Tighter Skin Without Surgery-but this actually works

If you look through any magazine, newspaper, put on the radio, or TV within minutes you will find an ad that advertises “Tighter Skin Without Surgery”. The majority of these claims come more from a dehydrating effect on the skin that shows some results but is very short-lived. I never subscribed to this therapy, but many of friends and colleagues involved with such systems admit to these limitations.

I am the only doctor in the northeast in possession of the newest non-ablative procedure for skin rejuvenation. This device is called Radiage. The main difference compared to its predecessors is that it works. I too was skeptical at first, but have been using it and seeing lasting results for months. The company claims results lasting 1-3 years. I do not yet have patients that far out after treatment to evaluate this, but so far its results have been very impressive.

What does it do?
By patented radiofrequency technology, Radiage heats and modifies the collagen in the skin to tighten and contract. Fine wrinkles are almost completely obliterated, loose skin in the neck is lifted, and those with no wrinkles walk away with ‘baby smooth skin’. Most patients see results immediately, however the results are gradual over a 3-6 month period as skin tightens and new collagen is formed.

Approximately 30% of people have no response to Thermage, another different skin tightening system. These people have responded to Radiage.

I am one of two surgeons in the US performing this new procedure. It is not yet FDA approved, but its approval is coming in the very near future. This technology has been used for other surgical applications since 1969. It has been used in Europe with excellent reviews.

It is non invasive.
There is no incision, no injection, and no tissue damage.
There is no bleeding or bruising.
It can be combined with a filler or Botox.

I invite you to visit us for a consultation and take advantage of our introductory specials for Radiage. It is that good. Truly.

18 year old girl dies during breast augmentation in Florida

The headline says it all. Any unforeseen, untimely death is a true tragedy. This is particularly true in a healthy person undergoing an elective procedure. This blog entry is not to place or relinquish blame on any party, only to educate the public on the facts of the case and how to help avoid such a disaster.

FACT:
1. The operating surgeon was a BOARD CERTIFIED PLASTIC SURGEON
2. An anesthesiologist was performing the anesthesia
3. It was performed in an accredited ambulatory surgery center

Early reports of this incident point to a diagnosis of MALIGNANT HYPERTHERMIA as what caused this terrible event.

What is malignant hyperthermia (MH)?
MH is a hypermetabolic state involving skeletal muscles that is triggered by certain anesthetic drugs in genetically susceptible individuals. Its incidence is less than 0.5% of all patients exposed to anesthetic agents.

Which patients are at risk of developing MH?
1. Someone with a first degree relative with a diagnosis of MH (it is autosomal dominant inherited)
2. An elevated resting blood creatine kinase level and family with suspected MH tendency
3. central core disease
4. musculoskeletal disease associated with MH
a. dystrophinopathy
b. phosphorylase deficiency
c. minicore disease
d. myotonia
e. King-Denborough and Barnes myopathies

Patients who are susceptible to MH can have a muscle contracture test performed prior to surgery. A muscle biopsy is another alternative for diagnosis.

There are a number of drugs that can trigger MH. Most of these drugs are drugs used to induce and maintain GENERAL ANESTHESIA. This is another reason I choose deep sedation whenever possible to perform surgery to avoid these drugs. The patients still have no recall of the surgery, are comfortable, but are breathing on their own without the need for a mechanical ventilator, breathing tube, or being paralyzed for the surgery.

These drugs are:
INHALATION ANESTHESTICS:
Halothane, Enflurane, Isoflurane, Desflurane, Sevoflurane

DEPOLARIZING NEURMUSCULAR BLOCKADE AGENTS:
Succinylcholine, Decamethonium, Suxamethonium

OTHERS:
Ketamine, Catecholamines, Phenothiazines, Monoamine oxidase inhibitors

How does the doctor know if MH is occurring during the surgery?
An unexplained rise in CO2, or heart rate following induction of anesthesia are important signs. Additionally, early masseter contracture following the administration of succinylcholine can be a clue.

How is this treated if MH is diagnosed during the surgery?
There is a comprehensive treatment algorithm for treating MH including the administration of dantrolene sodium. If administered and the correct protocol is followed the survival rate is 100%. If dantrolene is not administered the survival rate is less than 60%.

How can MH be prevented?
Patients at an increased risk for MH should be recognized in the preoperative phase of treatment planning. These patients should not be given these triggering agents.

From what I have read about this particular recent case, it sounds like this young lady did have an episode of malignant hyperthermia. Unfortunately, it appears that her being identified as a high risk of developing this, was not established prior to the case. In addition, it seems like the correct treatment protocol was put in place, but too late. She was transported to another facility before the dantrolene sodium dosing was started.

If a fear of developing malignant hyperthermia is a concern for you in preparing to undergo cosmetic surgery-good. It is a concern for us too.

What should ease your mind is at CAMEO Surgery:
1. those at risk of developing this are easily identifiable (is has been on our medical history questionnaire since day 1)
2. we are fully prepared to treat any incidence of this during surgery, by myself and our board certified anesthesiologist
3. we avoid these triggering drugs by avoiding general anesthesia, and instead use deep sedation (a safe and comfortable alternative for your cosmetic surgery)

For those of you with more questions, please contact us. Additoinally, there is a hotline available 24/7 to help in the management of MH in the US; the number is (800) MH-HYPER. Outside the US call (800) 644-9737. Their website is http://www.mhaus.org

At last, The Perma facial Implant

No, I am not a fortune teller (if I were I wouldn't have bought Knicks season tickets this year). However, I consider myself to be "on the cutting edge", and always equip with knowledge of the most state of the art procedures and techniques.

I pride myself on being the FIRST and ONLY surgeon in the northeast performing the newly FDA approved Permafacial implant. I have now placed dozens of these implant, without any advertising the news is finally spreading (these lips have done the talking). I have recently been approached by multiple national circulating magazines interviewing me on this procedure. I have discussed the Permafacial implant in a blog entry earlier in the year. Finally, the press has brought this marvel to the public eye. I felt it necessary to address is again. Since the April issue of ELLE magazine, which featured the Permafacial implant and my experience with it, the phone has been ringing off the hook-rightfully so. It is that good.

It is very simple.
The procedure is short and painless.
The results are natural.
It lasts forever, but is easily reversible if the patient so desires.
It is 100% safe.

People who worry about silicone and its possible side effects are talking about liquid silicone. This is entirely different.

Doctors who have have previously frowned upon lip implants are talking about the implants made from other materials. This is entirely different. Only a few doctors are permitted to place these implants, chances are they are not one of them (see the list at www.surgisil.com).

Find out for yourself.

Schedule a consultation appointment with Dr. Blyer. You won't be sorry.

Permanent fillers (Part IV of IV)

Perhaps no other product in the field of cosmetic surgery has as marred and misunderstood history as silicone. Since 1965 the FDA has maintained that no physicians are to use injectable silicone for cosmetic surgery purposes. Long used without official sanction, the FDA in 1997 granted the use of liquid silicone for the treatment of detached retinas. AdatoSil 5000 and Silikon 1000 are the only two injectable silicones approved on the market for intraocular injections. . Despite its disapproval, a survey by the American Academy of Cosmetic Surgery of 2000 cosmetic surgeons discovered that silicone injections was the ninth most popular procedure in cosmetic surgery in the mid 1990s. There were nearly 60,000 injections reported in the United States in 1990. After the initial use of injectable silicone during World War II for breast augmentation, silicone had been led down a defaming path from a lack of good common sense, impurity of materials, and ignorance of guidelines between and after injections. Silicone is permanent, minimally antigenic, non-carcinogenic filler. It is technique sensitive and should not be performed by a novice. Although there are complications inherent in the injection of this material, with good patient selection and proper technique these risks are no greater than the other materials spoken of. As an off label manner silicone can successfully be injected to treat the glabellar, marionette, and nasolabial folds, tear troughs, flexible acne scars, lips, genial and malar regions, and post rhinoplasty deformities. Because of its permanence, it should probably be delivered after the resorption of a pleasing trial with temporary filler. Overcorrection should be avoided and the patient should be forewarned to return for multiple visitations and supplementation injections at 1 to 2 month intervals. Injections too superficial will result in beading.

ArteColl is a permanent implant popular in Canada and Europe and recently introduced in the United States as ArteFill. Polymethylmethacrylate microspheres comprise this filler along with lidocaine in a collagen suspension. Upon injection the body resorbs the collagen in the suspension, as the body encapsulates the PMM with connective tissue. This process terminates in 8-12 weeks. At this time only 25% of the volume remains. Patients should be informed of the need for multiple treatments at a minimum of two-month intervals. It has excellent results thus far in highly mobile areas. Allergy testing is required for this product due to the sensitivity to bovine collagen in it.

Aquamid is polyacrylamide hydrogel and is used for facial volume augmentation in Australia, Europe, South America and the Middle East as of August 2006, has received approval by the FDA to begin clinical trials. A 2.5% hydrophilic polyacrylamide and 97.5% water together forms a transparent gel substance that is permanent filler for tissue augmentation. Although still a neophyte on the market, Aquamid has proved to yield very high (>90%) patient satisfaction and minimal, minor side effects.

Temporary long duration fillers (Part III of IV)

Temporary long duration fillers (2-3 years)

Two fillers derived from cadaver tissue include Cymetra and Fascian. Cymetra is an injectable form of Alloderm (dermis from a cadaver), approved by the FDA in 2000. Its lifespan in tissue varies between 3 and 9 months. Fascian is particulate graft material from derived from human cadaveric muscle tissue. In 1999 it has been introduced as injectable filler.
Radiesse is an amalgam of 30% calcium hydroxylapatite microspheres (25-45 µm) in a 70% gel consisting of 1.3% sodium carboxymethyl cellulose, 6.4% glycerin, and 36.6% sterile water. Despite have microscopic pieces of calcium this product is smooth and excellent for deep folds and wrinkles. Its clinical effects are reported to last for 2 years, with the added benefit of stimulating new collagen formation. There are no allergic reactions associated with Radiesse. This filler cannot be used in the lips but is outstanding for nasolabial folds. This filler is my personal favorite to address deep folds around the mouth, nose, and ‘hollowed out’ appearance below the eyes. The makers of Radiesse report its duration to be 2 years. From personal experience, I have seen the positive effects of this filler even longer, depending on the site of injection (likely due to its ability to enhance new collagen production). Additionally it maintains its ‘mold ability’ for 7 days, so if you notice some unevenness it can be massaged out.

Sculptra is a biodegradable, biocompatible, synthetic polymer from the alpha-hydroxy –acid family. It is comprised of crystalline, irregularly sized microparticles of poly-L-lactic acid. It undergoes volumetric in that is increases in size up to months after initial tissue introduction. As degradation continues, collagen production occurs as well. Patient typically should be under filled and are re-evaluated at two-week intervals if further augmentation is warranted. The benefits of Sculptra typically last between one and two years.

The public’s concerns regarding the use of donor tissue in this venue have impelled the development of Isolagen The theory behind this product is treating the atrophic dermis with cultured fibroblasts from one’s own body. It is a living network that produces an immediate fill with a continuum of growth over a period of 1 to 2 years. Follow up thus far has shown no loss in volume over a 4.5 year follow and is still awaiting final FDA approval. Although the company reports this product will be cost effective in that its results have so far been long lasting, the price tag remains to be seen.

Autogenous fat has been and remains an excellent option for volume restoration in the face. Although its durability and longevity as injectable filler is controversial it is inarguably a wonderful non-immunogenic, plentiful, and most often-short term option in the lips. Some surgeons believe that half of the fat volume remains while others believe all of the fat is eventually resorbed and the remaining volume is consistent with scar tissue. Usually three months between a second series of injections is allowed for. Additionally, the harvesting of fat has also been controversial with regard to the fragility and viability of the adipocyte before, during, and following transfer. There is much variety with regard to harvesting, preparation, and injection techniques most of which is anecdotal and based on surgeon preference.

Temporary short duration fillers (Part II of IV)

Temporary short duration fillers (3- 8 months)

The collagen fillers are from another specie of animal (Zyderm, Zyplast, Resoplast, Fibril) last for 6-12 months but are no longer in favor since they require skin testing first and although they are fine for deep facial wrinkles.
Human collagen (Cosmoplast, Cosmoderm) is derived from fibroblast cell cultures and is less lumpy then Zyderm and Zyplast. Cosmoderm is used for fine lines such as crow’s feet and to fill in the shallow wrinkles around the lip line. Cosmoderm is a more viscous formula and used in the treatment of deeper lines and furrows as well as lip “plumping”. As Cosmoplast does treat deeper wrinkles, it also includes lidocaine, a local anesthetic, in the formula to minimize discomfort.

Hyaluronic acid (HA) fillers (Restylane, Perlane, Juvederm, Captique) are the most popular fillers used in the US and are produced from a bacteria, Streptococcus equi. HA is a natural substance found in skin and works to trap water and plump skin, thus while you’ll often find it in your everyday moisturizer. HA helps in maintaining volume and shape in your face and lips, but as skin ages, its levels decrease, resulting in a loss of volume, skin elasticity, and the appearance of wrinkles. There are many forms of hyaluronic acids, most of which have little to no side effects, making them extremely popular. It is superior in that is undergoes isovolumetric degradation (it maintains its volume during the break down process by recruiting water, until it is fully resorbed). These fillers typically last between 4 and 6 months. Captique’s duration appears to be closer to 3 months. Hylaform (Hylaform Regular, Plus, Finelines) is another hyaluronic acid filler derived from rooster combs.

Juvederm recently approved by the FDA is a “next generation” dermal filler, a synthetic gel made of hyaluronic acid. The injection process takes a quick 15 minutes and results are immediate, with minimal recovery time. Juvederm provides the highest concentration of cross-linked HA available, making it an ideal filler to smooth away facial wrinkles and folds, like nasolabial folds (smile lines) around the mouth. It is most effective in this “lower third” of the face. Interestingly, Juvederm is the first FDA approved hyaluronic acid filler proven safe and effective for persons of color.

Restylane and Perlane are non-animal HA produced from a purified and stabilized streptococcus bacterium. These fillers can be used successfully to treat moderate to severe facial wrinkles and folds (around the nose, between brows) and can also be used to create volume (in lips). Injected into the skin below the wrinkle, it literally lifts the wrinkle out to the desired correction. Results are immediate and can last up to 6 months with 1 in 2,000 individuals having any type of allergic reaction. Perlane is a larger molecule than Restylane and therefore does last longer, but has a slightly higher chance of lumpiness.