Last weekend, hundreds of the world’s most brilliant facial plastic surgeons gathered in Washington, D.C. to discuss new techniques, trends and more at the 13th International Facial Plastic Surgery Symposium. We were front-and-center to get the scoop directly from the experts, and these are 10 noteworthy things we learned.
Surgeons Are Improving Recovery Times Using New Techniques and Approaches
“We’re really doing a lot more facelifts than we were pre-pandemic, and it’s almost as if we’re going more invasive than less invasive,” says New York facial plastic surgeon Matthew White, MD. “Minimally invasive interventions have a role and will keep coming out, but people are really loving the results of their facelifts and they’re spreading the word. During the pandemic, there were so many patients wanting facelift surgery because they had the time to recover, and we also learned ways to help them recover more quickly.
There are surgical technical approaches we can do, and one of the biggest things is using tranexamic acid. After a surgery where the soft tissues were repositioned, the blood vessels tend to be a little bit leaky—it’s a normal part of swelling and inflammation—but tranexamic acid essentially galvanizes the blood vessels to seal them off. This means less swelling, less fluid in the tissues, less inflammation, and less discomfort. I’d say most surgeons are using it in the numbing medicine or local anesthesia they inject before they start an operation, but some people are giving it in an IV too. It’s very helpful.
There are a lot of things people are doing more now with oral medicines, too, like anti-inflammatory Celebrex, which tends to reduce swelling and bruising. There are also different methods of anesthesia and more doctors are using ketamine, so patients come out of anesthesia happier and don’t have that hangover feeling, like you had two or three margaritas the night before. I think many of us are very focused on ways we can make the overall patient experience better.”
A Cheek Lift Can Be Done as a Standalone Procedure (Without a Full Facelift)
Boston facial plastic surgeon Waleed Ezzat, MD has seen a big demand for mid-facial rejuvenation at his practice. “I think the cheek lift procedure is unique because it can be done as a standalone and a little bit earlier in one’s life without having to take a patient through a full facelift,” he explains. “The cheek is one of the first areas to show signs of aging, and it shows before you develop jowls or excessive skin laxity. There’s always a genetic component to it, too, but for patients in their 50s, 60s and 70s, it restores the cheek to where it used to be when they were younger. There are two discreet incisions: one inside the mouth and one behind the hairline that hides really well. We’re able to release the ligaments that hold the cheek in place and have started to sag. We reposition the entire cheek to its youthful position and it’s a really quick procedure. It allows us to do what fat injections would do, or maybe an implant, but we’re using your own tissues, and therefore getting more natural results. The tissues are still there, but they’ve just fallen because they’ve been bombarded by gravity for all this time.
People start approaching their candidacy in their late 30s and early 40s because that’s when you start to see the cheek begin to sag and show signs of aging. Fillers do a great job of camouflaging what the underlying issue is, but the best thing about this procedure is that we’re able to address the underlying issue and give a more youthful, refreshed appearance without having the patient get filler injections over and over again. Fillers also address the lack of volume, but they don’t reposition the skin that’s fallen.”
Exosomes Are the Next Big Thing in Regenerative Therapy
“Exosomes are the packages that carry messages from one cell to the next, and they’re used in many different ways to help with wound healing and skin rejuvenation. Right now it’s a bit of the Wild West because there are many companies making exosomes and there isn’t regulation on them, but I think they’re the next big thing. I just think we just don’t know enough yet.
I’m an investor in Rion Aesthetics, which is a physician-dispensed skin-care company using platelet-based exosomes that come from human platelets. The initial studies showed improvement in redness, fine lines and wrinkles, all from a topical skin-care regimen that is phenomenal. It’s absolutely mind-blowing what they’re doing. The products are also great as an adjunct procedurally. There are only a few practices in the country that have it, and most are investors in the company, but it’s great around procedures: surgically, I give it to my facelift patients to help with healing and improve their results. But you can also use them after microneedling, RF microneedling, lasers. It speeds up healing and improves results. I truly believe in exosomes, but we need to see more studies. They’re also very expensive. And, one really important question we should be asking is how the exosomes are derived, and how they are processed and made.”
Facial Plastic Surgeons Are Giving Back in the Ukraine
“It’s really horrific what’s going on in the Ukraine, and as part of The Facial Plastics Academy, I’m chair of the FACE TO FACE Committee, which is the humanitarian arm of the Academy, and we’re helping to give back,” says Poughkeepsie, NY facial plastic surgeon Manoj T. Abraham, MD. “I’ve done lots of medical missions all over the world, and we typically take care of kids with cleft lips and palates or craniofacial issues. But when this started happening in Ukraine, we heard about some horrible injuries to the face from blast injuries, bullet wounds and burns, and we put a team together to help.
There were five plastic surgeons, including myself, and we collaborated with our colleagues in Ukraine and aid organizations to fly in to Poland, cross the border and enter a hospital where we did some really complex reconstruction surgeries. The injuries were pretty catastrophic: People were missing their jaws, their eyes, and other parts of their face. We treated 34 patients, and it was also an educational experience for the Ukrainian doctors: 130 physicians from all over the country came to the hospital to watch us. We’re setting up a collaboration moving forward to send teams back to help and continue educating. It was a really big Facial Plastics Academy effort and I was really happy to lead it.”
“Ethnic Rhinoplasty” Needs a New Name
“We need to get away from this term,” says Dr. Ezzat. “The traditional opinions of rhinoplasty have been that there’s a Caucasian nose, and then there’s ethnic, and that no longer applies in our society. We’ve evolved to have a very multicultural society, and some of my most beautiful patients are mixes of Hispanic and Asian, or African-American and Hispanic, etc. There are better ways to classify those noses, and each one of them actually represents its own entity. We’re really not either socially or scientifically accurate when we say ‘ethnic nose.’ Usually I break my patients down my region, but even then, it may be inaccurate. For example, I may have a Southeast Asian patient who doesn’t have the traditional mesorrhine nose that you’d expect to find. They may have more of an Eastern European nose.”
New York facial plastic surgeon Steven Pearlman, MD says, “Ethnic rhinoplasty is used as a catch-all term. I recognize that each ethnicity has a natural look, and as surgeons, we have to understand what works for each person. The Indian nose is different than a Middle Eastern nose. Most Middle Eastern patients want to maintain a slight hump for ethnic identity, but some Persian patients want a scooped nose. The goal is to make you look better and soften the features you might not like, but not take away from your natural identity. When I was a resident in the ’80s, there was a surgeon who came from Korea to watch us in the U.S. and he was fascinated watching us do rhinoplasty because to him, rhinoplasty was augmentation—adding to the nose—and he saw reduction: taking down humps and reducing tips. He was flabbergasted, and to him, that was ethnic rhinoplasty. Computer imaging—I use Canfield Mirror, which I think is the best one and I’ve been using it for more than 25 years—is a great way to show the patient the potential results and ask the patient if it matches their goals.”
Asian Eyelid Surgery Is Trending
“The Asian eyelid is built differently than the non-Asian eyelid,” says Fairfax, VA facial plastic surgeon Jae Kim, MD. “About half of us don’t have a double lid or crease—it affects all nationalities across Asia; my patients are Chinese, Korean, Japanese, Thai, Vietnamese—so we can change that anatomy to make a crease and make the eyes look brighter. If you’re watching a Korean TV show and the actor or actress blinks their eyes, you can kind of see a little bit more of a defined line, even when their eyes are closed, but half of people already have it to begin with, so it’s prevalent now and it still looks natural. Some people say, ‘It Westernizes you and makes you look less Asian,’ but I would beg to differ. If you’ve seen the Netflix show Bling Empire, one of the characters is contemplating Asian lid surgery, and his friend says, ‘I had it done and I look Westernized; I don’t look like myself.’ So it’s an inner battle sometimes, but I talk to the patient during the consultation about their goals and objectives. What I often tell people is that it’s kind of like home renovation these days: Everyone wants open concept, but this is the opposite. It’s like you’re putting a wall between your kitchen and your dining room.”
Fat Grafting Is More Pure and Precise Than Ever Before
“I’m doing a lot of fat grafting, and one of the talks that I’m giving here is how we can better process the fat and size it so that when it’s reinjected into the face, it’s more reliable and lasts longer,” says Bryn Mawr, PA facial plastic surgeon Jason Bloom, MD. “You’re getting stem cells from the fat to rejuvenate the skin, as well as the volume. I run the fat through something called PureGraft, which removes 97 percent of the impurities. It looks like an IV bag and you bring it in the operating room, so it’s easy to use. There’s something else called Dermapose Refresh, which sizes the fat. As a facial plastic surgeon, I’m mainly using fat under the eyes and in the midface area, and I need small, precise fat. It’s kind of like a syringe that sieves the fat—a screen mesh sizes the fat to make it more consistent when you’re injecting it. That’s been awesome and I use it for every one of my fat grafting cases. It improves the results and gives the patient less downtime—about a week with bruising, but swelling could last another week—because you’re taking out any broken fat cells or oils, as well as white blood cells that cause inflammation and red blood cells that cause bruising. The fat is also super smooth, which we especially need under the eyes. Studies of PureGraft show that about 30 percent of the fat dies in the long-term—five years—so I tend to overcorrect by about that much when I inject.”
Deep Chemical Peels Are a Becoming a Thing of the Past
“This is an art form that has kind of gone away because of laser technology,” says Chattanooga, TN facial plastic surgeon James R. Shire, MD. “I am anti laser-resurfacing—Co2 is not meant to resurface. The problem with resurfacing is that you don’t want to damage anything beyond the papillary dermis. If you go below the low papillary dermal level, you’re going to get cicatricial scarring and hypopigmentation. And, it denatures elastin, which means that initially after your treatment your skin looks smooth and tight, but if you look at the skin in three to five years, it looks like crepe paper because the elastin has been destroyed by the thermal heat radiation. With chemical peeling, there is no heat. They can get rid of sun damage, deep wrinkles—I’m talking roadmap faces—and rough skin. Patients look like they have the skin they had when they were 25 years old.
There are not that many what we call ‘peelers’ left in the country—there are probably only about dozen people doing it. This is because there’s a steep learning curve with the deep peels, although it looks easy. Another reason is that the downtime is intense. You can’t be in the sun, and that’s a downside to resurfacing in general. If you destroy the upper dermal levels, you’ll have exposed pigment cells that will hyperpigment immediately, so you want to avoid that. You’re not allowed to be exposed to sunlight until all pinkness is gone, and sometimes that can be months.”
Threads Can Be Used During a Necklift for Long-Lasting Rejuvenation
“People are not only interested in minimally invasive treatments, but also long-lasting results. Some of the newer trends provide short-term results, but not necessarily long-term happiness,” says Dr. Abraham. “When it comes to the neck, I perform a modification of the Giampapa method, and it’s done using sutures but also incorporating the deep-plane facelift at the same time. It really works well to define the angle of the jaw, and it’s a little bit more minimally invasive because the sutures help in terms of not needing to push that deep lift all the way through.
If a surgeon is doing a necklift that involves a really aggressive, deep dissection of the neck, they’re going all the way under the platysma muscle and cleaning that area out—almost like a cancer removal surgery—and there are some critical nerves and glands there, so there are risks involved. It is effective, but very aggressive. My technique is less aggressive because, although I’m still doing the dissection to help with the sagging muscles and skin, I’m using the suture to essentially create a sling. I compare this to tightening a belt around a big belly. If you just tighten the belt, the belly will just flop right over. But if you use a suture to create a sort-of corset, it brings everything up in a nice, natural way. I’m still using the tried-and-true deep-plane techniques that provide long-lasting results, but I’m combining them with minimally invasive approaches for the best of both worlds.
And after I do a lift, something like Morpheus8 is a great maintenance treatment. It rebuilds the collagen framework and keeps the skin tight and toned. It takes a year to reach 100-percent healing after a necklift, so there’s nothing wrong with waiting a year to get a complementary treatment like this, but for many patients, they’re healed 90 to 95 percent after three or six months and opt to do it then.”
There’s a New Option for Rib Grafts Used in Rhinoplasty Surgery
“In rhinoplasty, sometimes we need cartilage grafts, and as part of that, most surgeons will rely on the patient’s own rib, which is kind of the gold standard,” says Greenwood, IN facial plastic surgeon Mark Hamilton, MD. “But, for those of us who don’t do rib grafts or are trying to get away from the morbidity of that, discomfort of that or risk of that, there’s a rib graft we can use that we can basically ‘get off the shelf’—it’s from a cadaver and kept in a freezer—that’s reliable, and that’s really nice. In the past, we had radiated cadaveric grafts, and some doctors have had great success with it, but others haven’t. These newer grafts have much higher reliability, according to the studies. How it works is that the doctor determines the patient is a candidate and then calls MTF—it’s a nonprofit that seeks out tissue from donors and they’re really careful with who they pick—and orders it for their patient. Sometimes we can get what we need in a week or so, but sometimes it can take months. In the case I was working on recently, I used the rib graft to support the tip of the nose, but they can be used for a variety of things in rhinoplasties.”
