Our Valentine's Day Specials are a HUGE hit!!!

Please contact the office if you are interested in treating your lady to the best Valentine's Gift you can get her.

Trust us, this is what she really wants.

Gift certificates are available and we can email them to you in time for Sunday.

Exceptional care, exceptional results, exceptional prices for this special holiday.

Time is running out....

Hear Boomer and Carton's experience with CAMEO Surgery!!

/Cameo%20Surgery%202-9-10.mp3/Cameo%20Surgery.mp3/Cameo%20Surgery2-8-10.mp3

The Good news: Botax is dead, The Bad News: You will be dreaming of a white Christmas

Good news for you and I: Congress has decided to remove the "Botax" from the health care reform bill this past Tuesday. I think it was me flexing a little muscle over on Capital Hill that got these clowns a little nervous, not to mention our CAMEO congregation that joined the fight.

Bad news: If you plan on getting "a fake bake" for your holiday party, get on it now. Instead of the tax on cosmetic surgery, Congress has added a 10% tax on indoor tanning. They estimate raising $2.7 billion over 10 years instead of the projected $5 billion from the cosmetic sugery tax. The American Academy of Dermatology was behind this idea to replace the prior tax. So indeed, you may be having a white Christmas after all.

Botax causes frowning

What’s next-additional taxes on getting haircuts, getting a manicure, or buying designer clothes? In an effort to fund President Obama’s 1 trillion dollar new health care revamping, a 5% tax on cosmetic surgery was been introduced on Nov 18th as part of the new health care reform bill. According to IRS Publication 502, that includes "any procedure that is directed at improving the patient's appearance and does not meaningfully promote the proper function of the body or prevent or treat illness or diseases."

We have heard it time and time again, “those who cannot learn from history are doomed to repeat it”. Taxing cosmetic procedures is an unreliable non profitable concept. In 2004, New Jersey was the first state to invoke a tax on cosmetic surgery. It was predicted to generate $24 million its first year, but only generated $6.8 million. There is a grey area in procedures that are cosmetic that could be considered medically necessary. It is estimated that $3 are spent for every $1 generated in discerning the difference between cosmetic procedures and those that are reconstructive in nature.

Cosmetic surgery is not just for the rich and famous. Perhaps that how it is depicted on shows like Nip Tuck, Dr. 90210, or Addicted to Beauty? This is not the case. In our practice we do have a fair share of celebrities and the super wealthy, but more often we have the school teacher that has been saving for the past 5 years to have a breast augmentation, or the average hard working person who wants a little refresher with Botox or filler. National statistics show that one-third of the people who are getting cosmetic surgery make under $30,000. Eighty six percent make less than $90,000. Additionally, 85 percent of procedures are paid for by credit. So the tax would hit lower income people the hardest.

Implementing this tax to fund the health care reform is not only an already failed concept, but a grave mistake targeted at the wrong population. Working women is the most common population of patients seeking these procedures. In today’s economic environment, when everyone is looking for the best bargain, I fear people will turn to dangerous alternatives. Unlicensed physicians, or non FDA approved treatments from other countries may be sought. People often consider having surgeries overseas to save money. Adding this tax is just another reason a person may make a poor decision to do so.

Cosmetic surgery does not only address the outward appearance of a patient, but also their self esteem. There have been studies that have proven more attractive people do better in the workplace. Changing one’s appearance can also help them live a healthier lifestyle. So many of liposuction patients change their diets and exercise lifestyles after losing a few inches off of their waste after liposuction. A tax on these cosmetic procedures will not have a counterproductive effective effect on the economy, but its wake will be felt in all the wrong places.

Breast Cancer Awareness Month

I just saw a preview for the movie 'The Box'. It is the story of an unhappily married couple who receives a small wooden box on their doorstep. At the push of a button, the box brings its bearer instant wealth but also instantly kills someone the bearer doesn't know. I neither saw the movie nor have any intention of seeing the movie, but from what I gather, Cameron Diaz decides wealth is more important than the life of someone whom she doesn't know.

For many we have much to look forward to this year. For others, 192,370 will be diagnosed with breast cancer. The numbers may mean absolutely nothing to you, unless you or your family are one of them. 40,170 will die of breast cancer this year. The reality is, you probably do someone affected by this disease.

Early detection gets pounded into our heads, yet so many women fail to get routine mammograms and do not give themselves self exams.

If you do not know how to do a self exam ask your doctor, or call the office and I can show you how.

Women should get mammograms every 1-2 years after the age of 40. If a first degree relative had breast cancer, this should be done even earlier.

What are your chances of getting breast cancer?

Check out this link to calculate your risk

Take care of the girls girls.

When should you start with Botox?

I recently had a patient send me this article which convinced her at the age of 30 to have Botox injected by me. The link is at the bottom of this text, it was written in the Archives of Facial Plastic Surgery, 2006.

Botox has become so mainstream to so many, I sometimes forget how 'big of a deal' it is to some. When should you start having Botox treatments? I will leave that answer to you. When you feel you are ready. I will say, that I treat myself and really believe it is easier to treat a wrinkle in its infancy rather then when it is fully developed.

A wrinkle is a result of your muscles of animation constantly causing a fold in the skin. Over time, this wrinkle will actually cause the dermis and epidermis to atrophy in this created crease. Almost like the effect of erosion.

Botox weakens the muscles causing the wrinkle. If you only have wrinkles when you animate (frown, smile, look surprised, etc), Botox will eliminate these wrinkles. These are what I like to call baby wrinkles (not yet so deep).

If you have been animating with strong facial muscles over a lengthy time, you will have these wrinkles at rest, because of this atrophy phenonmenon (erosion of the layers of skin in the depths of the wrinkle crease). We call this type of wrinkle an 'imprinted' wrinkle. Will Botox help this type of wrinkle? Yes. Will the wrinkle still be there? Yes. You may need a filler, to 'fill' in the crease where the atrophy took place as well.

In this article that I will attach a link to, 2 identical twins were examined. The twin on the left was injected 2-3 times in 7 years. The twin on the right had Botox injected in her forehead and crow's feet 2-3 times per year for 13 years. The photos speak for themselves. Please read the article. It is a very easy read and speaks volumes about prevention of wrinkles, by starting Botox before the wrinkles begin to take shape.


/Twins%20Botox.pdf

Better than Botox?

Newer, yes. Better, maybe?

It appears that Reloxin will soon gain FDA approval after years of being used in Europe under the name of Dysport. Purtox is another new player from Johnson and Johnson that will likely be available in late 2009 or 2010.

Preliminary studies show similarities and differences between Botox and Reloxin.

Similarities:
Botulism Toxin A is the active ingredient in Botox and is found in Reloxin as well.

Differences:
Reloxin spreads to the surrounding tissues more so than Botox. This can potentially be a bad thing in that you have less control of your injection. In sensitive areas (for example-around the eyes) this can potentially be a problem. On the other hand in a safer area where one desires a broad treatment area (armpits, hands), this may mean less injections.

Reloxin is slighter cheaper for the doctor to purchase than Botox.

When I receive Botox, it comes in a powder. I reconstitute the Botox with sterile saline before administering it, as recommended by the manufacturer. This Botox is only effective for a few days for patient use after mixing. Reloxin has a longer time where it is still "usable". This benefits the doctor.

Conflicting data:
Although the company claims Reloxin should last longer than Botox, some studies show Reloxin to lasting equally as long as Botox, while others have Botox lasting longer.

There are some that believe that Reloxin is more likely to produce Antibodies against it, which translates to a tolerance to Reloxin after multiple treatments, in which Reloxin would no longer work.

My perspective

Whenever something new comes out, doctors often want to be the first to have it. Patients often want to be the first to try it. Just because it is new, doesn't mean it is better. We have seen this with different laser liposuction devices, Gortex implants, and even facial thread lifts. I will do my due diligence, and keep you in the loop.

What's thick, long, and black?

It could be your eyelashes, thanks to the newly FDA approved treatment known as LATISSE. With a disposable applicator, the solution is applied to the upper eyelid margins each night before bed. Within a few weeks, you will have longer, thicker, darker lashes! This is a drug that requires a prescription and we can talk about whether you are a candidate.

The downsides appear limited:

1. 4% of the people who used this complained of an itching sensation or red eye
2. There can be a slight darkening of the skin adjacent to the lashes which is permanent
3. If you stop using this product all of the added lash length, thickness, and new lashes are again lost. You are back to where you started-much like Cinderella after the clock struck midnight.

If you have any questions, concerns, or would like to discuss LATISSE any further, please give the office a call or drop an email.

Learn more about LATISSE from the website:
www.latisse.com

You can pick your friends, you can pick your nose, but you can't pick your friends' nose?

Whoever said that was full of it.

Cosmetic surgery in today's day and age is an amazing thing. Image alteration software are becoming better and better and I for the longest time wasn't a huge believer in it. I thought that this tool was used more to "sell a procedure" and show the magic one could do with the computer. Surgeon's fear using it today's litigious society, because they can not guarantee these results for the patient. There is definitely a role for it, as my personal beliefs have changed.

Please read the following true story from an encounter with a patient that visited my office:
"I just recently has a patient visit the office for a rhinoplasty (nose job). The person had a pretty nose but I felt it was slightly wider, then it should be and she had a hump that I believed was unattractive in a profile view. I pointed these things out to the patient with a mirror, and we agreed these things should be addressed.

I then took photos of her and showed her what she would resemble after we accomplished these goals using the computer prediction software. I loved the result. So did my staff, her parents, and her friend that she had brought to the consultation. She did not like it. I asked her to find some pictures of her own from magazines that exemplified the perfect nose for her.

She returned to the office with photos of a celebrity famous in her culture. She, by textbook definition, had a very imperfect nose. Showing this photo to colleagues of mine, we all concurred, that this nose had many flaws. This was the nose she liked. I superimposed this nose on her face, and she loved it. This was the nosed she wanted."

Noses are a very "picky" anatomical landmark. The ideal dimensions and projections of a nose are one thing. Whether it fits someones personality, ethic identity, or actual face is something else. There is truly no better way to demonstrate these concepts to a patient than computer software that can perform prediction surgery.

Please make sure, before agreeing to undergo rhinoplasty surgery or any surgery for that matter, that you have a clear vision and that your doctor shares this vision with you. Never tell a doctor, "I trust you, you are the expert". These are words I hear all the time. Although flattering, this is your face. Patrick Dempsey doesn't have a perfect nose, but it works on his face. Halle Berry's nose looks much better after surgery than it did prior. Bring in photos, bring in your friends, bring in your opinions, make sure you are being heard. This is your face.

Are prettier people more successful?

Are attractive people more successful than unattractive people? Most research to date points to an answer of yes.

We were all told, what is "on the inside" counts more. Was that all a hoax created by an ugly person? You make the call.

CNN reported the following:
FACTS:
Attractive students get more attention and higher evaluations from their teachers
Attractive patients get more personalized care from their doctors
Attractive criminals get lighter sentences than less attractive convicts

Attractive people make 5% more in their pay.

In a collaborative study by Michigan State University and University of Texas, financial earnings were examined:
Good-looking people made the most money
Average looking people made 3-8% less
Plain looking people earned 8-18% less

Similarly, a London Guildhall University survey of 11,000 33 year olds showed unattractive men earned 15% less than attractive men. Plain women earned 11% less than their attractive counterparts.

Even studies of babies show that children look and study more intently at an attractive face than unattractive one.

Do I think everyone should run out to have cosmetic surgery to save their careers? Obviously not. But you should feel comfortable in your own skin. Confidence is so important to creating an attractive aura.

I have seen shy introverted women who had very low self esteem transform themselves to totally confident women after a breast augmentation or abdominoplasty (tummy tuck). Sometimes all it takes is that little fix that you need to take that next step. Most importantly do it for yourself.

Dancing With The Scars

Poor Priscilla Presley; we have all have seen her on "Dancing with the Stars," it's just too bad more of us are looking at her face than her feet. An absolutely gorgeous woman, who now looks mummified after seeing the wrong plastic surgeon. As the media has recently showed cased her as "plastic surgery gone bad", there were many things that went awry in her treatment. She has reminded us of a few lessons; even the hollywood elite can fall into the wrong hands.

What happened?
Dr. Daniel Serrano a charming doctor licensed in Argentina tapped into the A crowd, offering them a permanent fix to facial rejuvenation. He was injecting industrial, low-grade silicone into the faces of his patients. This was the same quality of silicone that caused silicone breast implants to be pulled off the market, after just being reintroduced this year. This resulted in a terrible outcome, and my heart goes out to all of his patients.


What we have learned?

1. Avoid things that cannot be reversed. One of my mentors taught me, "always have an escape plan". For this doctor, it is probably leaving the country (just kidding, this is not what I mean). A good surgeon thinks 10 steps ahead, imaging what can go wrong on every step and how to avoid and fix it. Silicone injections are permanent and cannot be removed. This is why I do not use the product. As we age, our face changes and this material does not. This results in an unpredictable result. Additonally, if by operator error, too much is injected or in the wrong place it cannot be retrieved. Responsible doctors that do inject silicone use tiny "microdroplets" at mutliple visits, to insure that an error is not made. There are many wonderful fillers that are lasting longer that should be considered instead (see my prior fillers blog entries). This is not the same silicone in breast implants now, and the lip implants that I used are solid silicone-an entirely same form of silicone.

2. Don't believe hype. Do your own research. Ask for before and afters from the doctor. Someone who is in the right crowd or very wealthy is not always the best.

3. Come to CAMEO Surgery and let me take care of you. I am just joking, no I'm not actually.

I applaud Ms. Presley for still competing on the show, holding her head high after being seen each week by millions of viewers. If she came to me tomorrow there are some things I could do to try to camouflauge the damage done, but never will she have her pre-surgery face back. Although I do feel terrible for her cosmetic outcome, Adam Carolla is still getting my vote on the show.

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.

Allow me to "fill you in" (Part I of IV)

Injectible fillers: where we started, where we are, where we are going

In the next 3 blog entries I will discuss all of the fillers available on the market. To simplify this, I have categorized them by their longevity:
I. Temporary short duration fillers
II. Temporary long duration fillers
III. Permanent Fillers

This single entry is an introduction for the general characteristics and qualities that differentiate each filler.

As cosmetic surgery continues to become more mainstream, injectible fillers have become the appetizer which many more patients are willing try before sitting down for a full meal. Fillers are wonderful in that they are a quick fix, with minimal to no downtime, affordable, and work well in the right situations. As fillers continue to become more popular, more and more fillers are becoming available. This has become a point of confusion to many patients, and quite honestly many doctors have asked me for my opinion to what is the best filler for each area. This blog entry is written to give you the “what you need to know” for fillers.

What characteristics do we look for when evaluating a filler?
An ideal filler should be:
1. biocompatible
2. predictable
3. easy to inject, with little downtime
4. inexpensive
5. long lasting-or permanent
6. reversible
7. appears natural

What makes a filler different than another?
Fillers differ in
1. What they are derived from
Since Neuber’s use of fat in 1893, and the short-lived use of paraffin in the 1900’s the options for fillers now available to us are tremendous. In the 1940s silicone injectable fillers were being used for facial augmentation with success, but with the misuse of adulterated product a growing number of complications lead to its ban by the state of Nevada in 1964. In 1965 the FDA classified silicone as a class III medical device. Since 1997 is has been approved only in the treatment of a detached retina.
In the 1970’s xenografts (derived from a different species) were among the first fillers used, and FDA approved in 1981. These were Zyderm and Zyplast, which were bovine (cow) collagen, and Fibrel porcine (pig) collagen. These fillers required skin testing due to their high rate of allergies (3 in 100). This went against the grain of today’s cosmetic surgery patient and spawned the birth of human derived collagen, Cosmoderm and Cosmoplast, in 2003. These have replaced the use of Zyderm and Zyplast. Shortly thereafter, hyaluronic acid fillers (Restylane, Perlane, Juvederm) became popular and had a much lower rate of allergic response, not needing any pre-testing.

2. Size of the particles in the filler affects viscosity, and therefore duration
Fillers consist of small particles in a gel matrix carrier. Generally speaking, the larger the size of the particle, the longer duration the filler lasts and the greater its viscosity. Additionally, the larger the particle size the greater chance for lumpiness upon injection. Restylane Fine Lines contain 200,000 particles/ml, Restylane 100,000 particles/ml, and Perlane has 10,000 particles/ml. Perlane has the least amount of particles, but its’ particles are the largest and therefore has the longest duration of effect, but is more likely to be lumpy if injected too superficially.

3. Concentration of the filler affects viscosity and duration
The higher the concentration of filler, the longer it remains in its injected site. Juvederm (24 mg/ml) appears to be the highest concentrated FDA approved hyaluronic acid filler available (Restylane, Perlane 20 mg/ml). We will further discuss these specific and other fillers in the sections to follow.

5 Things You Should Bring To Your Cosmetic Surgery Appointment

So many patients eagerly anticipate their consultation appointment, that they actually frantically run out of the house forgetting half of what they wanted to bring. Below is a checklist of items for your consultation appointment (if you forget some items, that's ok-I promise).

1. Photos: if you have a photograph of your “old nose”, before it was broken, or those breasts that you admire so much a picture is worth a thousand words. Do not be shy about bringing in a naked picture from a magazine, or the profile you love from US weekly. Doctors are normal people-most of us at least- the more information we have the better we can communicate and create a shared vision.

2. Personal information: Driver’s license, insurance card, doctors' phone numbers. If you have an action packed schedule the day of your consult and don’t want to waste time, call the office prior. Many times the initial patient forms are available online or they can be faxed to you, to save wasted time, sitting in the waiting room.

3. Medications: If you are taking medications bring not only the name, but the dosage, and why the medication is being taken. I have had many patients come in taking a blood thinner like Warfarin, but have no idea why they are taking it. If you have any recent blood work or EKG (electrocardiogram) bring this in as well.

4. Bring a family member or friend. Sometimes four ears are better than two. Most doctors welcome a friend or relative into a consultation. To many people, doctors may be intimidating. When someone is nervous, the left side of the brain is dominant. It is the right side of the brain that is resposible for reason and logic. There is a good chance when walking out of the appointment, you may not remember if your questions were answered, and during the appointment you may forget the questions you wanted to ask! Bring your questions in writing.

5. Your schedule: make sure to bring in your calendar. It is best to have your schedule handy to make sure you can be seen in a timely fashion. Many times I have seen a patient who thinks they have planned out their facelift to be completely healed in time for her daughter’s wedding, but cannot fit this surgery into their timetable. Having your appointment book at your consult, will insure you and your cosmetic surgeon can accommodate. Sometimes a deposit is required to hold a date, so you may want to bring a check or credit card.

It’s Not Just Lip Service

In the quest for perfectly plump and pouty lips, it’s safe to say many women have bitten off more than they can chew. From celebrity photos in tabloid magazines to the real people aspiring to these looks, maintaining a lip that is full yet manages to balance harmoniously with the rest of the face, is no easy feat. However, there is a new option on the horizon: Approved in early October 2007 by the FDA, Perma Facial Implant is a new permanent lip implant, tested in the UK (by the name PermaLip), and poised to take center stage, offering cosmetic surgeons the most natural lip augmentation option yet.

As a cosmetic surgeon, I currently have two options to offer my lip augmentation candidates: temporary or permanent enhancements – both of which have their pros and cons. Temporary techniques, the more popular of the enhancement choices, are typically administered with injectables such as Restylane, Perlane, Juvederm, etc. The drawback here is that these fillers are just that – temporary. Plus, using more of the filler doesn’t ensure it lasts longer; it simply makes for an unnatural finish.

To date, patients looking for a more permanent “fix,” only had the option of lip implants created from materials such as Gore-Tex (yes, the same Gore-Tex used in your favorite rain jacket). The practical upside to any implant is that, unlike an injectable, it can be removed. The biggest concern with these implants, however, is that over time they can become hard and feel unnatural. More recently, actual saline-filled implants with a silicone shell have been approved for use and are becoming increasingly popular. While these implants appear to better maintain their natural structure, the actual aesthetics can be limiting; although the volume can be adjusted intraoperatively, the length cannot, compromising customization and therefore a truly authentic result.

Enter Perma Facial Implant…

If saline filled lip implants are the ready-to-wear of lip implants, than Perma Facial Implant is the couture. It is the only implant designed exclusively for lip enhancement. Thus, it comes in a shape resembling the dimensions of the lip, and actually tapers at both ends to mirror the lips’ natural shape. The implant itself is made of soft, solid silicone and therefore cannot rupture or leak, won’t grow into the surrounding tissue or degrade over time. The implant procedure takes less than half-an-hour, and since pain is minimal, most patients have little to no swelling after one week. Most importantly, since no two lips are exactly alike, Perma Facial Implant is available in a variety of diameters and lengths to accommodate the uniqueness of person’s characteristics, and can be manipulated as needed.

The first trials of Perma Facial Implant have taken place in the UK to nearly universally positive results. The FDA recently announced Perma Facial Implant’s approval for use in the US where it is being used exclusively in Manhattan at CAMEO Surgery Center.

CAMEO Surgery relocates to NYC-Let the blog begin

What a wonderful way to launch my blog and my New York City practice with such positive feedback from a former patient. I appreciate those kind words, and I hope all is well with you and your family.

That being said, I am please to announce the formation of my new practice, CAMEO (Cosmetic And Maxillofacial Elective Outpatient) SURGERY. At CAMEO SURGERY we offer state-of-the-art cosmetic surgery and non-surgical treatments for the face and body in a caring, safe and comfortable environment.

On this website you may notice a link to the Cosmetic Channel. I invite you to tour these videos that explore cosmetic surgery and other issues addressing improvements to your health and appearance. Each month these videos are updated and available to you through my website.

My hope in launching a blog is to provide a real-time exchange for people and prospective patients to post questions – and get answers. I have found that so many patients have the same concerns and questions and I hope my site will become a valuable resource to those contemplating cosmetic surgery for themselves or their loved ones. I will periodically post my point of view – the “what you need to know” - about different surgical procedures as they are approved or covered by the media. The best patient is an educated patient.

My first blog entry is dedicated to the lips. I have had many inquiries about more permanent options to enhance the lips and I am excited and pleased to announce the newly FDA-approved Perma Facial Implant, which we have been using at CAMEO for lip augmentation with much success. The Perma Facial Implant offers a reversible, safe, permanent, and natural result that is cost effective for the patient who enjoys the look of a more voluminous, sensual lip.

I am currently the only surgeon in New York trained to perform this procedure.

I encourage patients who have already tried a lip filler (Restylane, Perlane, Juvederm, etc) and liked the results to think about this solid silicone implant. Please read my blog entry with more information (the lip shtick) about the Perma Facial Implant.

Best wishes to all of you.

Dr. SMB

Welcome to CAMEO Surgery's Blog!