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Video Transcript: Facial Plastic Surgery

Part One:

Ellen Beth Levitt: Welcome to Maryland Health Today. I'm Ellen Beth Levitt.

We're all getting older, but don't necessarily want it to show on our face. We're talking about facial plastic surgery today. My first guest is Dr. Thomas Le. He's the director of facial plastic surgery at the University of Maryland Medical Center. He is also an assistant professor of Otorhinolaryngology?Head & Neck Surgery at the University of Maryland School of Medicine. Welcome to the show.

Thomas T. Le, M.D.: Thank you.

Ellen Beth Levitt: You're trained in facial plastic surgery and ear, nose and throat, or otorhinolaryngology as they call it these days, is that unusual, or do a lot of people who do what you do have that ENT training.

Thomas T. Le, M.D.: Yes, it's typical for facial plastic surgeons and most facial plastic surgeons in the United States were previously trained in residency before doing a fellowship in facial plastic surgery. It's mostly natural to have that training, in net, there's a lot of pathologies in the head and neck and lots of major reconstructions in the head and neck that train you for more delicate things down the road. Also, in ENT head and neck surgery training, a full fourth of the training is devoted toward facial plastic surgery during residency training. Up to about half of the training you do is related to some sort of head and neck reconstruction during residency.

Ellen Beth Levitt: Is there a difference in facial plastic surgery and reconstructive surgery?

Thomas T. Le, M.D.: Well, facial plastic surgery is cosmetic and reconstructive. The full title would be facial, plastic and reconstructive surgery. At the University of Maryland, we practice in our division of facial plastics within the ENT department. We practice both cosmetic and reconstructive surgery. And in many ways one helps to train for the other and diversify with the techniques we can do.

Ellen Beth Levitt: There are a lot of options now days for those of us who want to push back the aging process and looking younger, or not looking older, is that true?

Thomas T. Le, M.D.: There's lot of options to bring a person back several years in the way they appear. You see celebrities they are 60 and they look 30 and 40. The technology is there to bring a person back to a better look of yesteryear. Many options, there are surgical and nonsurgical options.

Ellen Beth Levitt: Let's talk about what happens as we age to the face, starting at the top. The forehead. Do people sometimes develop wrinkles in their forehead and in between their eyes? Is that a manifestation of getting older?

Thomas T. Le, M.D.: Yes, and as you get older, the lines start to show through, especially around the eyes, people like to raise their eyebrows and frown with the lines between their eyes and the crow's feet show through that's because of the changes that occur as you age mostly in terms of sun damage and soft tissue volume loss and as well as muscle acting on your skin to form creases.

Ellen Beth Levitt: Do genetics play a role? If your parents look young for a long time are you likely to have that younger look if your parent's faces age quickly?

Thomas T. Le, M.D.: Yes, genetics play a part. You could be blessed with a certain bone or skin structure that predisposes you to looking younger than someone without those blessed traits. Some of the things you might see in some race, some races have thicker skin matrix and they appear young they are age compared to other races. Asians and African Americans have a thicker dermis.

Ellen Beth Levitt: So the key is to have a thicker top part of the skin?

Thomas T. Le, M.D.: Yes, and also, if you were blessed with certain structures to your face, and that's based on your family and whether you were born with nice, high cheekbones or this and that. These things help to support those and they could allow sagging to occur more readily.

Ellen Beth Levitt: What's collagen and what role does that play?

Thomas T. Le, M.D.: Well, collagen is a major protein. And as you get older, some of the matrix regions in your dermis essentially lose volume. and when we use-- collagen was one of the early fillers we used to use to essentially augment lost volume, say in these laugh lines here and here and so on.

Ellen Beth Levitt: Oh, I see.

Thomas T. Le, M.D.: Now days, we have more expensive fillers and much more options.

Ellen Beth Levitt: Let's talk first about something called Botox. We were talking about the forehead and helping to smooth out the wrinkles there and also, perhaps around the eye. What is Botox; it's a toxin, right?

Thomas T. Le, M.D.: It's a toxin, but it's given in a very controlled medically administered format. It's given in very small doses and causes a relaxation of the muscles and there's a video here that demonstrates that. You can see this lady has some pretty obvious frown lines around her forehead and brow area. And so the shot is administered at that spot and relaxes the muscles and you won't make the frowns or eradicate the force that causes the crease.

Ellen Beth Levitt: How long does it last?

Thomas T. Le, M.D.: About five to six months. Some people longer and some shorter.

Ellen Beth Levitt: Do the effects come right away?

Thomas T. Le, M.D.: It usually takes about three days for the manifestation to show and it lasts about five to six months.

Ellen Beth Levitt: Is it safe?

Thomas T. Le, M.D.: Its FDA approved drug for the wrinkles. And so there are the other doses. You can obviously give it in higher doses and those can been riskier because that can potentially spread to other things around the area. In the doses we use, they're small and by in large extremely safe.

Ellen Beth Levitt: And I'm sure with people who have experience doing it, it's safe.

Yeah, you need someone whose board certified and experienced with it. If you put it in the wrong place, you cannot move your eye correctly.

Ellen Beth Levitt: Well, let me ask you, we were talking about the eye area. There's something called a brow lift, what's that?

Thomas T. Le, M.D.: Well, it's simply a procedure and there's a number of ways to do it and a number of approaches to do it. Basically, we have, as we get older, the brow tends to droop, the brow may drop so much it can cause you to appear angry and also cover up over your upper eyelid.

Ellen Beth Levitt: And it affects the upper eyelid skin?

Thomas T. Le, M.D.: Yes, it affects your vision to a certain degree. What we'll do, we would like to improve your vision, but we would like to have the brow at a certain elevation over this orbital rim. If you feel the bone. You can see. It should be here.

Ellen Beth Levitt: What's a centimeter?

Thomas T. Le, M.D.: Well, there are 2.54-centimeters in an inch and 1 centimeter. You do the calculations.

Ellen Beth Levitt: I can't do it. Around 1/4 or 1/2 inch.

Thomas T. Le, M.D.: Yeah, less than 1/4 -- 1/2 inch. so that one centimeter is a typical guideline we like to get the brow to and we would like to add the highest point of the arched brow for a woman to be centered over the outer part of the eye or over the outer part of the pupil.

Ellen Beth Levitt: Wow, there's a lot of thought given to it.

Thomas T. Le, M.D.: Yeah, there are a lot of studies given to it. We're up to date on the latest trends, too. And the trends change over time, there's the look of an eyelid in the 50s compared to what we consider attractive these days. It depends on what the patient wants to look like, too.

Ellen Beth Levitt: Those are surgical procedure, right?

Thomas T. Le, M.D.: By in large, yes and there are nonsurgical brow lifts as well and formalities coming out that are done with radio frequencies now.

Ellen Beth Levitt: Really? When will they be available?

Thomas T. Le, M.D.: We have those available in the office and we can talk about them now or we can talk about them later.

It's just basically an electro current passed through certain tissues to tighten the collagen and it gives you a nonsurgical brow lift. There's nothing better than surgery to give you the best results, but the nonsurgical lifts are a very popular alternative.

Ellen Beth Levitt: I've heard about blepharoplasty, what's that?

Thomas T. Le, M.D.: Well, it's an eyelid plastic surgery. We're changing the shape of the eye. If you have droopy brows, it could cause droopy eyelids and there are also bulges we want to contour down and the video shows that. We make incisions to remove sagging skin that could cause you to look like you have a drooping or sleepy eye. Also, we can get rid of the "bags" under your ice. Is there a particular age when these are most commonly done?

Well, by in large, the largest populations of the eyelid patients notice them at 40, over the hill type of age that everyone seems to think that.

Ellen Beth Levitt: 40, please, that's so young!

Thomas T. Le, M.D.: People at age 40 start noticing the bags even though it's rising to a slow degree over the years. They start coming in around age 40 and up. It's usually a popular procedure around 40, 50, 60s age.

Ellen Beth Levitt: And then, you also did surgery I know for people who have been born with an eyelid that looks irregular or something like that?

Thomas T. Le, M.D.: Right.

Ellen Beth Levitt: It can be done for those reasons as well?

Thomas T. Le, M.D.: Yes, for example.

Ellen Beth Levitt: Here's a patient of yours?

Thomas T. Le, M.D.: Yes, this is an Asian female. She was born with an upper eyelid without a crease in it and in the Asian culture, it's treasured to have a crease there, some people consider it westernization and it's something the Asians treasure, 50% of Asians have the crease in their eyelid, you can see on the right side, we created a crease that didn't exist before.

Ellen Beth Levitt: Nice symmetry.

Thomas T. Le, M.D.: And it gives it a platform so that you can apply makeup.

Ellen Beth Levitt: I want to talk to you about rhinoplasty as well. I know facial plastic surgeons do nose surgery, does this make a difference in someone's life?

Thomas T. Le, M.D.: It does, the nose is in the center of your face and it's the most anteriorly projecting portion of your face. If you change a nose that's drawing attention to itself, basically, the eyes and jaw line come out more. It makes a difference in a person's facial structure. You can see here, a lady had a moderate tip and on the front view, you saw she was wide in the tip and so by making things more petite, she looks better.

Ellen Beth Levitt: Well, she's pretty to begin with, but you enhanced it even more.

Are techniques making the surgeries sort of less dramatic and less of a recovery time?

Thomas T. Le, M.D.: Yes, in the past, back in the 50s and 60s, the studies have shown that some of the techniques aren't the best things, they were more aggressive cartilage cutting procedures and now days, we tend to preserve the cartilage and now you don't have breathing problems afterward. You need that safe guarded.

Ellen Beth Levitt: Exactly, and I notice you added materials to the chin if someone has a smaller chin to make the profile look better.

Thomas T. Le, M.D.: Yes, we do that because that's a part of the face and if it's not projecting enough, essentially, we have a loss of balance and a longer looking lower third of the face.

Ellen Beth Levitt: Well, thank you, we have to take a break and when we come back, we'll talk about new approaches to help our skin look younger, stay with us.

Part Two:

Ellen Beth Levitt: Welcome back to Maryland Health Today, I'm Ellen Beth Levitt. On the show today, we're talking about facial plastic surgery and some non-surgical approaches. Joining us now is Dr. Bryan Ambro, a facial plastic surgeon at the University of Maryland Medical Center. He's also an assistant professor of Otorhinolaryngology?Head & Neck Surgery at the University of Maryland school of medicine. Glad to have you on the show.

Bryan T. Ambro, M.D., M.S.: Thank you very much.

Ellen Beth Levitt: Now, we were talking earlier with dr. le about the different procedures and he mentioned some of the filler materials that people can use to sort of erase lines called restylane and so forth. Could you tell us about those and how the materials improved a little bit?

Bryan T. Ambro, M.D., M.S.: Well, the older fillers are replaced by longer lasting fillers like restylane and other types of fillers, which is a substance found in the bones of your bodies as well as other fats can be placed in your face to plump up and fill in the areas of wrinkles and areas hollowed with age, as we age in the face.

Ellen Beth Levitt: Are they safe and how long do they last?

Bryan T. Ambro, M.D., M.S.: Well, yeah, certainly, we wouldn't put anything in anyone's face that wasn't safe. Depending on the material, it can last between 6 and 18 months. The acid filler's less than that. The facial, the fat transfers in some places can be permanent.

Ellen Beth Levitt: Now I've heard that there are treatments that use radio waves to try to sort of tighten the skin a little bit so the wrinkles aren't as pronounced, is that true?

Bryan T. Ambro, M.D., M.S.: Correct, there's newer technology that uses a small, noninvasive hand piece that sends a small amount of energy into the lower portions of the skin that dr. le talked about. That collagen plumps out and fills in the skin and tightens some of the laxity that we see with the aging of the skin as well.

Ellen Beth Levitt: We're seeing an example of that right now?

Bryan T. Ambro, M.D., M.S.: Yes, this is the device that's being used to kind of tighten some of the laxity underneath the chin area, and this is--typically, in this area, it takes 15 to 30 minutes depending on how large the area is.

Ellen Beth Levitt: How many treatments do you need?

Bryan T. Ambro, M.D., M.S.: Well, everyone's skin is different, but on average, five to eight treatments. Given a few weeks apart and this can set back the aging clock a little bit and it won't stop the clock from advancing forward and after the treatments are done, we'll have people come in for a touch up to offset the aging that occurs.

Ellen Beth Levitt: Is this new?

Bryan T. Ambro, M.D., M.S.: Well, the original machines came out about four years ago or so and some of the newer machines that we saw in the video have a lot of software, fine tuning type of things that make it safer, certainly the most important thing, faster and it's easier to use.

Ellen Beth Levitt: Well, it looks noninvasive.

Bryan T. Ambro, M.D., M.S.: Well, I tell people it's like someone snapping their finger on their skin. People will come in during their lunches and go back with no down time at all.

Ellen Beth Levitt: Now, lasers have been around for a long time. What role do lasers play in helping the face look younger?

Bryan T. Ambro, M.D., M.S.: Well, there are a lot of different lasers. The one that we use for the skin are the co2 lasers that are used to remove the top layer of the aged skin and stimulate the production of collagen underneath. Some of the older ones were quite aggressive and this video here showing newer fractional co2. It less aggressive and gives good results with a lot less down time.

Ellen Beth Levitt: Down time meaning recovery time so that you don't look unusual?

Bryan T. Ambro, M.D., M.S.: Well, it can take a few weeks for the older techniques to heal the skin, but with this, it can be three to five days. If you have it done towards the end of a workweek, you'll be back on the following Monday.

Ellen Beth Levitt: It looks like it was breaking up the skin and making bubbles and dots.

Bryan T. Ambro, M.D., M.S.: That's what it's doing, actually. Just small amount of laser energy through the skin and stimulating the collagen and it removes pigments like sun spots and aging spots.

Ellen Beth Levitt: Can people wear makeup after it's done?

Bryan T. Ambro, M.D., M.S.: Normally, after that three to five day recovery time, it needs to heal first before you apply makeup on. Within a week, you can put it back on. Is that safe?

Bryan T. Ambro, M.D., M.S.: It is. The side effects are minimal and some of the darker skin types, you can see a loss of pigment and that's certainly less than 1% of the patients that we treat.

Ellen Beth Levitt: Okay. You also performed surgery in addition to doing these less invasive treatments. Tell us about the facelift, do people still get facelifts these days?

Bryan T. Ambro, M.D., M.S.: They sure do. It's the gold standard of rejuvenation of the lower face and neck for people that have the laxity here in front of the jaw line and the muscle banding you see here, that's the typical procedure that we recommend for those types of problems.

Ellen Beth Levitt: So it's not for someone with just a lot of wrinkles around the eyes?

Bryan T. Ambro, M.D., M.S.: Correct, it's for around the lower face and neck.

Ellen Beth Levitt: And what's done?

Bryan T. Ambro, M.D., M.S.: Well, the incisions are in front and behind the ears and you can have a small incision here and just the laxed muscles of the face and the skin laxities, they lifted and tightened into a more youthful position.

Ellen Beth Levitt: Do men as well as women get facelifts these days?

Bryan T. Ambro, M.D., M.S.: They do. We see a lot of men. It's more accepted in the community now and more men are coming in for these types of procedures and they want to look young and stay competitive with the people in the business world.

Ellen Beth Levitt: How long does it take to recover from a facelift? How long do you stay in the hospital and how long before you are looking sort of more yourself and ready to get back to things?

Bryan T. Ambro, M.D., M.S.: Well, most people go home the same day; some prefer to stay overnight, if that's their comfort level. There are different types of facelifts. Everyone's faces are aging different, different people will require more of less of a lift. There's bruising that can come down and normally, within two to three weeks, people are back up and about and able to put makeup on and feel like themselves again.

Ellen Beth Levitt: Years ago, people used to laugh about facelift; it looked like someone was in wind tunnel and their face stretched really tight. But things are different now, right?

Bryan T. Ambro, M.D., M.S.: They have, they have. The facelift is excellent for lifting the skin and muscle which are two, really, the four things that our face ages. Some other areas of the face can be the fat and the bone itself and they can shrink down and the facelift won't address that. if you had a person that lost the volume and youthful look to their face? and you're lifting and tightening, but not really restoring that lost volume you can get kind of an unnatural appearance and sometimes it doesn't look right.

Ellen Beth Levitt: Now day, you have techniques to make people look --

Bryan T. Ambro, M.D., M.S.: Absolutely. We have fillers and things to restore the other areas of the age. It gives you a more youthful appearance.

Ellen Beth Levitt: We have 30 seconds left, is anything on the horizon?

Bryan T. Ambro, M.D., M.S.: Yes, it's a great time for facial plastic surgery. There are a few techniques for tissue engineering that we would love to see in the future of the development of the tissues we can use. Growing tissues.

Ellen Beth Levitt: You mean using your own tissues to fill in wrinkles?

Bryan T. Ambro, M.D., M.S.: Absolutely. I think there's very; very promising future for these things and it's exciting to see these things coming forward.

Ellen Beth Levitt: Right, and as the baby boomer generation ages, there will be more and more people interested in these things, I'm sure.

Thank you for joining us. My guest has been Dr. Bryan Ambro. He's a facial plastic surgeon at the University of Maryland Medical Center and an assistant professor of Otorhinolaryngology?Head & Neck Surgery at the University of Maryland School of Medicine. We would also like to thank Dr. Thomas Le, who was our guest in the first half of the program.

If you have any comments or questions about our program, send me an e-mail. The address is eblevitt@umm.edu.

To reach Dr. Ambro, Dr. Le or any other University of Maryland physician, call 1-800-492-5538. Or visit the web site, where you'll find a great amount of health information and see other Maryland Health Today shows. That web address is www.umm.edu.

Take good care of yourself.

We'll see you next time for Maryland Health Today.

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This page was last updated on: March 6, 2009.

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