Schneider Centre for Plastic Surgery

At the outer level of the neck are three main components that exhibit the signs of aging. These are the skin, a layer of fat, and the platysma muscle. Aging in the neck is manifest by loss of elasticity in the skin, wrinkling in the skin, and sagging in the platysma muscle, and changes is fat distribution.

Most patients present to the plastic surgeon initially complaining of sagging bands in their neck. This aging is manifest by one or two sagging bands first starting above the Adams apple and eventually descending along the entire neckline. The bands that develop in the neck are due to the flaccid drooping of the platysma muscle.

The platysma is a paired broad thin muscle that runs from the collarbone to up above the jaw line and extends from the middle of the neck in the front to about the ear. The platysma is an interesting muscle in that it is not supported on any bone. Therefore, it just sits on the soft tissues of the lower face and neck. As these tissues start to age, they lose volume, loosen and descend. The platysma follows these structures and does the same.

This aging may also be accompanied by a change in the volume of fat above the platysma and deep below as well as the changes in the skin.

A necklift is designed to repair the aging changes isolated in the neck. It is almost always included in a modern facelift. Some facelift “factories” that specialize in your “lifestyle” may try and include it as an after charge to an old style facelift. The necklift is designed to isolate and correct the aging changes from the jaw line down. This is a very important point to understand because the jowl often has a facial component and a neck component. Patients often believe that a necklift will completely correct the jowl. However, the necklift is really designed to only correct the neck component of the jowl.

There are many different types of necklift incisions and procedures. Typically the operation uses a transverse incision under the chin for access to the front of the neck. It also uses an incision behind the ear for access to the backside of the neck. These limited incisions give the surgeon access to the neck from the jaw line down. The surgeon will use either liposuction to contour the fat or excise the fat directly. The muscle is lifted in the midline and the right and left sides are sutured together via a variety of techniques and then tightened in the back. The incision in the front is then closed and the skin is advanced in a posterior – behind the ear direction, to eliminate the loose skin.

For most patients who are correct candidates, the recovery involves very little discomfort and minimal swelling. Most patients are able to return to work within a week. For more information to see if the neck lift is right for you, please see your Plastic Surgeon.

Face it, for most people, getting rid of unwanted hair is a daily drudgery. Alternatives that allow for less shaving are painful, costly, and need to be repeated forever. Waxing, electrolysis, and even laser treatments are painful and in some cases require topical medication to soothe the pain.

Pain-Free, Hair-Free™ laser hair removal with the Soprano Laser by Alma is a painless, permanent hair reduction treatment system. It truly is painless for most patient’s…even men.

Laser hair removal works because the laser energy is absorbed by melanin (a pigment) within the hair follicle. Most laser hair removal systems are very painful as the laser energy is applied to the skin. In addition, they only work for very dark, coarse hair and cannot be used on dark skinned patients.

The patented Soprano laser system is safe for all skin types, for hair colors, and on any hair types. The system gently and safely heats the targeted areas of hair with pulses of energy that are directed to the hair follicles. The systems cooling mechanism makes the skin comfortable and the process enjoyable. Many patients report that the technique reminds them of a hot rocks massage.

Hair usually grows in several stages: Anagen, Catagen, and Telogen. The Catagen and Telogen stages are when the hairs have stopped growing and are resting. The Anagen phase is when the hairs are actively growing. This is the phase when the laser treatment is effective. Typically, 25% of the hairs treated in a given area are going through their Anagen phase. This means that to hit all the hairs effectively, the patient will need 4-6 treatments. As many patients grow new hairs throughout their life, some may require touch-up treatments two years after they were first treated.

All regions of the body can be safely treated. Men who are tired of shaving their heads or beards can have these areas effectively treated. Backs and chests can be treated in 15-20 minutes. Legs, bikini areas, underarms, and private regions can be comfortably treated with the system.

The Brazilian Butt-lift, otherwise known as fat transfer to the gluteal region, is designed to enhance the shape and size of the buttocks. The technique utilizes minimal incisions and allows for a fairly fast recovery and return to normal activity.

Fat transfer is a technique that is several decades old but has only within the last years, become fairly standardized and routine. In the past, fat transfer was fraught with fat loss and volume loss after the fat was transferred. In the 1990’s, it was discovered that if the fat was injected in very small amounts throughout a given region, then most of the fat would survive. This is because the small fat cells were surrounded by healthy tissue that would allow for blood vessel in-growth into the transferred fat. The reason fat did not take with other techniques is because the fat was injected as a large glob and new blood vessels could not grow in before the fat began to die.

Dr. Schneider uses liposuction to harvest fat from one region of the body and then concentrates the fat and injects it into another. The procedure starts by making a tiny hidden incision in the area for liposuction. Then a fluid called tumescent solution is injected into the fat of the area. The tumescent solution helps prevent bleeding and also provides anesthesia to the area. Classically patients are sedated or asleep for the procedure, however, many have opted to have the operation done while they were awake.

The patient is then repositioned for the fat transfer. Several small punctures are made in the gluteal region. The concentrated fat is then injected into the gluteal region in small aliquots until the desired shape and size is created. Band-aids are then applied. Patients are instructed not to sit or lay on the area for several days but they may shower and begin activities the next day. The result: an enhanced more shapely buttocks and a contoured smaller region that underwent liposuction.

You look in the mirror and the reflection you gaze upon is starting to resemble your mother or father. Yikes! Did this happen overnight? It may have seemed to. For many it may be a gradual process that at a certain point becomes undesirable. What happened? Can you get that youthful healthy look back? Can you look as good as you feel?

Below the skin sitting on top of and around the muscles, is a collection of fat pads. The volume of the different fat pads changes with the aging process. Some compartments tend to decrease in size while others increase and some remain the same. Fat regions that decrease in size tend to produce characteristic hollowing of the aged face. These are located in the temples, in the cheeks and in the chin. As they sit next to areas that may stay the same or increase, this accentuates what patients see as the jowl, parentheses lines (nasolabial folds), and marionette folds.

In addition to changes in fat pad volume, the face also undergoes loss of bone thickness. This is seen in the orbit, the bones that hold the eyes in position, and in the maxilla and mandible, the bones in the central portion of the face and jaw. The sagging in the face that accompanies aging is due partially to this loss of volume. The skin and soft tissue structures do not shrink so this larger envelope now sags on a smaller frame.

True rejuvenation aims to reset the clock of aging by restoring volume. This can be done surgically with fat transfer or, it can be done non-surgically with a product called Sculptra™.

Sculptra™ is made from the same material as absorbable sutures. It comes as a powder that the Dr. Schneider mixes with water and xylocaine (a local anesthetic). When Sculptra™ is injected into the soft tissues it stimulates the body to produce new collagen. This new collagen adds volume to the region where the product was injected.

Gradually, over six weeks, Sculptra™ works its magic and the body gradually produces collagen to fill in the regions treated. In numerous studies, Sculptra™ has been demonstrated to last a minimum of two years. Most patients will occasionally come in for a touch up of volumization as they see the continued effects of the aging process.

A facelift is a surgical procedure designed to lift and correct the sagging in the face that occurs as a result of aging. Not every patient sees the same problems in their face and so the facelift family of procedures needs to be tailored to the patient’s individual problems and their goals.

A facelift is a generic term that can cover several different regions of the face. Plastic Surgeon’s divide the face into the upper region called the brow, the eyelid region that is sub-divided into the upper and lower eyelids, the mid-face region that runs from the cheeks to the jawline, and the neck that runs from the jawline to the collarbone. A facelift can include all of these regions or it can be broken down into individual regions based on a patient’s choice.

Most commonly, patients considering a lifting procedure often choose to have the mid-facial and neck region performed together. This combination rejuvenates the loose skin and fat from the neck (often times called a turkey neck), the jowl, and the nasolabial folds (parentheses lines). Often the outside part of the eyebrow region would also benefit from elevation and the lateral browlift accomplishes this. For most patients, this is what is considered a facelift.

There are many different ways to perform a facelift and there is no one technique that has been proven to be the best. The facelift started over 70 years ago when a surgeon discovered that after removing a large skin cancer located in front of the ear of patient, that that side of the face looked better. The surgeon then did the patients other side similarly for cosmetic reasons and lo and behold, the facelift was born. Since that time Plastic Surgeons have been searching for better and better techniques that provide greater lift, greater longevity, more natural appearance, and restore normal youthful anatomy. Thus procedures with shorter incisions, hidden incisions, multiple layers, composite layers, deeper planes, safer dissections, and lesser dissections have all been invented.

The key, and we have to emphasize this, the absolute key to a natural appearing facial rejuvenation, is for the surgeon to understand what has changed with time in the individual patient, what the patients goals are, and what is necessary to accomplish this task. Therefore the first step taken with every patient is a consultation whose goal is to determine what bothers the patient and what approach is best.

As the face ages, it loses volume in the bone and volume in the fat of certain regions. This causes the surrounding tissues and skin to sag. If the volume loss is small and the sagging minimal, then sometimes volume restoration alone, performed with fat injections, is enough to produce the desired result. Many times, a combination of lifting techniques and volume restoration is necessary to produce a natural, youthful, rejuvenation. One technique, one type of surgery, is never the standard technique used for every patient.

When considering a facial rejuvenation procedure, meet with your surgeon, discuss what you see as your goals, and make sure the approach addresses your desires.

In our first part of this series, we considered how a patients weight would affect their risks during elective Plastic Surgery. In this second part, we will consider how weight will affect the cosmetic outcome of our surgery and whether patients should or should not lose weight prior to surgery.

A variety of Plastic Surgery procedures may be affected by a patient’s weight. The most common procedures where this may be an issue is in facelift surgery, breast reduction and breast lift surgery, abdominoplasty (tummy tuck), and liposuction. As we discussed previously, we would like a patient to have a BMI < 30 prior to having any elective surgery because this tends to improve their healing and decrease their risk of complications.

For the patient with a BMI < 30, they often want to know if they should lose weight prior to their surgery. This really depends upon how a patients weight affects the area that we are considering performing surgery upon.

When patients lose weight, certain regions are affected more than others. This varies from patient to patient. For example, there are some patients who lose a great deal of volume in their breasts when they lose weight. If we were performing a breast reduction with the goal of creating a certain “cup” size, then weight gain or weight loss after the surgery would significantly affect the result. There are many patients in whom weight loss does not dramatically affect the appearance of a certain region. So for example, if the patient was considering a facelift and their face is not significantly thinner with weight loss, the result would not be expected to affected after surgery.

We also consider the individual and their dieting habits. There are some patients who may have only recently (over the last one or two years) gained weight and they are confident that they can lose this weight and maintain their normal weight. In this patient it may be reasonable for them to try and lose the weight prior to surgery. Clearly, certain areas of the body and certain procedures have significantly enhanced results if the patient has less body fat.

However, weight loss may not be necessary for every patient. For example, say we have a patient that has a stable weight that is 15-20 pounds overweight. The patient is seen because they would like to decrease the volume of the fat in their belly with liposuction and they would like to take that fat and perform either fat injections to their breasts or a Brazilian butt-lift. Weight loss in this patient would eliminate the need for liposuction but it would also eliminate the opportunity to enhance their breasts or buttocks with this method.

Other patients may be yo-yo dieters. This means that they frequently increase and decrease their body fat with dieting. If this patient were to lose weight for the surgery, have their procedure, and then gain the weight back, there is a significant chance that they will be disappointed with their results.

Thus there is no general answer that can be given as to whether it is recommended for all patients to lose weight prior to their surgery. Each patient and their expectations must be evaluated individually.

One of the most common questions we hear from patients considering plastic surgery is whether they should lose weight prior to their surgery. Obviously, all physicians want their patients to be in the best health prior to any elective surgery and obesity adds risks to elective surgery. Yet, not all patients are the ideal body weight prior to their surgery. The question then becomes, what factors do we take into consideration regarding a patient’s weight?

There are 2 basic factors we consider regarding a patients weight and elective cosmetic surgery. The first is risk. Are the patient’s risks of surviving the surgery increased due to their weight and are their increased risks of complications. The second is result. Will a patient have a good outcome from the proposed surgery at their present weight?

In this first part of a 2 part series, we will consider risk first. Certain surgical risk factors increase in a patient who is significantly overweight. We call patients that are significantly overweight, obese. Obesity is defined as any patient who’s body mass index is greater than 30. Morbid obesity is considered anyone with a body mass index greater than 40. Body mass index (BMI) is determined by a formula that uses your height and weight. The ideal BMI is accepted to be 19-25. The BMI is a rough scale as it does not take into consideration extremes of muscle mass. As an example, in 2010, their were numerous news stories concerning Shaquille O’neal who had a BMI greater than 30. O’Neal, being a professional athlete, has a muscle mass that pushed his BMI calculation into the obesity range. [For anyone interested in checking their BMI, calculators can be found on the internet by searching BMI.]

So what does a BMI of greater than thirty mean? The average American male is 5’9” tall. The ideal body weight for this individual is from 130 -163 pounds. However, in 2008, this average American male weighed 195 pounds. That’s a BMI of 28.8 and would be equivalent to a body fat of 26%. For this individual it would mean carrying around 48 pounds of fat!

How does this extra poundage affect the surgical patient? Significantly! Studies performed by several different surgical subspecialties demonstrate dramatically increased risks for the patient with a BMI greater than 30. If our average American male had a 10 pound weight gain over the holidays, this would suddenly propel him into a BMI > 30 range.

In Plastic Surgery, numerous studies have demonstrated that the risks of surgery may be increased with a BMI > 30. Infections tend to be higher as well as poorer wound healing. The greatest risk may stem from an increased chance of a patient developing blood clots following surgery. Therefore, patients with higher BMI’s must be aware that their risks may be higher and certain surgical precautions will need to be taken during their surgeries. Ideally, patients with a BMI > 30 are encouraged to lose weight prior to their surgery, if they can.

The skin basically consists of two layers, the outer layer called the epidermis, and the inner layer called the dermis. The epidermis functions as the barrier to the outside environment. As it ages, it tends to get thicker with a duller appearance. The dermis is the foundation of the skin. It contains several components that produce the elasticity or stretch-ability of the skin: collagen, elastin, glycosaminoglycans (Gags), and reticular fibers.

As we age and as a result of environmental factors, the dermis loses its volume and the quantity of its structural fibers are decreased. These include collagen fibers, elastin fibers, as well as the quantity of Gags. The end result of this aging process is that the epidermis thickens and the dermis thins, so the skin literally falls in on itself producing a crevice. Thus the wrinkle is born.

Over the years, a variety of treatment protocols have been designed to eliminate wrinkling. These include dermabrasion, chemical peels, laser resurfacing, and microneedling. The key to rejuvenating the skin is to increase the quantity of elastic fibers in the dermis and to make it thicker. In order to do this, one needs to produce a controlled injury to the skin that promotes healing and the production of increased collagen. Experience has taught us that the deeper and more significant the injury, the greater the healing response and the more successful the treatment.

Therefore, treatments such as microdermabrasion that only remove a layer of the epidermis, produce no long lasting effects on the skin. They do make the skin appear nicer because they are removing the thicker, flaking, dead outer layer. 

Dermabrasion is mostly considered an old, imprecise, technology. Chemical peels are still useful but most consider the gold standard to be laser resurfacing. There are many different types of lasers that have been used, including CO2, erbium, and fractionated versions. Quicker healing lasers do not penetrate as deeply or their density of penetration is less.  With less penetration, there is significantly less injury and thus significantly less final result. Deeper penetration and increased density of laser injury produces a greater controlled effect and significantly greater wrinkle resolution.

 The key to any successful treatment is for the patient to understand what they want, what you are willing to accept, and if the treatment will work for you. Hopefully, this will help expand your knowledge of wrinkle treatment.

You look in the mirror and the reflection you gaze upon no longer looks like what you remember.  For some this seems to happen overnight.  For others it is a gradual process that at a certain point in time becomes undesirable.  Friends or coworkers may have told you that you look tired but inside you feel like the same vibrant individual you have always been. Can you get that youthful healthy look back?  Can you look as good as you feel?  The purpose of this article is to explain the anatomic changes that occur in the face with aging so you can address what you feel is important.

Aging happens at different rates for all individuals.  The process may be accelerated with environmental stimulants such as excessive sun exposure, cigarette smoke, and poor nutrition.  Aging is not skin deep: it is deeper.  The process affects the skin, the underlying fat, muscle and bone of the face.

The skin consists of two basic layers: the outer epidermis that protects the body from the environment, and the inner dermis that holds the elasticity of the skin. When the skin is youthful the epidermis is thin and smooth relative to the dermis. The dermis holds the skins organs and its elastic fibers such as collagen and elastin. As the skin ages, the epidermis tends to get thicker and the dermis thinner.  The dermis is the skins foundation and it loses some of its collagen and elastin. Thus the skin begins to form wrinkles and have less elasticity.  This means it does not snap back like it used to.

Below the skin are a variety of thicknesses of fat that cover and surround a multitude of layers of muscles, nerves, and blood vessels. The fat is separated into multiple different compartments throughout the face and each compartment ages differently.  Some compartments tend to decrease in size while others increase and some remain the same. Fat regions that decrease in size tend to produce characteristic hollowing of the aged face.  These are located in the temples, in the cheeks and in the chin. As they sit next to areas that may stay the same or increase, this accentuates what patients see as the jowl, parentheses lines (nasolabial folds), and marionette folds.

Superficial muscles in the face surround the eye and form a covering throughout the neck. These muscles tend to sag and elongate with time.  This can produce the characteristic aging changes around the eye and in the neck.  In fact in the neck, the bands that people see as they enter their mid forty’s and become exaggerated in their fifties and sixties are caused by the large flat platysma muscle loosening from the deeper structures of the neck.

Even the bones in the face change as we age.  We lose bone throughout areas of the facial skeleton. This is seen in the orbit, the bones that hold the eyes in position, and in the maxilla, the bones in the central portion of the face.  As a result, the older a patient gets, the more the eyes sit farther back in the eye sockets and the bones around the nose and mouth shrink. 

Aging of the face therefore causes wrinkling in the skin, decreased elasticity in the skin, shrinkage of some fat compartments and an apparent prominence of other fat compartments, muscle laxity and loss of bone.  When you are youthful, the envelope that forms the outward appearance of your face has a certain surface area and volume. It is also elastic.  As we age the outer surface area remains the same but it loses its elasticity and the inner volume shrinks.  The result is that the outer envelope begins to sag and we interpret that as the signs of aging.

To create a natural youthful appearance, the plastic surgeon must address the individual issues that each unique face presents.  Skin quality, fat volume, muscle redundancy and bone loss should all be appropriately evaluated and addressed to create an anatomically correct rejuvenation.

The tummy tuck, otherwise known as an abdominoplasty, is a surgical technique used to improve the appearance of the abdomen or belly. Most abdominoplasties involve tightening the muscle wall to help flatten the abdomen and liposuction to contour the flanks and hips.

Aging, pregnancy, weight loss or weight gain, and environmental effects such as smoking will change the elasticity and laxity of the abdomen’s skin. The skin can loosen either in just the lower abdomen, it may loosen only in the upper abdomen, or it can loosen throughout the abdomen. Where the skin has become lax and the quantity of laxity, determines our surgical approach. Abdominoplasty incisions for skin laxity vary significantly.  In fact, we perform 5 differently located incisions based on the problem.

The endoscopic abdominoplasty uses the smallest incision, slightly shorter than a c-section scar and located in the same place.  The procedure is only used in patients who have no skin laxity. Through this incision, liposuction and muscle plication is performed.

The mini-abdominoplasty procedure uses an incision a little bit longer than a c-section scar and enables us to remove small amounts of laxity of the lower abdomen.

A full abdominoplasty scar also lies low in the torso’s natural skin creases but extends to the hips. It allows the surgeon to remove the skin from where a c-section scar would be located to above the umbilicus (belly button). This produces tightening of both the lower and upper abdominal skin.

A reverse abdominoplasty incision is located under the breasts. There are some patients who only have skin laxity in the upper portion of the abdomen. This incision is ideal for this patient.

Finally the last incision occasionally used is the vertical midline incision.  It may be used in patients who have had an extreme amount of weight loss and have significant laxity or in the rare patient who only has significant stretch marks located centrally around the umbilicus but these extend both above and below the belly button.

A variety of options exist depending upon the patients desires and how their abdomen has changed with time.