Board Certification is vital for patients seeking any medical or surgical procedures. Board Certification can be and should be the first step in selecting a physician or surgeon for any medical or surgical issue, including plastic surgery. The value of Board Certification to patients is that certification proves the physician or surgeon has met stringent training requirements and subsequently has passed rigorous oral and written examinations. Even after training and exams, more stringent Boards (i.e., the American Board of Facial Plastic and Reconstructive Surgery) require years of post-training surgical experience and ultimately must have their surgical cases closely evaluated. Lastly, Board Certified physicians or surgeons take pledges and are expected to uphold the highest ethical standards.

The second step for patients is to determine if the Board that certified the physician or surgeon is recognized by their state medical board. In California, the Medical Board of California is the entity that not only grants physician licenses; it also determines which Boards are recognized. Recognition is important because any individual or group of physicians can create a “Board”. The Medical Board of California has strict requirements for which Boards are recognized, and those that don’t meet their requirements are prohibited by law from advertising their un-recognized Board. Unfortunately, this law is often broken and rarely enforced. The following link will help you determine which Boards are recognized by the Medical Board of California.

http://www.mbc.ca.gov/consumer/board_certified.html

The next step in the process is to make sure that your physician or surgeon is Board Certified in the particular field of medicine or surgery that you are seeking care or rejuvenation. From the link above, that directed you to the official website of Medical Board of California, you will notice that only two Boards are recognized by the State of California for plastic surgery: the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Plastic Surgery. The final step is to meet your physician and surgeon and determine if he or she is the best fit for you.

Timothy R. Miller, M.D.

Fundamental to any lift, using modern day techniques, involves moving, tightening, or re-positioning a layer of tissue located underneath the skin called the SMAS (said like SMASS).  The term SMAS is an abbreviation for the official medical term Superficial Musculo-Aponeurosis System.  It is often referred to as “the Muscle layer.”  The Bottom line here is that any lift you choose should be more than the removal of loose skin.  The removal of skin is only one of many steps required in a modern-day lift.  Why is this so?

Only a few decades ago, facelifts were skin only removal procedures, but these lifts did not last long (weeks) and the results of these lifts were often not natural.  To improve results and longevity, surgeons devoted time and research and found that by tightening the underlying SMAS layer (“Muscle layer”) the results were better and lasted longer. 

These “second generation” techniques, popularized in the 1970s and early 80s, tightened the SMAS layer by grabbing the SMAS with sutures and pulling the layer back, the official medical term for this is plication (Ply-K-shun).  Although these techniques were an improvement, the tension created by pulling eventually released (much like a rubber band snapping back) and laxity recurred months later, unfortunately patients were commonly left with secondary problems such as pulled down ear lobes and visible scars to name a few.  

In order to improve the longevity of these plication lifts, surgeons would pull harder, or pull in a different direction, or use intricate suturing patterns, such the purse-string suture pattern seen in the MACS lifts.  Despite these changes, the revision rate was still very high (50% in some techniques) leaving patients unsatisfied and with the secondary problems mentioned before.  Despite these issues, plication lifts continue to be performed and are heavily marketed to patients, sometimes on infomercials with attractive, catchy names.  The Bottom line here is that plication lifts are NOT surgical or medical breakthroughs and are, in reality, older techniques.  They maintain their popularity because they are quick to perform (1-2 hours) and do not require years of surgical training to perfect, so many non-board-certified plastic surgeons are performing them.   However, more discriminating facial plastic surgeons were not satisfied with the results produced by plication lifts, and as in other areas of medicine and surgery (e.g., cardiology, neurosurgery, orthopedic surgery, etc.) further studies and investigations developed better techniques with substantially better results.

The next advancement was removing a strip of SMAS and pulling the SMAS as in the plication lifts.  These lifts were often called SMAS-ectomy (ek-toe-me) lifts and some offered improved results over plication lifts but further advancements were made.

The renaissance in lifts occurred when Deep Plane techniques were developed and perfected.  The Deep Plane is a term used to describe the layer below the SMAS layer.  But let’s review before we move forward.  In terms of the layers we are dealing with in face-lifting procedures there is the skin, then the SMAS layer and then the Deep plane.  By addressing this deeper layer to the SMAS, that is the Deep plane, the SMAS layer can be freed.  As a result, the SMAS layer can be re-positioned tension free and in more natural vectors and positions, thereby providing significantly improved outcomes and much longer lasting results.  The High-SMAS lift is considered the gold-standard of Deep Plane lifts and continuously provides the best results for facial rejuvenation.  It is this technique that is presented at facial plastic surgery meetings and the one requiring substantial skill of the surgeon.  It is my lifting procedure of choice for facial rejuvenation.

Bottom line:  Ask your surgeon if they perform a Deep plane lift.  Next, ask if they fully release the SMAS layer, most surgeons do not have the training or skill to do so, leaving their patients with results similar to plication lifts.  Lastly, Deep plane lifts have stood the test of time and have been shown through peer-reviewed publications to offer the best and longest lasting lifts.

Next topic:  Mini-Lifts: Is doing less really more?

Timothy R. Miller, M.D.

One Liquid Facelift uses the FDA approved product Sculptra.  This well established product, which interestingly looks like simple sugar water, is placed deep into the facial tissues.  Here, Sculptra stimulates collagen production and over the course of weeks and months lost facial volume is corrected.   The results are slow but steadily progressive.  Consequently, Sculptra is NOT for patients who want immediate results.  It is intended for those patients who want a slow, gradual improvement, which is an excellent treatment option for those who don’t want friends, family, or co-workers to know they are having anything done.  Additionally, Sculptra typically requires 3-4 treatments each spaced 6 weeks apart.  Please visit an earlier blog of mine which discusses Sculptra in more detail.

The other Liquid Facelift that I perform uses a combination of safe, FDA approved products such as Botox and the popular fillers: Radiesse, Restylane, and Juvederm.   Most patients who chose this treatment option are looking for quicker results, perhaps to look their best for an upcoming wedding, reunion, or other social event.   The reasons do vary but the end result is the same: a more youthful, beautiful, and rested appearance.  I typically recommend performing this type of Liquid Facelift at least two weeks before any important social event. 

As with any “Lift”, liquid or surgical, proper analysis of your unique facial features is critical.  I cannot emphasis this enough with regards to Liquid Facelifts.  Indeed, too many patients, and even those who commonly inject fillers, incorrectly focus only on the nasal labial folds (that is, the grooves or folds that extend from the nose to the sides of the mouth).  Unfortunately, just filling this area is costly and does almost nothing to one’s overall appearance.  As an illustration, the patient in the pictures below had no filler to her nasal labial folds yet she looks significantly better, softer.  Remember, even infants and toddlers have nasal labial folds, so if you really think about it, it is actually un-natural not to have them.

Lastly, during the initial consultation I frequently receive questions and hear concerns about unusual, distorted appearing celebrities, or the plastic look of a friend, acquaintance, or passer-by and all too often a presumptive conclusion had been made that this is the end result of all Facelifts, Liquid Facelifts, fillers, or Botox.  Nothing can be further from the truth.  The following pictures, my other blogs, as well as my other photos on the website should help assure that excellent, natural results are quite possible and actually routine if performed in the right hands.

As an illustration of a Liquid Facelift, the person below desired improvement for her daughter’s upcoming wedding.  I recommended a Liquid Facelift.  She had Botox and then volume enhancement using a combination of Radiesse, Restylane, and Juvederm to her temples, lips, and into the front and sides of her cheeks and jawline, which all help to produce a more refreshed, youthful appearance.    

Timothy R. Miller M.D.

Before

After

The Aging Neck 

One of the most telling signs of age is looseness and sagging in the neck.  The appearance of loose skin and “bands”, with or without excess fatty tissue, typically begins in the fourth decade of life and, unfortunately, continues to worsen as the years go by. 

If we look more closely at the aging neck, we can recognize particular features that directly affect our appearance.  For instance, the distinct separation of our face from our neck, seen in our younger years, becomes blurred and the youthful definition of our jaw-line diminishes.  Additionally, we may see the development of fullness in the so-called submental area, which is the area below our chin.  These changes are especially evident from our side or profile view (an observation that may not be readily seen or realized by ourselves while looking in a mirror but often noticed in a photograph).

To regain a youthful neck contour it is essential to correctly diagnose what anatomic structure(s) or layer(s) are causing the problem, which is to say that there is no single cookie cutter approach or treatment for the aging neck.

Non-surgical rejuvenation procedures for the aging neck are limited but do exist.  For patients with neck “bands”, and with minimal to no skin laxity or fatty tissue, Botox is an excellent and popular treatment option.  Since Botox works on muscles and because neck “bands” (sometimes called “cords”) are actually a muscle called the platysma (Pla-tis-ma), Botox is extremely effective.  Botox will help temporarily relax and “elevate” the neck “bands” thereby diminishing their appearance.   In contrast to Botox, there are many products advertised and marketed for neck bands that are not effective.  Despite the claims made by these products that are often seen in stores, magazines, and talk shows, neck “bands” can not be eliminated by special neck exercises, shocked away by repetitive electrical pulses, or improved by night time straps or skin care products.  

Many times patients will come in seeking neck rejuvenation by liposuction alone or by heavily marketed treatments such as laser-liposuction wand devices.  There is no question that liposuction has a role in neck rejuvenation, but its role is often over emphasized and over done in many (many) cases.  To understand why this is so some knowledge of neck anatomy is important.  It is easier to understand neck anatomy if you consider the neck in layers.  First there is, of course, the outer skin layer.  The skin layer covers a fatty tissue layer and this fatty tissue layer covers the platysma muscle layer (i.e., the layer causing the “bands”).  Why is this important?

This is important because liposuction, including liposuction by laser-liposuction wands, is done in this fatty tissue layer which covers the platysma muscle (“bands”), and even modest removal of this fat can lead to exposure of neck bands that were once hidden by the fatty layer or even expose neck bands even more.  Furthermore, laser-liposuction wands do not treat neck bands; currently the only way to treat neck bands with any longevity is by a formal surgical neck lift.  Consequently, laser-liposuction is not the “magical” wand for neck rejuvenation as is often advertised.

On a final note, most fullness under the chin and lower neck is more often caused by a different, second fatty tissue layer that resides underneath the platysma muscle (“bands”) layer.  It would be dangerous to remove this fat by any liposuction method without first beginning with a formal neck lift.  By focusing treatment to the deeper fatty tissue layer underneath the platysma muscle, the neck contour can be rejuvenated without exposing the neck bands.  Additionally, the platysma muscle (“bands”) can be simultaneously tightened and this can all be accomplished through a small camouflaged incision under the chin.  Therefore, the neck lift is the safe, more consistent and in my opinion the most effective aesthetic technique for removing excess fatty tissue in the neck, while at the same time allowing for more definitive treatment of neck bands and the elimination of the excess skin, all features seen in most aging necks.

The patient below is a representative example of surgical neck lift.  She also had a mini facelift, fat augmentation, eyelid and eyebrow surgery as well as skin rejuvenation during her neck lift.  The fatty fullness aspect of her neck was located in the sub-platysma layer described above.  That is, the fatty tissue layer below the platysma muscle, a layer  not safely treated with liposuction or laser liposuction devices.  Additionally, only surgical removal of her excess skin would get her this degree of natural looking skin tightening.  Laser liposuction devices can not tighten skin to this degree, not even close in my opinion and experience.

Timothy R. Miller, M.D.

Today’s Blog is going to discuss a unique facial filler I have been using called Sculptra.  For those looking to bring back youthful contours and revitalize facial features, Sculptra may be the right filler for you.

The unique qualities of Sculptra have produced amazing results in Europe for over a decade.  At first, Sculptra was brought to America to correct the facial thinning in those inflicted with HIV.  The stunning aesthetic improvements and overwhelming safety of these treatments led to the FDA approval of this unique filler for cosmetic use in 2009.

To value how Sculptra is different from other facial fillers, a little knowledge of the dreaded facial aging process is helpful.  In actuality, the face begins to show the signs of aging most notably by the loss of facial volume.  This loss of volume in the face is similar to a balloon that loses air or volume.  That is, as air or volume is lost, the balloon becomes lax, sags, and wrinkles.  Unfortunately, a similar unrelenting process is occurring in our faces.

I often educate my patients that the loss of volume is occurring deep to the skin.  Examples of this are the loss of facial fatty tissue, collagen, and even the thickness and width of the bones in our face!  Facial volume truly does give support and structure to the skin, thereby keeping the skin firm around the cheeks, eyes, jaw-line and mouth.  For example, the loss of volume in our temples causes our eyebrows to drop and creates an aged and hollowed appearance to our upper face.   Hopefully, we can now value why maintaining or restoring volume to our faces is so important.

However, most current fillers like Juvederm, Restylane, and Radiesse, are simply gels and are typically placed in superficially in lines or folds, long after facial volume loss has occurred.  In contrast, Sculptra is placed deep in the tissues providing optimal volume correction where it’s needed most and as a side benefit slows the progression of the aging face.  Sculptra works by stimulating your own tissues to produce collagen.  Consequently, Sculptra is considered a new class of facial fillers, known as bio-stimulators.

Sculptra is a non-surgical procedure that is performed only by board-certified facial plastics surgeons at Facial Aesthetic Concepts, Orange County locations.  The results of Sculptra are long lasting, with results lasting at least two years.  I believe the treatments should be performed in a series, with treatment sessions typically spaced every 6 to 8 weeks apart.  Most patients require 3 to 4 treatments to meet their goals.  Some of the main advantages of Sculptra treatments include virtually no downtime, little to no discomfort, and the results are gradual and natural, so friends, family, and co-workers will not know that you’re having anything done.  Consequently, Sculptra has become the most popular filler choice for my patients.

The pictures below are representative of the results achievable with Sculptra.  This gentleman had 4 vials of Sculptra placed in his cheeks and surrounding areas over the course of three treatment sessions.  Noticed how he continues to look natural but more youthful.  The photos have not been altered.

Timothy R. Miller, M.D.

Facial Plastic Surgeon

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