Until recently the traditional plastic surgery operation called blepharoplasty has been the “Gold Standard” for rejuvenation of the eyelids to remove puffiness or lower eyelid bags, loose skin and hooding of the eyelids.

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More recent advances have included the use of the CO2 laser instead of a scalpel for blepharoplasty with a resultant decrease in the amount of bleeding and bruising and thus a shorter recovery. In addition, transconjunctival blepharoplasty, a technique done through the inside of the lower eyelid has improved results by avoiding an incision on the outside of the lower eyelid preserving eyelid support and natural shape. More recently, an internal eyelid ligament release called an arcus marginalis release, combined with fat grafting, has allowed plastic surgeons to permanently remove dark circles under the eyes. It is safe to say that in 2006, plastic surgical eyelid rejuvenation techniques are better, more effective, and when properly done by an experienced plastic surgeon more safe than ever before.

However, patients’ desire to avoid surgery coupled with advances in non-surgical technology, and also influenced by the vast number of physicians with no surgical training entering the field of “aesthetic medicine”, have resulted in many new non-surgical applications in the field of eyelid rejuvenation. While some non-surgical techniques have been dramatically successful e.g. Botox, many others are being marketed to patients and offered to patients before safety and effectiveness have been proven in clinical studies.

Two such techniques being promoted today are of concern to me.

The first is the use of soft tissue fillers to correct dark circles under the eyes. Many physicians are now injecting fillers like Restylane, Radiesse, Sculptra, Cosmoplast, Cosmoderm, Hylaform and others into the dark circles under the eyes to plump the dark circle. While acceptable cosmetic results can be achieved, the risks of injury to the eye are unacceptable, not only in my opinion, but the opinion of the manufacturers of the fillers. Companies that make the fillers recommend that the fillers not be injected around the eye. Unfortunately many doctors are not heeding these warnings, I assume out of ignorance of the vital structures that lie beneath the eyelid and can be damaged by the needle, or lack of concern for their patient’s safety. Blindness has been reported following the injection of a filler around the eye. If you would like to read the unfortunate experience of many patients who have been injured by filler injections around the eye check this link.

The second technique that concerns me is the non-surgical blepharoplasty or eyelift performed by using a radiofrequency skin-tightening machine on the eyelids, directly over the eyeball. Astoundingly the demonstration on a web link showed a doctor performing this procedure with no eye protection for the patient. Radiofrequency is a high-energy heat source that shrinks skin by heating the deep dermis. Sophisticated cooling devices are used to cool the skin as the radiofrequency energy passes through the skin so that the skin is not burned. Were the eye exposed to radiofrequency energy the eye could be severely injured. Thermage, one such radiofrequency skin-tightening device has already been shown to melt fat beneath the skin resulting in permanent defects or depressions in the skin. I am concerned about the effect of such high-energy heat on the delicate eye structure and the fat and muscles beneath the eyelid. While the device called Aluma can be safely used on the eyelids and peri-occular skin, it is important that the skin be pulled away from the eyeball against the bony orbit and not directly over the eyeball, in my opinion.

Unfortunately it is up to you, the patient to educate yourself and avoid unproven, risky new techniques that promise the miracle of non-surgical eyelid rejuvenation or blepharoplasty. Your safest course is to consult an expert. Seek the advice of an experienced board certified plastic surgeon when considering eyelid rejuvenation, blepharoplasty or eyelid lift. An experienced up to date plastic surgeon will be aware of which non-surgical facial and eyelid rejuvenation techniques work and are safe. Avoid the hype and marketing-if it sounds too good to be true it usually is. With thousands of physicians with no plastic surgical training entering this field every year these are dangerous times. Do not pay to become an experimental subject. Caveat Emptor. For further information contact me or read Save Your Face.

Dr. Brooke Seckel.

Boston, Massachusetts

So far patients have reported visible lumps on the eye and cheek area and significant swelling of the eyelids and have been told by their Doctors that nothing can be done to correct the problem. I fear much more serious complications such as injury to the eye.

Eyelid rejuvenation, that is correction of puffiness or bags of the lower eyelid and dark circles under the eyes are one of the most frequent complaints of patients seeking plastic surgery. The most effective and commonly recommended options to correct aging of the eyelid is a plastic surgery operation called a blepharoplasty . When properly performed by an experienced board Certified Plastic Surgeon on an appropriately selected patient, the blepharoplasty can safely produce excellent rejuvenation of both the upper and lower eyelids.

Many people however want to remove dark circles under the eyelids and rejuvenate the eyelid appearance but want to avoid surgery and are having soft tissue filler injections into the eyelid to plump up the dark circles. The theory is that if soft tissue filler is injected beneath the dark circle, the filler will plump up the dark circle and make it less noticeable. The technique can be successful but it is a temporary solution unlike blepharoplasty, which is a permanent solution.

The problem however is that soft tissue filler injection into the eyelid is, in my opinion, a potentially very dangerous procedure, and the companies that make the soft tissue fillers recommend against it.

The major risk is that the filler could be inadvertently injected into one of the blood vessels that feed into or drain the eyeball and if this were to occur the eye could potentially be injured and blindness could result. Worse, an inexperienced Doctor could inadvertently inject the filler directly into the eye causing serious damage.

In some cases the doctors who are doing soft tissue filler injections into the eyelid have had no training in surgery of the eyelids and do not possess the intimate knowledge of eyelid anatomy that is required to be doing invasive procedures on the eyelids. Even Ophthalmologists, the eye specialists use special care when injecting with needles around the eye.

The soft tissue fillers that are currently in use include Collagen, Zyderm, Zyplast, Hylaform, Perlane, Restylane, Radiesse, Sculptra, Cosmoplast, Cosmoderm, Evolence, and others.

Perhaps in the future controlled clinical studies will be reported which show the benefits and safety of injecting soft tissue fillers around the eyelid. For now, however, the reports I have had from patients who have had complications following this technique are an early warning and should be heeded.

I recommend that patients avoid this technique. If you have dark circles and puffiness under the eyes see a Board Certified Plastic Surgeon and get an expert opinion on the best procedure to obtain the result you want. There are non-surgical eyelid rejuvenation procedures available which are safer than the fillers. If you feel that you must have a filler injected into the eyelids then by all means see a board certified plastic surgeon or occuloplastic surgeon who has experience and knowledge in eyelid anatomy and surgery. If you have a complication you want to be under the care of an experienced Doctor who can take care of the problem. For further information read Save Your Face or contact me by email.

Dr Seckel,

Boston, Massachusetts

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While Plastic Surgery is truly a much more comprehensive field including reconstructive surgery following burns, cancer surgery, and birth defects, the image most often projected in the media is that of image or beauty enhancement and non-surgical and surgical facial rejuvenation of otherwise normal people by surgery.

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Revolutionary technological advancements in the past decade have significantly impacted the field of Plastic Surgery creating a shift from traditional surgical procedures to new non-surgical methods for correcting aging changes and improving appearance.

Laser Resurfacing-Contact Dr Seckel

Today Botox® injections can remove crow’s feet, frown lines, worry lines, and help lift the sagging brow. Prior to Botox® major facial surgery such as a brow lift and blepharoplasty (eyelid lift) were performed to correct these aging changes.

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New fillers such as Restylane® and Radiesse® are injected into the nasal-labial fold, lips, and marionette lines, those deep lines running from the lips down around the mouth and chin. Previously, a face lift was performed to correct these lines.

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Skin tightening technology such as aluma, ActiveFX, LuxIR, Titan® and Thermage® are becoming better and can improve facial sagging in 30% patients if used early before the sagging is severe. Many patients choose to have one of these techniques rather than a face-lift. Many other new exciting techniques for laser restoration of skin collagen (Laser Genesis®) and improvement in skin wrinkling, removal of pigment, and removal of red spots and blood vessels on the face are already in use today.

These dramatic advances coupled with increasing public awareness of the importance of sun protection, a healthy anti-inflammatory diet, exercise, stress reduction, and a healthy lifestyle undoubtedly will impact the Plastic Surgery practice of the future. The Plastic Surgeon of the future will still have to be a highly skilled, knowledgeable surgeon, but I predict he/she will need to be an expert in the newer laser, light, pharmacological, and lifestyle therapies as well.

Plastic Surgery is becoming more non-surgical with every new technological advancement. The 6-step facial rejuvenation program encompases all the new non-surgical facial rejuvenation techniques. For questions read Save Your Face, or contact me.

Dr Seckel

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A startling 12.4 million cosmetic plastic surgey operations were performed in this country last year and estimates are that nearly half of them were to correct facial aging and this does not include the millions of non-surgical facial rejuvenation procedures.

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As the baby boomers reach their 50’s everyone wants to look younger but no one wants to have surgery. Most people do not want to have surgery especially if it is not for serious medical reasons.

However, revolutionary advances in technology have made it possible for many people to reverse facial aging changes using new non-surgical facial rejuvenation techniques without having to undergo plastic surgery.

This past Wednesday, September 28, 2005, I spoke on a panel entitled Non-surgical Facial Rejuvenation at the meeting of the American Society of Plastic Surgeons in Chicago, Illinois. My topic was Botox, the soft tissue fillers including Restylane and Radiesse and the many skin peels used for exfoliation to remove wrinkles and signs of facial aging. I came away from that meeting very excited and enthused about all the wonderful new non-surgical facial rejuvenation therapies that are safe and effective for patients today.

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There are so many new wrinkle removing and skin tightening non-surgical facial rejuvention options available that the patient must understand exactly what facial aging change it is that they want to correct. Usually the patient just feels that their face looks older but cannot pinpoint exactly which facial aging change is causing concern. It is important to seek consultation with an experienced board certified Plastic Surgeon or Dermatologist who understands all the options so that the correct option is chosen for your very unique face. I advise you to avoid doctors who only do one or two facial rejuvenation procedures and tend to push patients to have the procedure that he/she performs rather than customizing the procedure to the patient’s needs.

The 6 Step Facial Rejuvenation Program™ consists of:

Step 1-Exfoliation-topical cremes, microdermabrasion, superficial skin peels with various fruit and salicylic acids to produce exfoliation to freshen the skin and give it a youthful glow and remove wrinkles. These treatments also stimulate the skin to form new collagen to replace the old damaged aged collagen, and help rejuvenate and tighten the facial skin.

Step 2- Stimulation of new collagen production- Controlled inflammation of the deep skin layer called the dermis causes the dermal skin cells called fibroblasts to manufacture new collagen to replace the collagen lost by sun damage and aging. Topical RetinA and the deep exfoliative process in step 1 start this process. Newer technological interventions like the Lux1540, Fraxel, Lux294o, Sciton Profractional, and Lumenis bridge therapy are powerful stimulators of new collagen production.

Step 3-Remove pigment and red spots-In addition to exfoliation new light and laser therapies such as IPL, Photo facial, Lux1540 and Fraxel® can be used to remove brown spots, pignent, broken blood vessels called telangiectasias, and rosacea from the facial skin. Pigment and blood vessels are a classic sign of facial aging and the non-surgical removal of these skin discolorations provides noticeable facial rejuvenation. These high tech yherapies can also remove wrinkles.

Step 4-Remove lines of facial expression wrinkles- Botox can be used to relax the muscles of facial expression and remove crow’s feet, worry lines, frown lines, and bunny lines and dynamic wrinkles, all of which are very early signs of facial aging. Botox® effectively removes these lines in most people for 6 to 9 months after a simple nearly painless injection.

Step 5-Fill deep facial lines called the nasolabial fold lines and marionette lines make the face look tired and old and coupled with the frown lines often make people look angry. Deep facial lines are deeper than wrinkles, and I do not use fillers for wrinkle removal. New soft tissue fillers can soften the nasal labial fold lines and marionette lines when they are injected into the skin beneath the aging lines. Commonly used soft tissue fillers are Restylane, Radiesse, Zyderm, Zyplast, Juvaderm, Sculptra®, Fascian®, Cymetra®, and Isolagen®. Each of these fillers has different characteristics and are better for some facial aging changes than others. For a thorough discusion of fillers consult Chapter 7 “No Down Time Facial Anti-aging Procedures” in Save Your Face, available on line at www.saveyourface.com.

Step 6-Skin Tightening. The final facial aging change to treat is loose sagging skin. While the plastic surgical operation called a facelift is still the “gold standard” for facial rejuvenation, several new technologies are evolving which can tighten aged facial skin. LuxIR and Titan®, devices using infrared waves, and Aluma and Thermage® which use radiofrequency waves, are all being used to heat the collagen in the deep layers of the skin called the dermis causing the collagen to shorten and tighten the skin. While these technologies are new and only about 30% effective and require multiple treatments, they will most certainly be improved in the future and effective skin tightening of aging facial skin will be possible. Some wrinkle removal is seen following successful skin tightening.

Non-surgical facial rejuvenation is here and is getting more effective as new products come out every month. One of my common expressions whenever I speak about the new non-surgical options for facial rejuvination is “plastic surgery is becoming non-surgical” and try to encourage my fellow plastic surgeons to embrace the new technology. I still believe that an experienced board certified plastic surgeon is the best doctor to provide the non-surgical facial rejuvenation procedures to patients because these doctors are the facial aging experts and they have the ability to do what is necessary for the patient whether it is Botox or a facelift. Each face is unique and a “one size fits all” approach just does not work in facial rejuvenation.

Contact me for more information on any of the above procedures, or read Save Your Face.

Dr Seckel

Boston, Massachusetts