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Issue Date: July 2013


Healthy Living

As innovations make cosmetic enhancements more attractive, doctors talk popular procedures.


Lynne Thompson

New Age

The man in Dr. Renuka Diwan's office was a retired college professor in his 60s who had remarried and become a new father. The joy of raising the boy, now in grade school, was mitigated by a single annoying fact: He looked more like his son's grandfather than his parent.

Diwan suggested injections of Sculptra, the trade name of a synthetic soft-tissue filler that stimulates production of collagen to restore the youthful contours of his cheeks and temples.

"I can think of a few people with that story," says Diwan, of the Laser and Skin Surgery Center in Westlake. "They've had second marriages, and they have young kids. They're out there on the soccer fields, and they don't want to look like an old daddy."

These men are among the growing number of male patients Diwan and other Northeast Ohio cosmetic-surgery specialists are welcoming to their facilities.

Men accounted for 9 percent of all cosmetic procedures in the United States in 2012, up 5 percent from 2011 and 22 percent from 2000, according to the American Society of Plastic Surgeons. Diwan reports a 13 percent hike at her practice from 2010 to 2012.

There was a time when men said they underwent cosmetic procedures, particularly facial enhancements, to remain competitive in an increasingly tight, youth-oriented job market. Now they're voicing more personal reasons.

"Some of my patients are coming in because they're divorced," Diwan says. "They're dating again, and they want to look better."

Like women, these men are driving a host of other cosmetic surgery trends — including increased demand. The ASPS reports that 14.6 million procedures were performed nationwide last year, up 5 percent since 2011. Local plastic surgeons say the developments they're seeing here largely mirror those nationally. Their observations provide a peek at what patients in Cleveland and around the country are getting.

Minimally invasive procedures made up about 89 percent of all cosmetic procedures last year, according to the ASPS. Although the results of these nonsurgical options are largely temporary in nature, they're less expensive and require little or no recovery time.

"They are bringing a lot younger patients into the practice, patients who are not ready for surgery financially or psychologically," says Dr. Michael Wojtanowski of the Ohio Clinic for Aesthetic & Plastic Surgery in Westlake.

These procedures are also being used to prepare for surgeries or augment their results. A patient planning to have a face-lift, for example, might schedule microdermabrasion — a controlled exfoliation of the skin with a sandpaperlike metal handpiece — before or after the operation.

"They have enhanced what we can do," he says.

New Age

Injections of botulinum toxin and soft-tissue fillers remain at the top of the list of most popular nonsurgical options, both here and around the country.

The former, more commonly known as Botox, temporarily relaxes facial muscles that cause lines like the vertical furrows between the eyes. The latter is used to fill the nasolabial folds that extend from the corners of the nose to the corners of the mouth as well as crow's feet, vertical lines around the lips, and other facial depressions.

"Volumization" is the latest buzzword in fillers, says Dr. Amy Kassouf, a dermatologist at University Dermatologists' Bainbridge and South Euclid locations. She uses fillers to restore roundness to sunken cheeks, shore up jawlines and fill hollows under the eyes.

"We're actually putting structure back in the face," she says.

Synthetic fillers such as laboratory-made hyaluronic acid, a version of the cushioning and lubricating agent found in the joints (the most recognized brand is Juvederm Ultra), are popular, mainly because they're available by the convenient pre-filled syringe and produce predictable results.

But patients are also turning to a natural substance that was used to smooth lines and fill hollows before the specialty of plastic surgery existed: their own fat. Continuing research on fat injections makes the procedure "very trendy, the cutting edge of plastic surgery right now," says Dr. Gregory Fedele of The Art of Plastic Surgery in Beachwood.

Fat requires harvesting via liposuction. And because all transplanted fat cells don't survive, more fat is injected into treated areas than initially desired, causing swelling and bruising, according to Dr. Steven Goldman of Beachwood Plastic Surgery & Medical Spa and Westlake Plastic Surgery & Medical Spa.

Refined harvesting and preparation methods assure more fat cells are transplanted intact, Fedele says. Such improvements can yield a retention rate of 60 to 65 percent — a result that, unlike synthetic fillers, may last for years or even permanently.

Because fat stem cells are harvested along with mature cells, patients enjoy improved skin elasticity and color as well as volume in the treated areas, according to Dr. Bahman Guyuron, chairman of the department of plastic surgery at University Hospitals and Case Western Reserve University School of Medicine.

"With one technique, one maneuver, we are actually attaining three goals," he says.

Shots of fat are also used to create a rounder, firmer bottom. Dr. Mark Foglietti of The Cosmetic Surgery Institute in Beachwood estimates he's seen a 20 percent increase in requests for buttock enhancements, primarily from women, in the last year.

"[Fat injections] also really work in an aging butt where the skin is starting to sag a little — not a lot," he adds. "It's almost like reinflating a balloon that's lost some air."

Advances in technology are helping Dr. Patricia Duggan of Vascular Interventions & Venous Associates in Mayfield Village eliminate unsightly spider and varicose veins.

Using radiofrequency technology to deliver heat through a needle, she can collapse the offending vessels, causing blood to be rerouted through healthier counterparts. This avoids the sometimes painful traditional sclerotherapy, which uses a chemical injection to achieve the same results and requires patients to restrict activity, wear compression stockings and avoid sun exposure during recovery. "It's revolutionized the concept of sclerotherapy," she says.

Dr. Nicholas Husni of The NEO Aesthetic Institute in Independence sees more of his patients turning to technology marketed under the trade name Cool Sculpting to eliminate stubborn areas of fat.

"Anywhere on the trunk, it works really well," he says. The procedure involves gently suctioning "anything that you could pinch with two hands" into a handpiece that cools it to 37 degrees Fahrenheit and keeps it at that temperature for an hour.

The area "looks like a frozen stick of butter" for one to three minutes immediately after treatment, adds Nicole Ponte, spa director of Spa West in Westlake.

The process kills about 25 percent of the subcutaneous fat cells, which the body gradually eliminates, without damaging the skin.

Four Cool Sculpting treatments are required to get rid of a roll of fat. Ponte notes that some clients require more or less.

"The results can be very different," she says. "But I've given over 150 treatments. And every guest, on every area, has seen some type of result."

Despite all the minimally invasive procedures performed last year, Wojtanowski believes their numbers have hit a plateau. He points to the growing number of face-lifts and eyelid lifts he's performing as evidence.

Dr. James Zins, chairman of the department of plastic surgery at the Cleveland Clinic, credits the uptick to advances such as the short scar face-lift, a surgery in which the incision stops at the bottom of the ear instead of continuing around it, and a neck-lift done through a small cut under the chin.

"People will do the nonsurgical procedures for a while," says Wojtanowski. "Then they're like, •OK, I'm ready to move on and do something more aggressive.' "

Breast augmentation remains the most-performed cosmetic surgery on women in the U.S., despite the 7 percent decrease in the number of such operations between 2011 and 2012, according to the ASPS.

The Food and Drug Administration recently approved the form-stable implant, a variant of the silicone implant colloquially referred to as "the gummy bear" because its consistency is similar to that of the candy. The soft rubber material is designed to be less susceptible to leakage than the usual saline-filled implant.

Goldman stresses that no concrete link has been established between leaking silicone and diseases such as cancer and rheumatoid arthritis. But it can cause the thin, delicate scar-tissue envelope around the implant to harden over time, in turn changing the breast's look and feel.

"The [manufacturers] are basically saying that because these are soft rubber, if they do start to leak, they're not really going to leak in the same way," he adds. "They're going to keep their shape."

Liposuction continues to be popular for both sexes nationally, ranking in the top five of surgeries. At Vanek Plastic Surgery in Mentor, more patients are improving their physiques by booking liposuction to remove stubborn love handles, muffin tops and other problem areas.

Dr. Paul Vanek credits the increase to Vaser-brand liposuction, which employs ultrasound waves via a titanium probe that measures a mere 3.9 millimeters in diameter. The incisions needed to accommodate it are only 4 millimeters long, much shorter than those required by the typical half-inch suctioning tube. The instrument is "tuned" to emit ultrasound waves that break only fat-cell membranes, according to Vanek.

"It does not damage the blood vessels, nerves or collagen," he says.

Zins' Cleveland Clinic colleagues are doing more body-contouring surgeries, particularly tummy tucks, upper arm lifts and lower body lifts. The development, Zins explains, is a result of the growing number of obese adults opting for bariatric and other weight-loss surgeries.

Upper arm lifts experienced a 3 percent boost in 2012. And arm lifts in women have skyrocketed an amazing 4,378 percent since 2000, according to the ASPS.

Vanek's staffers attribute his 600 percent increase during the last year to the sleeveless-fashion rage, not the admiration for strong-armed women such as first lady Michele Obama that the ASPS also cites.

Regardless of the procedures patients choose, they can have multiple procedures performed by different specialists at the same time, says Guyuron. For example, a face-lift and breast augmentation or neck-lift and liposuction might be combined.

Guyuron notes that studies have shown the practice does not increase patients' risk of developing postoperative complications. They save money by paying facility and anesthesiology fees only once. And they save time by scheduling a single surgery and recuperative period.



Smile High

Kathy Ames Carr smile

Dr. Scott Rose objects to the philosophy of putting your best foot forward if you want to impress someone.

"No one looks at your feet. They look at your smile," the Solon-based dentist says. "Your mouth takes up a third of your face. When you're meeting someone for the first time, a nicer smile goes further."

Advances in technique and technology are making cosmetic dentistry more accessible to generations young and old, says Rose of the Center for Aesthetic & Restorative Dentistry.

In fact, a 2012 American Academy of Cosmetic Dentistry survey suggest adults will pay for teeth repair before weight loss help. The survey reports that of the 80 percent of adults willing to spend money to correct aging flaws, 62 percent would choose to maintain their teeth, while 48 percent who would invest in weight loss methods and one-third would address thinning hair or dark under-eye circles.

"An increasing number of my patients in their 40s and 50s are requesting cosmetic dentistry to gain an edge over people in their 20s in today's competitive job market," says Dr. John Pyke III, a dentist in Avon Lake.

Indeed, it's hard to grin and bear crooked, chipped or discolored teeth.

Rocky River dentist Dr. Anthony Heibili has been seeing more patients seeking to address those blemishes because they want to "look perfect."

Many patients are favoring Lumineers, a thin porcelain veneer, over traditional porcelain veneers. Like a contact lens, the Lumineers' shell is thinner and looks more translucent, similar to the outside of a coffee cup.

It's an easier procedure, with more tooth structure staying intact, Heibili says.

"We recontour the teeth as needed, then pick the color and shape and bond it to the tooth's enamel," he says. "They're just like false fingernails."

Composite veneers are another increasingly attractive alternative to veneers, Rose says.

They come in different sizes and shades and cost about $600, or half the price of a veneer. While porcelain veneers feel like glass, the composite resin is akin to plastic glass.

"We lightly prepare the tooth, shave it down slightly and bond the veneer under a local anesthetic," Rose says.

The composite veneer is still strong and stain-resistant.

"You can go down the street in a Mercedes or a Ford, and either way, it still gets you where you want to go," Rose says.

Clear aligners have been eliciting broad appeal, from teens to patients in their twilight years, says Dr. Dean Carmichael of Rockside Family Dental Care. He's observed about a 25 percent increase in use over the last five years, as new technology has replaced the old silver wires and brackets for clear braces. That's especially true for those 50 and older.

"There are a lot of grandparents with expendable income who want to look good," Carmichael says.

Improvements to technology are aiding dentists in making teeth look more natural.

Dr. John Heimke, of Facial Aesthetic Designers in Rocky River, is focusing on crafting customized grins for patients of all ages with "digital smile design" software. He takes about 10 photos of the patient's affected areas, uploads them and designs the desired smile with his customers.

"Do you want the fang tooth to be more rounded or more square?" he may ask the patient before fabricating the final veneers. "Technology is allowing dentists to become artists."

In years past, dentists had to fabricate the impression of oral cavity structures using polyvinyl siloxane, a gooey material that could be unpleasant if one had a gag reflex, says Dr. Michael Gallagher of West Park Dental Associates.

Now, oral scanner systems produce those models after a wand the size of a Sharpie pen peruses teeth and yields 3-D images that are sent to a dental lab.

"The industry is in its infancy, but now a dozen companies are getting into this technology," says Gallagher, who expects to add a new digital scanner this fall.

Just about every week, new lifelike porcelain materials and tints are surfacing to make modified teeth indistinguishable from their natural brethren.

"I did a single crown on the front tooth of a patient, and the patient asked, •Which one is it?' " Gallagher says. "If it doesn't match, it looks like a headlight."


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