Dr. Larry Nichter featured in Time Magazine’s Article “Nip. Tuck. Or Else.”

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Hitting newsstands today and Monday is an interesting article featuring Dr. Nichter and his patient, written by Joel Stein for Time Magazine, discussing the evolution of cosmetic surgery and it’s undeniable relevance in today’s world. The article titled “Nip. Tuck. Or Else” points out how thanks in part to social media we are now on the red carpet 24/7 posting pictures of ourselves on Facebook, Instagram, SnapChat, Vine, and more, so it’s imperative to look our best at all times. The social media frenzy is one reason why there has been a spike in the number of non-invasive procedures performed on the younger demographic.  It can certainly be said that no longer are cosmetic procedures just for the aging population.

Here is the full article – Nip. Tuck. Or Else.”

by Joel Stein 

Time Magazine Plastic Surgery Shoot You’re going to have to do it. And not all that long from now. Probably not a full-on, general-anesthesia bone shaving or muscle slicing.

But almost definitely some injections into your face. Very likely a session of fat melting in some areas and then possibly moving it to some other parts that could use plumping. Not because you hate yourself, fear aging or are vain. You’re going to get a cosmetic procedure for the same reason you wear makeup: because every other woman is.

No, it’s not fair that–in 2015, with a woman leading the race for the Democratic nomination for President–in addition to dieting, coloring your hair, applying makeup and working out, you now have to let some doctor push syringes in your cheeks just to look presentable. It’s not fair that you have to put your surgery on your credit card just so the other moms on the playground don’t overestimate your age. It’s not fair that you may risk your life going under general anesthesia just to keep up.

Then again, maybe it’s not fair that some women are born straight-nosed and full-breasted. That some people don’t have trouble staying thin. That workers with above-average looks will make $230,000 more over their lifetime than people who are in the aesthetic bottom seventh, as a study by University of Texas economics professor Daniel Hamermesh found. Maybe it doesn’t feel fair that a man is writing about this, even if more and more males are starting to feel the same kind of pressure that women have dealt with for decades.

“It’s becoming harder and harder to say no without being read as irrational or crazy,” says Abigail Brooks, the director of women’s studies at Providence College, who recently completed research comparing women who undergo antiaging interventions and those whom she calls “natural agers.” The former group described the latter using phrases like “let herself go” and “not taking good care of herself.” Brooks worries that that pressure is not only exhausting but also keeps women forever 21 emotionally. Continue reading “Dr. Larry Nichter featured in Time Magazine’s Article “Nip. Tuck. Or Else.””

The “Skinny” on Non Invasive Body Contouring and Fat Reduction

Dr. Larry Nichter
Dr. Larry Nichter

Body contouring techniques can be separated into non-invasive and invasive techniques.

Liposuction, though “invasive”, still remains the gold standard in body contouring. The procedure uses small suction cannulas sometimes assisted by lasers, ultrasound, propulsive jet sprays, radiofrequency energy or vibrational movement (power-assisted liposuction) to actively remove fat by suction from localized areas of fatty accumulation. Liposuction, also called suction assisted lipectomy or “lipo”, is still by far the most successful and predictable way to quickly, safely and effectively create the contouring figure that you desire. However, compared to non-invasive techniques there is some risk, increased recovery time, and discomfort associated with liposuction. Less invasive techniques involve inserting a Radiofrequency (RF) probe (e.g. ThermiRF™ to melt fat for smaller areas without liposuction, but still has more risk than non-invasive techniques). This has led to the growth of non-surgical, non-invasive body contouring.

Non-invasive body contouring technologies use an energy delivery system to injure, destroy, “convince cells to die slowly over time” or alter the architecture of the fat cells without any incisions or placing any device under the skin, and without performing any surgery. Other techniques that are evolving include injecting a substance to reduce fat (Kythera®, FDA approved to reduce fat under the chin).

The common non-invasive energy types utilized to create non-surgical body contouring include RF, focused ultrasound, infrared, RF-coupled suction and massage, and diode laser energy. These non-invasive energy sources that reduce areas of enlarged fat concentrations such as tummy, hips, thighs, and the back — reducing fat without harming other structures like nerves and blood vessels. Some are more effective than others. For example, Zerona® claims that its cool diode laser has a generalized “whole body” slimming technology by making fat cells leaky rather than using thermal mechanisms or cavitation energy to alter or break apart the fat cell. To scientist physicians like myself, it is hard to believe that low level cool laser light waves will be able to penetrate more than a millimeter or two, much less where the majority of the fat lies. It is no wonder that at the time I write this it is ranked as only having 28% satisfaction rating on RealSelf.

On the other hand, there are many effective non-invasive fat reduction technologies available.

CoolSculpting® is effective but has some discomfort noted by many patients, and the applicator paddle sizes can only treat a few areas at a time, require several treatments (3–5), have to wait between treatments, and takes several weeks to see the full effect and occasionally fat ridges are seen above the treated areas.

UltraShape® by Syneron Candela uses focused ultrasound energy, can treat at three different levels, and the different size applicators can treat just about anywhere on the body and even do lipo-sculpting. It is painless and the results are seen quickly with treatments a few weeks apart (series of 3 is typical, more depending on desires may be recommended). It is great for localized areas.

BTL Vanquish uses RF energy to heat the fatty layer precisely, painlessly and selectively to a temperature that causes fat cells to undergo early cell death (apoptosis) by destroying the integrity of the fat cell. Like other techniques that accomplish the same effect, the body then clears the remnants by the lymphatic system.

The VelaShape III, is new technology and much more effective than its predecessors (VelaShape I and II). It is a non-invasive body shaping device used to reduce cellulite, and reduce (slim) the area around the tummy, back, hips and thighs. The machine combines four different technologies — infrared, bi-polar RF, pulsed vacuum, and massage rollers — to improve skin texture and reduce the overall volume of the treated area. It is often used alone for cellulite reduction but often used in conjunction with the other devices I mentioned to magnify their efficacy by smoothing and warming the tissues and clearing much of the edema and fat breakdown products using as an advanced lymphatic massage device. Please note RF devices cannot be used for patients with pacemakers.

For large areas of troublesome fat collections as well as specific areas of focal fat and accumulation you may be best served by the various forms of liposuction. The non-invasive focal fat contouring technologies now in the market place may not be as effective, but have reduced risk and recovery time. Deciding between these options should be done on a case-by-case basis between patient and physician.

Achieving Your Best Appearance with the Sciton Laser

Dr. Larry Nichter
Dr. Larry Nichter

As you age, skin cells lose their ability to make collagen and progressively die off rather than reproducing themselves (“DNA programmed cell death with age”).The Sciton Laser Platform allows multiple laser types and wavelengths to achieve both dramatic improvements of your skin but also maintaining its youthful appearance by reversing this process.

Here are some of the incredible treatment options available:

Forever Young BBL (Broad Band Light) Optimally delivers and visible light of many wavelengths to the epidermis and dermis. This increases the lifespan and ability of skin cells to produce more collagen and elasticity similar to a more youthful cell by making changes at the DNA level. A Stanford University Groundbreaking Research Study, the first of its kind , demonstrated that BBL treatments can restore gene expression pattern of aged human skin to resemble young skin. Results: Over 1,000 gene expressions became “rejuvenated” to be more like youthful skin resulting in more elasticity and more uniform collagen deposition; leading to improvements in fine wrinkles and pigmentation. – This increases the lifespan and ability of skin cells to produce more collagen and elasticity similar to a more youthful cell by making changes at the DNA level. Clinically the skin looks and feels smoother and more youthful.

In addition to the BBL using the SkinTyte settings also Optimally delivers Infrared and visible light to the epidermis and dermis. Infrared light is used to heat the dermal collagen which responds by becomes thicker. This in turn reduces wrinkles and causes skin firming. Typically a series of treatments weeks apart give the best results and maintained with yearly treatments. The best news is that there is no down time and easily tolerated with by itself or with topical anesthetics.

Additional filters and adapters allow selection of specific frequencies of the broad band light to treat specific problem areas. For example the smaller wavelengths are great for acne, vascular and pigmented spots like broken capillaries and red spots, rosacea, sun and age spots where some of the longer wavelengths can be used for darker skin types. A built in special temperature controlled Thermoelectric cooling at the treatment area decreases discomfort greatly

Skin Tightening with Sciton® SkinTyte

SkinTyte is the newest Sciton laser technology to tighten and firm skin without downtime.

Common conditions that benefit from this therapy include:

  • Sagging skin face jowls
  • Smile lines
  • Sagging skin on the neck, arms, abdomen, legs, and knee

SkinTyte is safe for all skin types and can be performed on any area of the body.

Frequently Asked Questions About Skin Tightening Laser Treatment

The Sciton SkinTyte system tightens the skin in the following manner:

The Sciton SkinTyte system delivers infrared light deep into the dermis. The heat from the special light:

  • Causes the collagen and elastic fibers to shrink and thicken. This process stimulates the deeper tissues to remodel collagen. The remodeled collagen responds by filling in wrinkles and restoring elasticity to sagging skin.

The powerful cooling system maintains the outer surface of the skin at cool temperatures before, during, and after each pulse making the treatment comfortable and safe with no downtime. The SkinTyte technology can be applied anywhere on loose skin, from your face to your legs. The best results come in the face and neck area, especially the:

  • Cheeks
  • Jowls
  • Nasolabial folds

SkinTyte laser treatment can also help tighten and improve the appearance of loose skin on the:

  • Arms
  • Breasts
  • Abdomen
  • Knees

It has proven beneficial in post pregnancy or after significant weight loss.

The Sciton SkinTyte system technology is FDA-approved and documented to be safer and more comfortable than the bulk heating approach of other systems because it is highly selective and more advanced in targeting collagen and elastic fibers in your loose skin.

Patients experience mild redness in the treated area immediately after treatment. This will last only a short time.

SkinTyte: Since the SkinTyte procedure is noninvasive, you can resume your normal activities immediately following treatment. There will be minimal discomfort during the SkinTyte laser procedure and topical anesthetics and local cooling will minimize any discomfort. The Sciton BBL hand piece has a large cooling sapphire crystal that keeps the skin cool and protects against discomfort. In addition, a range of energy and adjustments can be made to your comfort. The more energy you can tolerate, the better the results will be. During your treatment, there will be heat applied specifically to the dermal skin layer and you may feel a slight sunburn effect. Immediately afterwards, a tight feeling may be noticeable but no significant discomfort will be felt.

The SkinTyte system is the most advanced tissue tightening device available on the market today. A tightening effect will be visible immediately and skin will continue to firm throughout the month. A series of three to five treatments at four to six week intervals will deliver the most noticeable results of smoother, tighter skin. Improvements in the skin’s elasticity will continue over the next six months.

The Sciton MicroLaserPeel focuses on removing a thin layer of damaged skin to improve texture and provide a more youthful appearance. Being a laser it provides superior results by controlling precisely the depth of the laser. The procedure is performed our office and is custom tailored to your specific skin conditions and desired outcome with minimum down time.

Here is a synopsis of the procedure: The MicroLaserPeel’s beam is scanned over a treatment area to remove a very thin layer of the problematic skin. Removing the top layer eliminates some of the damaged cells that can give skin a tired, aged look. As the skin heals, fresh cells grow and resurface the treated area. This results in a healthier appearing skin, with reduced fine wrinkles and improved texture with color evenness. From tired looking skin to vibrant is the expected outcome. Depending on the depth of treatment the recovery time is usually 3-4 days (“week end peel”).

The following conditions can be treated with MicroLaserPeel:

  • Mild wrinkles
  • Scars
  • Keratosis (scaling lesions)
  • Sun damage (e.g. sun/age spots, freckles)
  • Pigment irregularities (dyschromias)

Most skin areas can be treated with the face, neck, chest and back of the hands most commonly treated. Your laser specialist will determine. under our Plastic Surgeon’s protocol, the best treatment choice and schedule for you to look your best. Both improvement and maintenance of your results will be discussed. These procedures can also be coupled with filler injections or Botox/Dysport if required or desired to complement your non-surgical rejuvenation.

Larry S. Nichter, MD, MS, FACS

How to get the best Neck Lift result

Best Neck Line Improvement Requires Best Neck Lift Options and Best Plastic Surgeon

Dr. Larry Nichter
Dr. Larry Nichter

Neck Lift is a general term relating to procedures that will improve your neckline. There are many possibilities so picking the best neck lift treatment(s) for optimal improvement is most important. A board certified plastic surgeon with a special interest and substantial experience in neck lift and lower face lift surgery is the place to start. The reason for a plastic surgeon is that he/she can offer all possible options and tell you specifically which ones are best for you. Click here for tips on finding the best plastic surgeon.

The best recommendations to improve your neck appearance depend on your needs, desires, and most importantly an examination to determine the best procedure for you. Your plastic surgeon will evaluate you for five main features that will determine your best options for neck line improvement:

  1. Amount of excess fat typically found beneath the chin, and in the upper neck. This requires liposuction with small cannulas or direct removal especially if the fat is beneath the platysma muscle.
  2. Presence of Significant (Platysmal) Banding – this requires bringing the muscles together in the upper/mid neck to a more youthful position and occasionally their release. This procedure is called a platysmaplasty or platysma plication. Mild banding can be treated non- surgically with Botox or Dysport but this requires injections 3-4 times a year for maintenance.
  3. Amount of excess/redundant skin (cutis laxa) and condition of your skin. In advanced stages this is called a Turkey Waddle or Gobble deformity. For example, younger age, darker skin colors and no large weight loss history most likely means there will be better elasticity and therefore better post-surgical contraction. In milder cases if not too much fat is present there will be enough skin shrinkage with just lipo alone. Mild to minimal skin tightening using non-surgical means like the Sciton Laser SkinTyte procedure, Ultherapy or Thermage could also be considered. My personal preference for non-surgical skin tightening of the neck is the Sciton Laser BBL SkinTyte® procedure as there is no down time, more comfortable procdure, is effective and is a more targeted treatment. For redundant upper and mid excess neck skin: I prefer the LiteLift® (lower facelift ) procedure or MACS for skin re-draping for mild to moderate excess skin management as there are minimal scars and the skin is lifted vertically allowing for minimal hidden scars resulting in a natural appearance “non pulled” appearance. However: for moderate to severe skin redundancy , a neck lift or traditional lower facelift (e.g.Lite Lift®, MACS and others) is needed with or without lipo for best results. For advanced Turkey Waddle correction wither a traditional facelift or posterior neck lift often with a platysmaplasty is required with more extensive scars that extend at the hairline behind your ears. The advantage of a facelift procedure rather than a posterior neck lift is that your lower jawline (e.g. jowls and marionette lines) are also improved at the same time.
  4. Chin deficiency. If you have a weak chin then you will not have adequate chin support to your neckline skin which affects your entire neck line. Sometimes especially in younger individuals this is all that is required and this can be done in the office under local anesthesia. There are a number of different sizes and shapes and your plastic surgeon will pick the optimal one for you.
  5. Presence of prominent Digastric Muscles or Submandibular gland fullness from laxity or enlargement. Although not a major concern for most patients, if present then partial resection is usually the best solution.

In summary, picking the most qualified and best plastic surgeon with the most experience in neck improvement is essential to ensuring that you will have a wonderful and lasting result. It is the plastic surgeon’s ability to evaluate both your anatomical features and aesthetic goals to guide you to one or more neck lift procedures to give you the best neck line possible.

Larry Nichter, MD, MS, FACS

Fat Grafts to Face, Buttocks, Breast and Elsewhere

Dr. Larry Nichter
Dr. Larry Nichter

A person’s own fat may be used to improve the appearance of his or her body by moving it from an area of excess (or where it is less desired, such as the thighs, hips or abdomen) to an area that has lost tissue volume due to aging, trauma, surgery, certain diseases, birth defects, or other causes.

Ideal candidates are in good health, and have excess fat in some parts of the body and too little in other regions. Fat grafting is most often used for the face, breasts and buttocks. Typically, the transferred fat results in a significant increase in volume of the body site being treated.

Fat for lipoinjection, also called fat transfer, is removed from unwanted areas of the body by a narrow blunt tip surgical instrument with side holes, called a cannula, through a small incision. The fat is then cleaned with sterile saline solution before being restored to the body. The fat is then injected into the desired area using either a smaller cannula or needle, or it may be placed directly through an incision. Since some of the fat that is transferred does not remain over time, your surgeon may inject more than is ultimately needed to achieve the desired end result. Over a few weeks, the amount of transferred fat will decrease.

There is a limit of how much fat can be safely injected into one area. The amount of fat that remains over time is variable from patient to patient. For some patients, more fat or other fillers may need to be transferred in a subsequent surgery to maintain or supplement the desired results.

Fat transfer procedures are performed using a local anesthetic, with or without IV sedation or general anesthesia, depending on the extent of the procedure and recommendations of your surgeon.

Alternative Treatments

Alternative forms of nonsurgical and surgical volume management consist of injections of FDA-approved injectable fillers, or occasionally implants.

Fillers include hyaluronic acid “HA” (Restylane, Juvederm), polylactic acid (Sculptra), calcium hydroxyapatite (Radiesse) and other fillers, use of man-made implants or other surgical procedures that transfer vascularized fat from body tissues nearby (flaps).

In general, injectable off-the-shelf fillers and fat are used for smaller areas such as in the face, whereas only fat is used to inject into larger areas such as the buttocks due to the quantity required to make the desired change.

Specific Risks of Fat Transfer Procedures

Every procedure involves a certain amount of risk. When choosing to undergo a procedure, an individual must weigh its risks against its potential benefits. Although the majority of our patients do not experience these complications, you should discuss all of your concerns with your plastic surgeon.

Infection — Infection may occur after any surgery and may rarely occur after fat transfer. The rate of infection increases with the amount of injected fat, but the overall rate still remains very low due to routine use of sterile technique and prophylactic antibiotics. Complication rates are higher in smokers, those with diabetes, and with multiple procedures.

Excessive Bleeding — Although bruising after surgery is common and occasionally prolonged, excessive bleeding is unusual during or after surgery. Unapproved medications and supplements, or strenuous physical activity too soon after surgery, can increase the chance of bleeding and complications in general. It is important to follow your surgeon’s postoperative instructions.

Change in Appearance — Typically the transferred fat loses some of its volume over time and then becomes stable. It is possible that more fat transfer treatments may be needed to maintain the desired appearance. It is important to understand that more than one treatment may be needed for optimal results. Additional costs are associated with repeated treatments.

Firmness and Lumpiness — While most transferred fat results in a natural feel, it is possible that some or all of the fat may become firm, hard, or lumpy. If some of the fat does not survive the transfer, it may result in fat necrosis (death of transferred fat tissue), causing firmness and discomfort. Oil cysts may also form at the site of the transferred fat. Needle aspiration or surgery may be required to improve such conditions.

Fluid Accumulation (Seroma) — After fat grafting with or without implant placement, body fluids occasionally collect beneath the skin called a seroma which can delay wound healing. If the fluid accumulation is significant, your plastic surgeon may aspirate the fluid with a small needle as an office procedure one or more times.

Fat Absorption Viability — Approximately 20-40% of injected fat does not remain and re-absorbs. Fat survival depends on the location of injection, age, co-morbid disease factors, smoking, weight gain or loss, and technical factors including expertise of the surgeon. Gentle massaging over the buttock area helps even out and smooths these areas during the recovery phase.

Skin Irregularities or Dimples — Contour irregularities, including bumps, dimples, and asymmetric fullness, as well as depressions or fullness in the skin may occur after fat transfer and liposuction. Visible and palpable wrinkling of skin may occur depending on skin elasticity. Postoperative massaging is often helpful in smoothing these areas.

Fat Necrosis — The areas where fat is transferred to and from may experience fat compromise or fat death that can lead to surface irregularities or result in fat calcification and produce areas of palpable firmness, “bumps”. Additional surgery to remove areas of fat necrosis may be necessary. This may result in contour irregularities.

Skin Loss (Skin Death) — This is a rare occurrence. The skin about the site of surgery or at the incision site may become necrotic or ‘die’. When this happens, skin may change color and slough off. If it is not a full thickness injury the skin will grow back, otherwise a wound will form and heal slowly. This may require further surgical and medical management.

Contour Asymmetry — The two halves of the body are never symmetric. Therefore, following fat transfers, these asymmetries may persist and appear as difference between the contour and volume of the two sides.

Long Term Effects — Subsequent changes in the shape or appearance of the area where the fat was removed or placed will occur as the results of aging, weight loss or gain, or other circumstance not related to the fat transfer procedures.

Fatty Cyst Formation — The transferred fat may form small fat clumps or oil cysts. This may interfere with the interpretation of future radiologic studies of breasts, and rarely, may need to be aspirated or removed.

Fat Transfers to Breast — Fat transfers have been widely used to improve the appearance of breast reconstruction. There are some potential concerns with regard to breast cancer detection. Since the transferred fat may become firm and cause lumps, it may be necessary to have radiological studies performed to be sure these lumps are not due to cancer. However, there is presently evidence nor nor reason to believe that fat transfer procedures may cause breast cancer.

The LiteLift™ is a type of modified SMAS facelift technique

Dr. Larry Nichter

A SMAS lift in general refers to any facelift technique that tightens the SMAS layer along with the overlying skin in a more youthful position making you look younger. Specifically, the SMAS face lift does its magic by lifting and tightening the jowls, neck, and cheeks to a more youthful position. These techniques generally produce more natural and long-lasting results than the “skin only” face lifts, and now considered by most board certified plastic surgeons as the most preferred method.

Here are some specifics of how this is performed.

SMAS is an abbreviation for a tissue layer called the Superficial Muscular Aponeurotic System. As this is a mouthful, most patients and surgeons use the acronym SMAS. The SMAS is a relatively thin layer of strong fascial supporting tissue that covers and surrounds the deeper tissues and structures of the face and neck, including fat pads and muscles, and the entire cheek area. It also attaches to the superficial muscle covering the lower face near the jaw line and neck called the platysma. As the SMAS attaches to all of these areas of the face, a SMAS lift surgically elevates this layer which in turn elevates the soft tissues and structures of the face. To do this, the SMAS layer can be folded superiorly and attached to itself, called SMAS plication, or it can be tightened and lifted by removing a redundant portion and then reattaching itself in the uplifted position (SMAS resection, or “SMASectomy”).

Now the confusing part:

The SMAS facelift may be part of the traditional facelift type procedures which have longer scars, more undermining of skin than some of the mini-lift procedures. Unfortunately there are a lot of brand names attached (especially to mini face lifts) and not all include the SMAS lift. The mini-lifts may be tough to choose from because of all the brand names such as LifeStyle Lift, S-Lift, Quick Lift, LiteLift, MACS and others. In many cases there are more similarities than differences between these procedures as they share the use of smaller incisions, quicker recoveries, and are often done under local anesthesia with oral sedation. Differences are often more related to the surgeon’s experience and preference of surgical technique. I understand how confusing this must be to the consumer. For example, in my practice we perform the LiteLift™—see below link for further details.

The skill and experience of the surgeon is far more important than the technique chosen. Factors such as the lift directional vector, how tight to lift it, and the skill to not go too deep where underlying important structures could be harmed is essential to the best outcome and longevity of the procedure. After more than a quarter of a century performing face lifts and seeing the results of other less-trained surgeons, my advice is: Always go with the best when it comes to facial rejuvenation.

Remember it is the skill and experience of the surgeon that counts—not the name! Great surgeons get great results, period. The best way to find one is to start with a Board Certified Plastic Surgeon or Board Certified Facial Plastic Surgeon with extensive experience over many years. Ask to see “before and after” photos, especially long term ones. Ask the number of times you will be seen afterwards by the surgeon rather than a medical assistant. A good place to start is “Find a Doctor” on the American Society of Plastic Surgeons or American Society of Aesthetic Plastic Surgeons web sites.

—Dr. Larry Nichter, MD FACS

The Impact of Indian Methods for Total Nasal Reconstruction

Larry S. Nichter, M.D., Raymond F. Morgan, M.D., and Mark A. Nichter, Ph.D., M.P.H.

“The operations whose object is to repair mutilations constitute one of the most brilliant triumphs of surgery.”
VELPEAU (1795–1867)

Dr. Larry Nichter

The Indian art and science of total nasal reconstruction comprise the first if not the most important chapter in the history of plastic surgery. Remarkably, centuries after their first use, the original Indian methods utilizing the cheek flap and median forehead flap for total rhinoplasty remain the basis for most reconstructive rhinoplastic procedures. The origins and diffusion of Indian rhinoplastic surgical procedures to the western world reveal the extent to which modern surgical procedures are indebted to their Indian forerunners.

Description of injury and disfigurement of the nose are commonplace in recorded medical history. Injuries are variously attributed to self­fliction, mutilation as a form of punishment, or a complex of disease states. The deliberate amputation of Lady Surpunakha’s nose in 1500 B.C. by Prince Lakshmana in India is the first recorded account of this practice. Accordingly, the mighty King Ravana arranged for the recon­struction of Lady Surpunakha’s nose by his physicians and thus documented the beginning of Indian nasal reconstruction.1 Continue reading “The Impact of Indian Methods for Total Nasal Reconstruction”

The Facelift History and Evolution of the Lite Lift™

Dr. Larry Nichter

The history of the facelift can be viewed as possibly the epicenter and roots of cosmetic surgery. This article is my understanding of the history of popular face lifting methods. It is not meant to be completely inclusive; it reflects what I feel are some of the most important historical developments.

Early Twentieth Century

The facelift surgical history began by removing a strip of skin in front of the ear, then stitching the skin together with minimal undermining if needed for closure. The skin strip excision method is probably the precursor to “mini facelift.” Here are some of the important first recorded events regarding face lifts and skin strip excision.

  • Hollander (Germany, 1901) published a short article about skin strip excision in front of ear.
  • Miller (Chicago, 1906) wrote a book on Surgical Treatment of facial imperfections.
  • Lexer (Germany, 1910) “natural evolution” of surgery to include maintenance of beauty also stressed cosmetic surgery — unique and complicated, requiring specialty training (no specialty boards then) — he added suturing of subcutaneous tissue. This put him ahead of his time. He also wrote about weakening muscles to reduce frown lines (the reason that Botox was later developed). Surgeons were highly secretive about the procedures they developed at this time; they did not want other surgeons to be able to offer the same techniques. Many surgeons did not even tell their colleagues that they were involved in plastic/cosmetic surgery.

As you can imagine, many surgical “misadventures” at the hands of untrained surgeons led to the formation of both the American Society of Plastic and Reconstructive Surgeons in 1931 and the American Board of Plastic Surgery in 1937. Despite the establishment of these institutions more than 75  years ago, there are still increasing numbers of rogue practitioners extolling expertise and unrealistic promises without training. Incredibly, some of these charlatans still use century-old techniques.

Mid Twentieth Century

  • Skoog (Sweden, 1973), Tessier (France), others in USA—developing the use of SMAS technique
  • Millard (USA) directly removed fat from neck to improve neck line.

The next major advances in facial plastic surgery gained popularity more than a half century later in the 1970s. To a large extent this was because of advances achieved in general anesthesia and the development of craniofacial surgical techniques, many of which were developed out of the need to reconstruct the casualties from World War II, the Korean War, and the Vietnam War.

Plastic surgeons began to do more extensive undermining and looked at the importance of deeper structures. This included the confluent thin layer of fascia, also called by the acronym, SMAS, covering the underlying muscles and soft tissue that also sags with the aging process. Many surgeons found that lifting this structure with sutures further improved results and longevity. However, it was also found that pulling in an oblique manner often resulted in a swept-away appearance.

Late Twentieth Century

The 1980s – 1990s were the next period of major evolution in face lifting techniques. This period was marked by even more aggressive and invasive approaches to face lifts. For example:

  • Hamra (1903) develops deep plane technique, composite facelift and others

These more invasive surgeries often took several hours under general anesthesia, involved longer scars, extensive bruising and swelling, long recoveries often lasting 1–2 months or more. Although results in expert hands were improved the downside of the long recovery, extended scars, and general anesthesia were/are of significant concern to patients and plastic surgeons alike.

Twenty-first Century: Better Results through Less Surgery

  • 2000–Present: Modified Facelifts such as the Lite Lift™, MACS, Short Scar facelifts, etc.

The last decade has seen a general movement in all surgical fields to less invasive yet more effective surgery. Dr. Nichter’s and Dr. Horowitz’s main focus during this period, like many other plastic surgeons around the world, was in distilling the essential elements of earlier facelifts while minimizing side effects.

Over and over again our patients have told us what they want during the past 15 years:

  • Easier, minimally invasive, and less radical surgery
  • Maintenance of youth rather than dramatic changes
  • Appearance of natural beauty so that others would not guess surgery was performed
  • A natural look without a swept-away appearance
  • Shorter scars that are hidden
  • Short recovery times
  • Option of in-office procedure with local anesthesia and oral sedation without IVs or general anesthesia
  • Affordability

The Lite Lift™ meets all of these 21st Century patient desires. The Lite Lift™ is a modified face lift with approximately 40% less scarring than a traditional facelift, with about half the recovery time. It is performed in an office setting with local anesthesia and oral sedation. This is what most patients prefer, but IV sedation or even general anesthesia options are available. The whole procedure takes about two hours. Each surgery is customized to our patients’ needs and desires. Frequently, as needed, other procedures can be performed at the same time such as Eyelid Lifts (blepharoplasty), Neck Tightening (platysmaplasty), Brow/Temple Lift, Fat Transfer, filler injections and/or skin resurfacing (e.g. Obagi Blue Peel). As healing for each of these procedures is simultaneous and not sequential there is still a short recovery time.

—Larry Nichter, MD FACS

Picking the Best Plastic Surgeon: Finding Dr. Right

The most critical decision to be made in achieving the best plastic surgical result is picking the most experienced and talented, that is the best, plastic surgeon possible. Too often, patients choose a physician based on a catchy ad, the brand name of a technique, the basis of one or two before and after photos, or their web site’s search engine ranking. These criteria will not find the most experienced and talented plastic surgeon.

My Background

Dr. Larry Nichter

I have been a practicing plastic surgeon for more than 25 years, having trained scores of plastic surgeons as a tenured professor of plastic surgery at USC, and I have had a private practice in Orange County since 1993. Speaking from all this experience, here is my advice and the criteria I would use to find the best plastic surgeon in Orange County, Los Angeles, California, or anywhere in the United States. These are the criteria I would use to select a plastic surgeon for my friends, my family, or myself.

First, I want to stress some general observations I have found to be true over the years.

Caveat Emptor: Buyer Beware

The longer a surgeon trains at his craft, the finer his skills and the better his judgment become. Board certification in Plastic Surgery (see below) is a bare minimum. Board certification in an additional surgical field recognized by the American Board of Medical Specialties, or for that matter “triple-board certified,” attests to a doctor’s advanced training and skill and judgment. It also means that they have attained Chief Resident Status in more than one field during their training which means they essentially ran a large departmental service and had senior decision-making and independent operating responsibilities. It is this step that is most maturing for a surgeon.

The institution where the surgeon trained is also important. More renowned schools usually attract the best faculty.

You can use the internet to research the background of a prospective plastic surgeon quickly. Please do this prior to making an appointment. “Just because you wear a baseball cap it doesn’t mean you are a good ball player.” The same applies to anyone wearing a white coat—it doesn’t make you a plastic surgeon, much less a great one.

Caveat Emptor in Latin means “Buyer Beware.” In most states, including California, any physician with a medical school diploma and state license is viewed as a doctor and a surgeon—even without any formal surgical training. In some cases even doctors who have completed only the minimal requirements (medical school, licensing examination, and a one-year internship that need not include surgical training) are touting themselves as “cosmetic surgical experts.” They make these claims of expertise despite the fact that they are only formally trained as family practitioners, OB/Gyns, emergency physicians, dermatologists, or ear-nose-throat specialists. Even physician assistants and nurses have made such claims.

7-Step Process for Finding the Best Plastic Surgeon

The following are my screening guidelines and criteria for picking the best plastic/cosmetic surgeon.

1. Board Certified Plastic Surgeon by the American Board of Plastic Surgery

The American Board of Plastic Surgery is the only certifying board in Plastic Surgery that is a member of the American Board of Medical Specialties. Use these links to look up a prospective surgeon’s status.

To become a plastic surgeon certified by the American Board of Plastic Surgery requires a minimum of five years of surgical training with a minimum of two years of training specifically in plastic surgery. Then the applicant must also pass a comprehensive written board exam. If successful, the candidate must present his/her clinical cases for critical review by board examiners (I was one such board examiner) and if accepted will take a series of oral examinations.

Since the 1990s, the American Board of Plastic Surgery Certification is only valid for ten years. To retain your board certified status, a plastic surgeon must complete a Maintenance of Certification including written testing and case review. This means that all who pass are trained and experienced in all plastic surgery procedures including facial procedures, breast, and body; essentially all cosmetic and reconstructive procedures.

If a Plastic Surgeon is additionally board certified by another surgical specialty recognized the American Board of Medical Specialties, then this also marks additional expertise and training at the highest level. The American Board of Facial Plastic Surgery (ABFRS) is not a licensing body nor an educational institution and the certificates it issues are not legal licenses to practice facial plastic and reconstructive surgery. The ABFRS is not recognized by the American Board of Medical Specialties (although it does note additional specialty training/interest in facial aesthetic surgery).

Likewise, beware of physicians armed only with certification from other non-ABMS recognized boards or special society memberships other than those I have recommended (eg. “Cosmetic Surgery Board,” “Lipoplasty Society of North America,” etc.).

2. Fellow of the American College of Surgeons: FACS

The American College of Surgeons is dedicated to improving the care of the patient and to safeguarding standards of care in an optimal and ethical practice environment. Members of the American College of Surgeons are referred to as “Fellows.” The letters FACS (Fellow, American College of Surgeons) after a surgeon’s name mean that the surgeon’s education and training, professional qualifications, surgical competence, and ethical conduct have passed a rigorous evaluation, and have been found to be consistent with the high standards established and demanded by the College.

To be a member you have to:

  • be board certified in a surgical specialty recognized by the American Board of Medical Specialties
  • be in practice in one location for a number of years, with a background check, nomination, and interviews which verify that you are an ethical and safe surgeon among other criteria.

Hint: Look for the “FACS” (or “FRCS,” see below) after the “MD” in a doctor’s title or in his/her Curriculum Vitae to see if he/she is a “real surgeon.”

Note for patients in Canada: The equivalent of FACS in Canada is the Royal College of Physicians and Surgeons of Canada, FRCS.

3. Member of the American Society of Plastic Surgeons (ASPS)

The American Society of Plastic Surgeons is the largest organization of plastic surgeons in the United States and one of the largest in the world. ASPS members are uniquely qualified because of the society’s membership requirements:

Beware of physicians without this membership but belonging only to similar-sounding societies as their claim to excellence eg. “American Society of Cosmetic Surgery,” “Lipoplasty Society of North America,” etc.

4. Member of the American Society for Aesthetic Plastic Surgery (ASAPS)

This is the most elite society in the United States and perhaps the world for Aesthetic Plastic Surgery. To be a member means that your career is focused in cosmetic surgery at the highest level. Among the requirements for invitation and election to ASAPS membership, a plastic surgeon must:

  • Be certified by the American Board of Plastic Surgery (or in plastic surgery by the Royal College of Physicians and Surgeons of Canada);
  • Be in at least the third year of active practice following board certification;
  • Participate in accredited Continuing Medical Education (CME) to stay current with developments in the field of cosmetic plastic surgery and patient safety;
  • Document the performance of a significant number and variety of cosmetic surgical cases to demonstrate wide experience;
  • Be sponsored by two ASAPS-member plastic surgeons to help ensure that the applicant’s professional reputation meets the high standards required by ASAPS;
  • Adhere to current ethical standards for professional conduct as outlined in the Code of Ethics observed by all ASAPS-member surgeons;
  • Operate in accredited surgical facilities; and
  • Be elected by at least 80% of the Active Membership.

Find an ASPS member online.

5. Hospital privileges to perform the same type of surgery

Hospitals often examine qualifications of doctors applying for hospital staff privileges and restrict privileges to only surgeons best trained and qualified to do certain procedures. For example, in order for surgeons to be granted plastic surgery privileges in most hospitals in Orange County, California, that surgeon must have completed plastic surgery residency training and must be board-eligible or -certified in plastic surgery to be allowed to perform plastic surgical operations in that hospital.

Non-surgeons and other physicians that are not plastic surgeons circumvent this process by performing surgery in their offices or in outpatient surgery centers where the credentialing process is less rigorous or nonexistent. In these settings non-plastic surgeons perform procedures in which they have no formal residency training.

I am not warning against use of outpatient surgery centers or in-office procedures. I am only recommending that you check that your physician has hospital privileges for these same procedures.

6. Surgical Experience in the procedure you are having

Few patients ask how long doctors have been doing a certain procedure or how many they have performed. When you consult with a plastic surgeon:

  • Ask to see typical “before and after” photos;
  • discuss the details of the procedure in a manner that is clear to you;
  • review benefits and potential complications;
  • get full answers to your questions.

7. Evidence of Excellence, Experience and Commitment to the field of Plastic Surgery

Here are some additional criteria to look for in your plastic surgeon.

  • Surgical Board Certification in more than one field
  • Plastic Surgical Fellowships in addition to Plastic Surgical Residency.
  • Number of years practicing.
  • Peer Review Honors in their own board certification from groups such as Best Doctors, Top Doctors, Super Doctors.
  • Current or Prior position denoting excellence in the field or high regard by their peers such as:
    • Prior or present Professor or Faculty affiliation with a University Plastic surgical program (the higher the rank the better)
    • Chairman of a Department of plastic surgery at a regional hospital
    • Honors from surgical societies of which they are members such as Board Examiner, etc.
  • Published Plastic Surgical papers in peer review journals are also a good sign that they are committed to being on top of their field.

Feel Comfortable with your choice

It is very important that after you have done this screening and met with your potential surgeon that you feel confident in your choice.

Complications are not common in cosmetic surgery, but if one did occur are you confident that this surgeon would take charge and handle just about any problem?

Do you feel that he listens to you and communicates well by answering your questions completely, doesn’t rush you in to a decision but rather makes you part of the decision-making process? You should truly feel that it is a combined effort.

Does the surgeon’s office run smoothly? Do the staff take good care of you? If you answered in the affirmative and have gotten this far in your screening guidelines then I think you have found your “Dr. Right.”

—Larry S. Nichter, MD, FACS

Advances in Minimal Scar Facelift Surgery: The Lite Lift™

Dr. Larry Nichter

Minimally invasive procedures are the focus of all surgical fields and plastic surgery is no exception. The trend for looking your best has moved towards procedures that have rapid healing times, reduced risk and leave significantly less scarring than traditional methods. More importantly, most patients want a natural, refreshed look without the appearance of having had surgery. The Lite-Lift™, modified facelift procedure, exemplifies these principles by having 40% less scarring, and nearly half the surgical down time. Rather than being performed with general anesthesia, most are performed in our office with oral sedation and local anesthesia without an IV. Dr. Nichter is an expert in this technique and is able to tailor your rejuvenation to better achieve the patient’s desired results.

It seems rational that the more extensive a procedure is, the more dramatic and long lasting the outcome will be but this is not always true. Though there is still a place for the traditional facelift, with it there is also increased recovery time and potential for problems. By using advanced techniques deep to the skin, we are able to minimize external skin incisions and scarring. For example, placing the scar within portions of the ear and ending the incision behind the earlobe crease eliminates the usual telltale scar of a full facelift. Similarly, repositioning the incisions to hide them is also used. For example, beveling the incisions just behind the hairline allows the sideburn not to be displaced too high while allowing hair to grow through the scar to conceal it. In contrast to the traditional facelift, the Lite-Lift™ re-draping of skin is upward, a more natural, antigravity, direction eliminating the “swept away” unnatural pull too often seen in Hollywood stars with older facelift techniques. These and other advanced techniques along with modifications and innovations by Dr. Nichter is what make up the essence of the Lite Lift™.

The techniques of the Lite Lift are advanced and predictable in the most skilled hands of Plastic Surgeons Board Certified by the American Board of Plastic Surgery of which Dr. Nichter is a member. The best candidates are those patients with some remaining skin elasticity (late 30’s to 60’s) but this technique is also applicable to most patients including those in good health but advanced age. Best of all, this technique can incorporate synergistic procedures such as blepharoplasty (eyelid lift), temple/brow lift, cheek lift, and liposuction of the neck and jaw line, chemical peels and more. These added procedures heal simultaneously so a speedy recovery is expected.

Our patients remain our biggest source of our referrals. Over time they remain thrilled with their Lite-Lift™ results. I share their enthusiasm and appreciate their long lasting rejuvenation which affects them inside and out.

—Larry S. Nichter, MD, MS, FACS

For more information about the Lite-Lift™ or other cosmetic procedures performed by Dr Nichter, call our office number: (714) 902 1100 or visit our dedicated website: LiteLiftDr.com.