Combining treatments for the best cosmetic surgery outcomes

Over the past fifteen years of my practice, I have found that patients are often looking for a one treatment, one procedure, fix it all type of solution.  For certain skin problems there may be a one treatment, one procedure fix it all solution.  Very often though, I find that the patient's true concern will need a medley of a few procedures to solve the problems that are contributing to the concern.  For example, a patient may come in with complaints of the parantheses (lines around the mouth) or nasolabial folds being too deep.  They have read that these lines can be filled with a filler.  Yes, perfect.  In many cases, just adding a bit of strategic filler directly into the folds will solve the problem.  In some cases, however, the volume loss that is contributing to the folds may be closer to the temples, upper cheeks, tear troughs and jawline.  Restoring volume via filler to these areas can give a very natural, soft, and more dramatic improvement to the original problem as the filler places the skin back into position.  Often accompanying this loss of volume in the face is also the fact that the skin is loosing collagen.  Under normal circumstances, we loose about 1% of our collagen content per year.  Genetics and lifestyle contribute to various degrees of deterioration over time.  The loss of collagen makes the skin less elastic, thinner and weaker.  Luckily, we have ways to combat this collagen loss with various procedures which heat the skin and force the skin to make new tightly woven collagen fibers.  If we start stimulating the collagen at the earliest signs of loss, it can go a long way in keeping our skin young as we age.  So, the patient with the nasolabial fold concern may not be happy with just fillers, but may also need some tightening of the skin to achieve the best, most natural and dramatic results.  Procedures such as Skin Tyte, Thermage, Exilis Elite, ThermiRF and Ultherapy can all be used depending on what degree of tightening is required and the patient's budget.  Of the tightening procedures, ThermiRF and Ultherapy win.  Or the patient may need a skin resurfacing procedure, if along with the loosening of the skin, there is also sun damage and wrinkling involved.  Venus Viva (fractional radiofrequency), Profractional, Fraxel laser and Broad Band Light can all be useful tools among others to improve the quality, texture and glow of the skin.  

Similarly, for body sculpting procedures, we may wish to combine procedures for the best results.  For example, we love what the Vanquish focused radiofrequency technology can do to eliminate 60-80% of fat cells in 4-6 treatments.  We love even more what Vanquish combined with Velashape will do to much more dramatically and quickly achieve desired results.  Velashape uses infrared, radiofrequency and suction to pull the skin up and massage the released fat from the treatment area towards the lymphatics.  The extra heat futher ensures optimal fat killing (also known as apoptosis).  We absolutely love it when patients are able to combine two to three procedures such as Vanquish, Liposonix, Sculpsure, Velashape, Vaser Liposuction, Smartlipo, ThermiRF and Exilis Elite to get the best benefits for themselves.  This combined approach is sometimes concurrent or it can be spaced out over some time.  In certain cases, we insist on a concurrent approach if we know from our experience that this approach will yield a far more dramatic result for the patient.

We welcome you to come into our office.  Our website www.cincinnatiskinandlaser.com should hopefully have some very useful information about the available procedures for those who like to do their research.  On our website, you can also research by the concern you are wanting to improve...just remember, we may end up suggesting a combination approach. We can fine tune and give our best recommendation during the consultation.  

Coolsculpting or Sculpsure

Many of you have heard of Coolsculpting by now.  The company has done a phenomenal job marketing their procedure for noninvasive body sculpting.  The idea comes from world renowned laser guru, Dr. Rox Anderson, of the Massachusetts General Hospital and Harvard Medical School.  By using cold temperatures to freeze the fat cells, the fat cells undergo apoptosis and die off.  It takes about 3 months for the body to slowly eliminate all the dead fat cells from your body.  About 24% of the fat cells are killed in one 40-60 minute session.  The fat must be pinchable and must fit into a predesigned applicator for the procedure to work.  If you are having upper and lower stomach and love handles treated, you are looking at 4 hours of treatment time.  Three sessions are recommended for best results, spaced from 6-12 weeks apart.  After a coolsculpting procedure, the skin has to initially thaw out.  Gentle massaging can be helpful here. Many patients feel uncomfortable after the procedure and describe pins and needles types of sensations.  The pain can continue or worsen over the next few weeks to months as the nerves are often affected.  There have also been cases of the fat deposits actually growing rather than shrinking, now well documented as Paradoxical Adipose Hyperplasia.  Finally, cryolipolysis does not offer any direct skin tightening benefits, though some clinicians are reporting seeing tightening of the skin.  I feel it is definitely a procedure that works and the aggressive marketing has made it a household name.  Is it the best procedure available for noninvasive body sculpting?  While it's a good option, we feel there are even better options.

One procedure we absolutely love is Vanquish.  Vanquish is completely painless.  It uses focused radiofrequency currents that are driven through the fat cells, causing them to heat up to 45 degrees celsius.  At this temperature, the fat cells undergo apoptosis or controlled cell death and die off.  They are slowly eliminated from the body over 12 weeks time. The fat does not need to be pinchable.  The procedure can be performed on slim to very heavy patients and BMI is not as critical in evaluating candidacy as it is with Coolsculpting.  A large area is treated over 30-45 minutes from the stomach to love handles.  It is recommended that the patient return weekly for 4-6 sessions.  Besides the stomach and love handles, other areas that can be treated include back fat, arms, and thighs.  For dramatic reductions of fat cells of up to 60-80% after 4-6 sessions, Vanquish is by far the most effective.  It also has no associated post treatment pain.  All normal activities can be resumed immediately.  No special diets are required.  We do, however, request that patients consume 8 glasses of water with any noninvasive body sculpting procedure to help flush the fat out.  There is also no danger of Paradoxical Adipose Hyperplasia as there is with Coolsculpting.  In our practice, we have seen some very dramatic results with Vanquish.  The skin usually also heats up to 42 degrees celsius during the procedure providing the added benefit of well documented collagen stimulation and hence true body contouring and skin tightening.

New to the market is a procedure called Sculpsure.  Although we love Vanquish, we feel Sculpsure has a good position for treating specific pockets of fat.  It can also treat larger areas.  The advantage is that it does not require weekly visits and can be accomplished in a single 25 minute session per area.  An area consists of 4 applicators that can be placed anywhere for that 25 minute session.  To treat an upper and lower abdomen and love handles takes 1-1.5 hours (compared to the 4 hours it would take with Coolsculpting).  One can expect to see at least a 25% reduction in fat cells after a single session.  Patients may need an additional 1-2 sessions spaced 6-12 weeks apart.  Unlike Coolsculpting, Sculpsure does not require the fat to be pinchable.  It can be administered on any part of the body except the chin (for now).   There is absolutely no recovery time or post treatment nerve pain.  One does not have to wait for the skin to thaw out as with Coolsculpting and there is no risk of Paradoxical Adipose Hyperplasia.  Also, heating is great for stimulating new collagen growth in the skin.  For all these reasons, most practices on the east and west coasts are switching to Sculpsure for localized areas of fat.  Below are some results from Sculpsure and from Vanquish.

Ultherapy or ThermiRF for tightening my neck and jowls?

Ultherapy and ThermiRF are both excellent procedures for neck and jowl tightening.  Ultherapy is entirely noninvasive whereas ThermiRF is minimally invasive.

Ultherapy uses focused ultrasound energy to target the SMAS (Superficial Musculo-Aponeurotic System), which is the muscular tissue that is normally sutured or shrunk during a facelift.  Unlike a facelift though, no incisions are required to reach this layer of tissue as the ultrasound will send directed energy waves to shrink it up.  Easy enough and no recovery time required.  A second pass is also made which targets the dermal collagen and forces the skin to generate healthy new collagen fibers to keep the skin firm.  Although the procedure does hurt during treatment, there is no pain afterwards.  Patients are able to tolerate and get through the procedure just fine.  You can resume all normal daily activiities right away.

ThermiRF is a monopolar radiofrequency device.  First, the neck and jowl skin is numbed using a small blunt canula.  The procedure is entirely pain and sensation free after the numbing.  Next, a thin probe is inserted in a fan like pattern across the neck and jowls, while heating the area of the SMAS and skin.  Temperatures of 60-65 degrees are reached under the skin to enable for tightening and shrinkage of the SMAS.  If there is excess fat in the neck, there will also be some fat apoptosis for better contouring.  The skin temperature target is 42-45 degrees for optimal collagen stimulation.  After the procedure, a chin strap is worn for 48-72 hours to provide mild compression to the area.  Swelling is seen for several days.  There is minimal to no bruising afterwards.  We recommend restricting activities for a few days or a week until the swelling subsides.  ThermiRF certainly delivers the more dramatic results for patients with more significant skin laxity.  It is the perfect procedure for someone requiring a facelift but does not want surgery.  You are entirely awake and alert throughout this painless procedure.

Both procedures are excellent options with excellent safety profiles and excellent results.  Give us a call at 513-985-9885 to learn more and help us help you decide which would be a better option for you.  There are a few other skin tightening procedures we offer as well including Exilis Elite, Skin Tyte, Thermage and Thermismooth which you may also be a good candidate for.  Our passion is to help you look and be your best.

Ultherapy Before and After Photo

ThermiRF Before and After Photo

How can I get my eyebrows to lift back up?

As we age (oh, that dreaded word), we sometimes notice that our eyebrows are beginning to droop, causing our eyelids to look heavier.  What can we do to fix this and why does it happen?  Similar to the drooping we experience in the lower face, jowls and neck, we see a loss of volume, specifically in the temples and above the brows, loosening of the fibromuscularature under the skin and loss of elasticity and collagen in the skin itself as being the prime factors.  Correcting some or all of these factors can give very pleasing and natural results.

Starting with the fibromusculature, there are several ways to achieve tightening of this layer.  First and most dramatic is a surgical or endoscopic eyebrow lift.  This is accomplished with an incision behind the hair line and lifting of the brow area much like a facelift.  If one wishes to avoid incisions and scars, recovery time, and the risk of an "overdone" appearance, there are several excellent noninvasive, nonsurgical options.  The best is Ultherapy.  Ultherapy delivers focused ultrasound energy directly onto the fibromuscular layer to cause a contraction and tightening to occur in this structure without having to suture it surgically.  The area treated is right above the eyebrow to the hair line.  Furthermore, Ultrasound energy is focused also into the deep dermis where it stimulates new collagen and elastin fiber formation.  Results are seen gradually over 4 to 6 months.  Cost for an Ultherapy brow lift procedure is $1500.  The lower eyelids can also be tightened for an additional charge.  If there is concurrent loosening and drooping of the upper eyelid, I recommend using Thermismooth, Exilis elite or Thermage to tighten the eyelid skin.  Ultrasound can not be used so close to the eye area.  Thermismooth, Exilis elite and Thermage are all monopolar radio frequency procedures which heat the skin to a target temperature of 42-44 degrees, inducing new collagen and elastin fiber formation.  The heat also likely affects the ligaments and fascia inducing a contraction within those tissues.  These radiofrequency procedures range from $650-$3500 depending on the technology used.  None of these procedures have any recovery time outside of mild redness and swelling from a few hours to a day.  Make up and  moisturizer can be worn immediately and all normal and strenuous activities can be resumed right away.  Patients can return to work and social activities immediately.  Possible side effects could include bruising, temporary sensation changes such as numbness or a possible skin burn.  While very effective, results can be dramatic or subtle from patient to patient.  Experience in administration and delivering the energy at the correct angle and temperature and time all work to give a superior experience and result for our patients.

Next, we can use fillers.  Fillers are made of natural safe ingredients such as sugar polymers (hyaluronic acid) or calcium particles.  Some of the fillers you may have heard of include Juvederm, Juvederm Ultra, Juvaderm UltraPlus, Volume, Restylane, Perlane and Radiesse.  I have not once seen an allergic reaction from fillers and allergy testing is not required.  Care must be taken that the filler is not injected into a blood vessel or near a neurovascular bundle as it could cause occlusion to these structures.  It's important to choose an experienced injector for this procedure.  Placement is of greatest importance with fillers.  The fillers will last anywhere from about 1 year to 2 years.  For a longer lasting result, I will use Bellafilll in patients who have already experienced fillers and are ready for a more permanent result.  To achieve a brow lift with a filler, I recommend first checking the temple area.  We often see hollowing of this area--the temples begin to look concave versus the youthful convex shape.  Adding volume back to the temples is very gratifying as it helps the brows and also helps to give a lift to the lower face.  The second area to inject is right under and right above the eyebrow itself.  This gives an instant lift to the eyebrow.  There's a small chance of bruising, but can be easily covered with makeup if that does occur.  Cost for filler is $500 and up per vial and several vials of filler may be required to get the right effect.  We will often combine a noninvasive approach such as Ultherapy, Thermage, Thermismooth or Exilis elite with a filler to get immediate and best results.

Another procedure I really like is called ThermiRase.  ThermiRase is a unique procedure using a small probe in the temple area right under the skin via a tiny needle puncture.  I can identify the nerve that causes the brows to move downwards towards the middle of the forehead.  This occurs when one looks angry or is frowning or concentrating.  We often Botox in this area to relax this tense expression and help soften the vertical lines that form between the brows called the elevens.  With ThermiRase, the probe rests directly on the nerve that causes the contraction and zaps it with direct heat, disabling the nerve.  If I can disable about 2 cm of this nerve, it rarely grows back and gives a permanent Botox like effect for the frown lines.  Eliminating the frown expression gives an immediate lift to the eyebrows as the downward pull from the frown muscles is eliminated.  If one is not ready for ThermiRase, of course Botox itself will also give a beautiful brow lift.  Botox will last about 3-4 months, but may not be required as frequently with consistent use, as it relaxes the muscle and the muscle memory or tetany.   Adding a little Botox to the RIGHT areas in the forehead and the lateral brow can give an amazing instant brow lift.  The right areas is emphasized because if injected into the wrong muscle groups, it can do the opposite and cause the brows to droop.  Fortunately, this very rare possibility completely reverses itself within a few weeks if it does occur.   Again, an experienced injector is key.

If one has wrinkles, extensive sun damage, and laxity of the skin, laser skin resurfacing works beautifully to rejuvenate the top layers of the skin and tighten the skin as well for a very dramatic beautiful result.  Recovery time can be from 4-10 days varying on the technology used and depth of laser ablation.  This is the only procedure with any significant recovery time issues.

I hope this is helpful in sorting out some of the options for brow lift.  I will mention but not recommend another procedure out there using threads under the skin to pull tissue up.  I used to do these types of treatments many years ago, but do not offer them any longer as the threads are not strong enough to get any type of long lasting benefit.  The problem is the thread may or not pierce and grab hold of the fibromuscular layer.  Usually it only travels through the subcutaneous fat which does not grab and hold the suture well.  With an exaggerated movement, it is easy to loosen the sutures under the skin and loose the intended effect.

Please also visit our website:  www.cincinnatiskinandlaser.com

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