much money. Also, they don't have time. We're an
instant-gratification society."
Drastic changes in appearance are the rare exception, despite the
potential influence of television shows that feature extensive surgery
like "Extreme Makeover" and "The Swan." More
typical is the surgeon who asks patients to bring in their high
school yearbooks, to see how to go back to the future.
Another force that continues to change cosmetic surgery is the emergence
of new technologies. In the past, liposuction and BOTOX ® injections
were revolutionary. New parts of the body are always attracting
attention. Calf implants never really took off, although they are
available. But gluteal implants, for what one surgeon called "the
J-Lo look," might take off, although numbers remain very small.
Much more important are a raft of new fillers coming on the market
for injection under the skin to fill out the face rather than lift
it. The whole idea of the lift, some experts say, is old-fashioned
and inappropriate. Gravity is not the enemy of youth, they say,
but loss of volume.
Face-lifts live, but they have become very specific. It's not the
face, but the brow or midface that is done. And there are new minimalist
techniques, some involving new sutures, used to produce the weekend
face-lift, so-called because the recovery time is so short.
But most surgeons are holding on to their knives, and few predict
that the traditional face-lift will be replaced entirely.
Dr. Sydney Coleman of New York is a partisan, the acknowledged guru
of fat injections. He developed techniques and instruments to take
fat from one part of the body and inject it in tiny quantities into
the face and other areas. Fat is living tissue and, under the right
conditions, will survive in its new location.
Dr. Coleman also works with other fillers, and he said these methods,
all to restore the volume of the aging face, are replacing old-fashioned
cutting. "Syd really doesn't do face-lifts," Dr. Young
said. "And of course, when you've got a hammer, the world is
a nail." But, Dr. Young said, fillers and more limited surgery
might well be the future in the intense worldwide pursuit of rejuvenation.
Another partisan of fat, Dr. Richard Ellenbogen of Los Angeles,
made a presentation to the assembled surgeons in which he argued
that injecting fat or other fillers could be an alternative to just
about every cosmetic procedure like face-lifts, breast augmentations
and removing bags under tired old eyes.
The business that seems to be changing direction is a big one. Last
year, according to the Society for Aesthetic Plastic Surgery, 1.8
million cosmetic operations were performed in the United States.
There were an additional 6.4 million nonsurgical procedures like
skin resurfacing or BOTOX ® injections. In fact, first liposuction
and then BOTOX ® have changed cosmetic surgery, moving it away
from the knife.
Dr. Coleman said liposuction was the single most common surgical
procedure in the world.
Statistics show that the traditional procedures, if BOTOX ®
and liposuction are included, continue to dominate the field. But
the new developments occupied much of the meeting, as surgeons disagreed
about the promise and safety of various procedures.
What was clear was the intense interest in new substances as fillers,
and in the approach to aging that suggests filling out is more important
than lifting up. Dr. Coleman and partisans of volume say the damage
from gravity has been exaggerated. The real culprit, he says, is
the loss of tissue under the skin.
A brow lift, he said, tackles the wrong problem. The brow, he said,
"descends only because you're missing huge volume, so yanking
it up doesn't really make sense."
He takes a person's own fat and pushes it under the skin in tiny
amounts, using a blunt-tipped instrument called a cannula. He does
the same for a sagging lower eyelid, arguing that it makes no sense
to cut muscle and fat, the usual surgery. That procedure leaves
a hollow-eyed look, he says.
For lips, however, he uses a new material, hyaluronic acid, a substance
found in the body that also fills out tissue but is not permanent.
Although there are 24 or so fillers on the international market,
few are approved in the United States. But that is changing, Dr.
Young said, noting, "The fillers are evolving so rapidly that
there's a new one every month almost."
One approved for use is calcium hydroxylapatite, also a natural
substance. Dr. Coleman was critical of its widespread use, although
many doctors find it useful. "No one has ever used it for more
than two years in subcutaneous tissue," he said. "There
is no experience."
Although hyaluronic acid is temporary, calcium hydroxylapatite is
semipermanent. It is not known how long it lasts, Dr. Young said.
"In dogs," he said, "it lasts up to five years. There
is no data in humans out that far."
Even with substances with long safety records, technique is crucial.
With a sharp needle, an artery can be pierced and the fat injected
into it can block capillaries, shutting blood flow to a part of
the body. Liposuction patients have died of pulmonary embolisms
in this fashion.
Injections in the face have caused at least two instances of blindness,
when the retinal artery was accidentally blocked, Dr. Coleman said.
In another case, the soft tissue on and around the nose died and
simply sloughed off the face.
Risks are part of surgery, but people seeking cosmetic fixes are
not sick, and, the surgeons emphasized, patients need to recognize
that as benign as something like liposuction sounds, it is still
surgery.
A more mechanical innovation involves barbed sutures. The synthetic
thread, used for stitching, has barbs all along its length, to help
it anchor in tissue. In a traditional face-lift, surgeons make a
large cut in the face, lift a section of skin and the tissue beneath
it and tie in sutures like bridge cables to pull up the face. The
recovery from such an operation takes weeks.
With the new barbed sutures, surgeons say, they can make a small
incision, then use a long needle to thread the suture under the
skin to the place where it needs to be anchored and tie it at the
top.
Dr. Woffles Wu of Singapore described how he performed what he called
the Woffles face-lift with barbed sutures. He presented the cases
of a woman who needed a quick improvement for her daughter's wedding,
three weeks away, and another woman who wanted to look fresh for
her husband, who was coming home after a long time away. This is
the face-lift as hairdo.
The safety of the sutures themselves was not questioned. But many
surgeons had doubts about their endurance and how the results would
appear. Dr. Fritz Barton of Dallas said at a panel: "Plastic
surgery is not different from the rest of life. There is no little
procedure with a big benefit."
There are other trends to watch, as well. One new technology uses
tools that emit radio waves to tighten the skin. Statistics show
that it does not work for 20 percent of patients, however, and,
like other procedures, can have negative effects, too.
The buttocks implant is one procedure that physicians are watching
closely. "I think the thing that's really unknown here,"
Dr. Young said, "is what the role of gluteal augmentation is
going to be. We only started keeping statistics on it a year ago."
The numbers are still small; 3,885 procedures were performed last
year, a 533 percent increase over 2002.
If Americans turn out to be as crazy about buttocks as they are
about breasts, plastic surgery has a whole new source of income.
More than 280,000 women had breast implants in 2003.
As Dr. Young pointed out, "in contrast to breast augmentation,
men and women can get it in roughly equal proportions."
"The question," he said, "is still, Is this a fad
or is this really one of these things that's reaching a tipping
point where enough people catch on to it?"
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