Is Less more?

By staff January 1, 2006

If you believe everything you read or see on television, plastic surgery has become as easy as teeth cleaning. Step into a doctor's office or medical spa, listen to music while doctors train gentle lasers on your face or inject fillers to plump up hollows under eyes, and be ready for a shopping trip with the girls the very next day.

Treatments that don't hurt, require no surgery and have no downtime afterwards are tempting options for a public seeking to look younger faster and with less hassle. With magazine and television reports of new fillers to plump sagging skin and less harsh, yet more effective, lasers to tease away wrinkles, doctors are often confronted by eager patients looking for a nonsurgical answer to aging.

Some of these new procedures help younger patients stave off an actual face lift by several years, and some noninvasive treatments work well in tandem with more serious procedures. However, most plastic surgeons, including the ones who offer the new noninvasive treatments, maintain that there is still nothing out there that can duplicate the results of actual plastic surgery.

"The question is, what are you trying to solve?" asks Sarasota plastic surgeon Dr. Eleanor Barone. "If you have too much skin, sooner or later, you have to go to surgery."

Surgery, says Barone, is more controlled and more permanent, and while a plethora of new procedures may work on surface issues, there is no option for getting rid of excess skin other than surgically removing it.

"I don't believe any machine is going to give you a face lift," concurs Dr. John Fezza of Center for Sight in Sarasota.

However, Fezza is excited about some of the newer treatments that can help soften the blow of aging without undergoing surgery. One such treatment is photodynamic therapy. Fezza explains that this involves pairing an ELOS laser treatment-a combination of intense light and radio frequency-with levulinic acid. When the light source hits the chemical, it becomes activated and attracted to brown spots and red patches on the skin, working to diminish them without the searing effects of traditional lasers.

While ELOS therapy on its own takes five to six treatments to show full effects, Fezza says the photodynamic therapy (ELOS combined with the acid) will do the trick in just one or two sessions.

This sort of combining treatments from a menu of procedures for the ideal result is pretty typical of what goes on in most plastic surgeons' offices nowadays.

"It's no longer a choice between a face lift and no face lift," says Naples plastic surgeon Dr. Stanley Gulin. "In the last 10 years there has been the development of procedures where surgery has become less invasive, with less downtime and good long-lasting results. It's no longer one procedure for the face; there may be half a dozen ways for treating cosmetic deficiencies, from a full traditional face lift to lesser cosmetic treatments."

Injectable fillers are among the cosmetic treatments that interest surgeons. Fezza explains that as we age, we deflate, and thick viscous, fillers (Restylane is an exciting new option) can help the nose, brows and lips look good very quickly. Even Botox can be used in different ways now, such as around the lips and the cords of the neck to fill out and soften.

"The best thing is getting away from lasers than really burn people," says Dr. Marguerite Barnett of Mandala Med-Spa. "There's more natural skin rejuvenation, intense pulse light therapy to stimulate collagen and remove brown spots. The science of skin care is so exciting. There are now patches that deliver medication, various creams for night and day. I'm a living example: I'm 51, and I don't need surgery because of products I started using. They won't tighten sagging skin under the neck, but they can knock a few years off."

Newer procedures range from variable pulse lasers that remove skin imperfections and wrinkles without removing pigmentation to endoscopic surgery, which allows tissue to be lifted upward rather than outward, giving a more natural appearance to the face.

With all the new technologies getting press time, choosing between effective treatments and ones that may have short-term or disappointing results involves some research. It's important to bear in mind that many procedures involve multiple treatments for the best effects and are enhanced with ongoing maintenance plans. Gulin advises potential plastic surgery patients to seek out procedures that have proven track records in medical journals, and recommends that all procedures, even minimally invasive ones, are performed by physicians certified by the American Board of Plastic Surgery, not by other boards from other specialties. Gulin suggests getting referrals to these physicians by calling (888) 475-2784 or going to

"My philosophy is, don't be the first and don't be the last to offer something," says Barnett, who says patients today tend to be smarter, better researchers and stricter about their expectations. "I tend to be more conservative and watch things for a year."

Barnett found the much touted Thermage, for example, to be exciting at first but is now critical about its efficacy. Another much publicized treatment is Contour Threads-a roughly hour-long procedure that involves making a small incision and inserting sutures with tiny barbs that will hold up the skin. While some plastic surgeons swear by the procedure and claim that it can work well on patients with mild to moderate laxity in the jowls, Barnett says she is not impressed.

"Sutures cut through tissues or break or patients will feel them under the skin," she says. "You get what you pay for, not just in terms of a dollar amount, but there does have to be a downtime sometimes. Physicians have to be honest about long-term results or say we don't know [how long a result will last]."

"The real crux of the issue is, there's a lot more emphasis on maintenance and on holding off on surgery," says Barone. "There's a lot of neat stuff with skin care, laser and injectibles that is going to give subtle and ongoing maintenance."

Botox, for example, has to be performed every one to three months the first few times, but as time passes, the lag interval becomes longer, says Barone. Part of the reason that people are drawn to these smaller procedures is because they allow for a subtle transformation that is maintained over time, and the trend now is toward looking more natural-more like a well-rested version of yourself after a relaxing vacation, and a far cry from the tight, "Upper East Side New York look," as Barone describes it.

"The trend is more natural, not hollowed-out eyes like we used to see," she says. "We're trying to get into restoration instead of pulling and flattening."

Thanks to advances in anesthesia and new procedures, many patients are finding that surgery itself is not too bad an option, especially when it's done for smaller, quicker and specialized procedures such as brow lifts or mini lifts. Sarasota resident Teresa, 51 (who didn't want us to mention her last name), underwent a laser treatment in addition to a surgical mini face lift, and says that if she had to do it over again, she would choose just the surgery. The lasers that Fezza used to remove lines around the eyes and mouth healed slowly and uncomfortably, while the surgery turned out to be much easier.

"The actual surgery was a breeze," she says. "I never even had to take pain meds. I never felt uncomfortable, and in a week, I could wear makeup and go out with friends."

"Mini-lifts, tucks, these are here to stay," says Fezza. "Thanks to less and lighter anesthesia, patients are in an awake state, recuperate quicker. The nauseous, spaced-out-feeling-days are gone."

And that's a good thing, because despite all the advances in skin care and noninvasive technology, the only way to remove extra skin is still to cut it out.

Says Barone: "When you see a new laser announced every six months that claims to do this or that, that's because there's no one laser that does everything."

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