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Modern Facelift Techniques: Individualizing the Technique to the Patient

29 September 2014, 10:59 pm

In the modern age of facial rejuvenation, a multi-technique approach is utilized to achieve a youthful refreshed look.  Some techniques have stood the test of time and other techniques are a more recent reflection of our greater understanding of the soft tissue anatomy of the face. 
In this blog article, I will focus primarily on the midface and neck.  I will address the brow and forehead in another article. 

Over time our faces become aged by the forces of gravity, genetics, and stresses of our environment.  We lose volume, elasticity, and elevation of the soft tissues.  Our bones also change in variable ways as a functional matrix of the stresses placed upon them.  In approaching a total facial rejuvenation, all aging phenomena need to addressed simultaneously or as part of a plan in order to achieve a predictable and harmonious result. 

Skin is often overlooked when thinking about surgical options, but is critical to the final outcome.  If not already part of your daily routine, I can help you develop a skin regimen that will help create a revitalized youthful cover for our underlying surgical procedures.  There are various excellent product systems on the market and even more that are a waste of money.  I have found the Obagi system to be best in class in my experience.  At the very least, your system must have Retin-A as part of the treatment plan.  You will need a plastic surgeon or dermatologist to prescribe this for you.  Lasers, dermabrassion, TCA peels and other techniques can be tailored according to each individual’s needs. 

The next component to consider in facial rejuvenation is soft tissue descent, laxity, and volume loss.  This is highly variable between patients.  For a fuller face, I may use a mid-level dissection plane and remove the redundant tissue after elevation is complete.  For a thinner face, I will use the same mid-level dissection plane (sub-SMAS) but overlap the tissues in the cheek areas giving an augmented cheek look that is only present in the youthful face.  I feel very strongly that accessing the robust, mid-level tissue planes (SMAS) is critical to achieving a long lasting result that will continue to look good for a decade or more.  By accessing the mid-level planes, more swelling results and with more swelling comes a slightly longer healing time.  Many patients want the facelift with the quickest healing time.  In many cases this is also a cheaper facelift.  Win win right?  I would caution against the quick fix.  In my experience, these are usually skin only facelifts that maintain their shape until the skin stretches out to its previous position.  This usually doesn’t take long and philosophically doesn’t make much sense to me as a surgeon.  A long lasting result must move the descended face to an elevated position that will maintain its shape in a lasting way.  This is why I insist on taking the time to address the mid-level planes of the face and restore them to their previous positions before gravity displaced them over the nasolabial folds of the cheeks and jowls of the jaw line.  The basic principles of this approach have stood the test of time and have reliably produced long lasting results. 

Fat grafting has become an important of my facial rejuvenation repertoire.  The fat compartments of the face have been studied extensively and published in the scientific plastic surgery literature over the past several years.  Fat grafting has allowed facial rejuvenation to be tailored with a degree of precision not previously attainable.  This has allowed true volume restoration and allowed previously great results to become truly phenomenal.  This has gained huge popularity with celebrities and can be used alone or in conjunction with facelift techniques depending on each person’s individual needs.  It is rare that I do not combine fat grafting into my facelift. 

The last and often most important part of facial rejuvenation is creating a youthful appearing neck.  The goals of a neck lift are to eliminate excess fat pads, tighten the skin, eliminate jowling, and create a beautiful jaw line that contours nicely with the mandible.  This is created by tightening, repairing, redirecting, and securing the deeper tissues of the neck.  The skin will follow the deeper tissues and allow the neck to remain youthful for a decade or more.

If you are interested in facial rejuvenation, I encourage you to schedule a consultation.  During your consultation I will perform a physical exam and we can talk about your goals and desires.  We will then formulate a plan to restore your youthful face. 

--Jason Mussman MD

Understanding the Aged Lower Eyelid

19 September 2014, 11:36 pm

When meeting a person for the first time, our mind naturally studies their face and draws conclusions on age, fatigue, and lifestyle based on clues we can find.  An aged appearing lower eyelid can overpower most other features of the face to leave a negative impression on others. 

So what makes an aged appearing eyelid?  Well, baggy lower lids with wrinkled skin are the obvious answer.  But one would be wrong to conclude that the lower lid skin has just become saggy with time.  The actual situation is much more complex.  To see the difference, open a magazine and study the lower lid of a youthful model.  It appears much shorter and tighter than the aged lid right?  In actuality, it is the same length.  Over time the fat pads of the cheek have both descended and deflated.  This is the fat on the outside of the lid, and is our friend in obtaining a youthful lid.  The fat on the inside of the eyelid is part of the cushion of the globe of the eye.  Over time, this fat has herniated outward and is pushing from behind the lid.  This is not a friend of the youthful eyelid.  In addition, the actual septum of the eyelid becomes looser and bulges over time.  This bulge combined with the septum’s attachment to the bone enhances what is called the “tear trough” area of the lower lid.  This is the area between the nose and the eyelid.  It becomes a shadow and is a giveaway of an aged lid.  Lastly, the skin of the lower eyelid can become lax and excessive over time.  This is the obvious problem to someone looking at their lower lid, but in reality, very little excess skin needs to be removed. 

Fortunately, obtaining a youthful lower eyelid is achievable with a combination of several plastic surgery procedures that address the precise problems.  First, the fat pads of the cheek need to be enhanced by replacing volume and/or lifting.  This can be accomplished using a number of techniques.  My most common technique is fat grafting to the cheek areas and “tear trough” area.  The fat is obtained from the neck fat (if available) through liposuction.  The fat is then purified and injected in tiny droplets to enhance and rebuild the cheek.  This is important in recreating the “short” youthful lower eyelid. 

Second, the bulging fat from behind the eyelid is accessed through the mucosa of the inner eyelid.  A tiny removal of the excess fat in this area can be the difference in obtaining a great result.  From this access point, I also like to release the tether of the “tear trough” area from its attachment.  This decreased the shadow between the nose and lower eyelid and allows the remaining fat of the inner eyelid to redrape into a softer youthful position. 

Lastly, the excess skin is addressed.  The skin may not need to be removed in all patients.  In reality, a lifted eyelid will create skin that the body will naturally tighten over time.  However, in most patients a tiny amount of skin will need to be removed to allow the final component of the enhanced and youthful lower eyelid to be addressed and corrected. 
If you are interested in restoring a youthful appearance to your lower eyelids, please make an appointment.  During the consultation, I will perform a physical exam and we can discuss your goals and desires and create a plan to achieve them.

--Jason Mussman MD

12 September 2014, 9:41 pm

Understanding the Effect of Breast Augmentation on Quality of Life

Breast augmentation is one of the most popular cosmetic procedures in the United States.  An estimated 300,000 women undergo the procedure each year in the Unites States alone. 
In my own practice, the positive effects of breast augmentation on self esteem and quality of life are seen every day.  Patients routinely seem more confident, make more eye contact, and are energetic and thankful after their breast augmentation.  After all, the true reason that people undergo any cosmetic procedure is that they want to feel better about themselves. 

So how much better do people feel about themselves?  Am I really achieving the benefits and desired outcome for my patients that I think I am?  These are fair questions and important questions to answer in the modern era of evidence based medicine. 

Until recently, the plastic surgery community had very little objective (number based) evidence to support our quality of life improvement claims.  In the April, 2014 issue of the scientific journal Plastic and Reconstructive Surgery, a multicenter, high powered study was published that quantified the amount of improvement that women can experience in their quality of lives after breast augmentation.  The results may surprise you. 

Over 600 women participated in the study.  They underwent highly controlled interviews and surveys to measure their quality of life improvements 6 weeks from surgery and 6 months from surgery.  All implants were placed in the submuscular plane.  Both saline and silicone implants were used depending on patient preference.

The study showed that women were 211% more satisfied with their breasts at the 6 week interval and 228% more satisfied with their breasts at the 6 month interval on average.  Psychosocial well being (Self esteem) also improved 64% at the 6 week interval and 65% at the 6 month interval over baseline.  Sexual well being also improved to 114% of baseline at 6 weeks and 122% over baseline at 6 months.  In a surprising finding, physical well being (ability to exercise and perform physical activity) decreased after breast augmentation.  Physical well being decreased 25% at 6 weeks and remained slightly lower at 12% below baseline at 6 months. 

As a plastic surgeon, I am thrilled that my esteemed colleagues have published these precise and objective findings so that I can communicate them to my patients.  I found the findings on improved satisfaction with breasts, psychosocial well being (self esteem), and sexual well being to confirm my experiences in my practice.  The slight decrease in physical activity observed is likely multifactorial.  Difficulty with exercise has been very well described in the population of women seeking breast reduction.  I theorize that by enhancing breast size, a slight decrease in physical activity is traded for increased self esteem, satisfaction with breasts, and sexual well being.  Ultimately, it is the patient’s decision.  I congratulate the authors of the study on answering a very difficult and important question for the plastic surgery community. 

Source:    Amy K.Alderman - Joseph Bauer - Dean Fardo - Paul Abrahamse - Andrea Pusic. Understanding the Effect of Breast Augmentation on Quality of Life. Plastic and Reconstructive Surgery – April, 2014 787-795.

4 September 2014, 5:06 pm

Understanding Migraine Trigger Sites

Migraine headaches are a severely disabling phenomenon.  Over 324 million people are affected.  Migraines rank at the 20th leading cause of years lost due to disability worldwide.  For decades the only available treatments included avoidance of common migraine triggers and medications.  Medications are effective for most, but come with side effects such as fatigue and dizziness.  

Fortunately, there is a new and powerful weapon in the treatment of migraine headaches. 
Migraine surgery has achieved improvement in 75-90% of sufferers in peer reviewed scientific studies.  This has revolutionized the concept of the origin of migraine headaches and has already improved the lives of thousands of American men and women.  For decades, migraines were thought to originate from an internal (in the brain) trigger.  It is now understood that external trigger points (outside the brain) can cause the migraines by pinching sensory nerves as they cross various muscles and anatomic boundaries. 

Trigger Site 1:  The Frontal Zone
The frontal zone is the most common site for external trigger of migraine headaches.  It can be accessed through a crease in the upper eyelid or endoscopically through tiny incisions behind the hairline.  This allows me to decompress the sensory nerves traveling under or through the muscles that cause the frown lines between your eyebrows.  The scientific names of these muscles are the corrugator supercilii, corrugator depressor, and procerus muscles.  After the surgery, numbness and tingling can be experienced.  These are usually temporary side effects until the swelling resolves.

Trigger Site 2:  Temporal Zone
A very small sensory nerve that supplies sensation to skin of the temple can be a trigger of migraine headaches.  This can be aggravated by stress and teeth grinding.  This nerve becomes pinched in the temporalis muscle.  I simply remove a small segment of this nerve.  The numbness is permanent but usually goes unnoticed by most patients. 

Trigger Site 3:  Occipital Zone
This area can be exacerbated by stress also.  Tightening of the semispinalis capitus muscle around the occipital nerve in the posterior neck can cause migraine headaches.  By releasing this tiny muscle and redirecting the nerve into the nearby soft fat, compression can be relieved and migraine trigger from this site can be eliminated. 

Trigger Site 4:  Nasal Zone
I may order a CT scan to evaluate this trigger site completely.  Some patients can experience pain and migraine trigger from deviated septum combined with overgrowth of an area of the nose called the turbinates.  When these two areas become inflamed with allergies or stress, contact can cause compression.  Compression can cause pain that leads to development of a migraine headache. 
These trigger sites account for an estimated 75-90% of all migraine triggers in the head and neck.  Over a dozen minor sites have also been described and can be explored if these sites do not relieve the migraines. 

If you are interested in migraine surgery, I encourage you to schedule a consultation.  During the consultation, I will perform a focused history and physical exam pertaining to migraine trigger sites.  We will review past treatments and start keeping a migraine journal.  We will then explore procedural options to help you regain control of your life. 

--Jason Mussman
(602) 331-7811
9250 N. 3rd Street, Suite 1003
Phoenix, AZ 85020

25 August 2014, 4:47 pm

Am I a good candidate for Migraine Surgery?

Migraine headaches are extremely common and severely disabling.  In the Global Burden of Disease Survey 2010, migraine headaches were ranked as the third most common disorder and the seventh highest cause of disability worldwide. 
Migraine headaches are diagnosed with the following criteria from the International Classification of Headache Disorders:
  1.  At least five attacks with the features of 2-4
  2. Headache attacks lasting 4-72 hours.  (untreated or unsuccessfully treated)
  3. Headache has at least two of the following four characteristics.
    1. Unilateral location
    2. Pulsing quality
    3. Moderate or severe intensity
    4. Aggravation by or causing avoidance of physical activity
  4. During headache at least one of the following:
    1. Nausea and/or vomiting
    2. Photophobia (sensitivity to light) and phonophobia (sensitivity to sound)
  5. Not better accounted for by another diagnosis.
Success of migraine surgery depends largely on selecting the right patient.  In addition to confirming the diagnosis of migraine headaches by meeting the criteria above, I arrange for a Board Certified Neurologist to evaluate and confirm the diagnosis of migraine headaches.  We will then talk about the duration, severity, location, inciting factors, previous treatments, and other characteristics of your migraine headaches.  We will keep a detailed log/diary of your migraine headaches for one or more months.  Depending on the location and previous treatments, Botox may be administered to areas or the forehead, temple, and/or scalp.  If Botox is effective, this is a very good prognostic sign that migraine surgery will be successful.  This will also help narrow the site of nerve irritation and direct a very precise surgery giving the maximal chance of success.  
If Botox does not work at reducing migraines, surgery may still be successful.  For example, if migraines are triggered by nose irritation from a deviated septum, Botox will not be effective, but surgery to correct the deformity may partially or completely relieve this site as a trigger for migraines. 
Successful treatment is considered a reduction in migraines of 50% or more.  Over 90% of patients have experienced this reduction when properly selected.  Migraine surgery is an exciting new field of plastic surgery.  As a fellow migraine sufferer, I am proud to make this treatment available to the Phoenix / Scottsdale area.  If you suffer from chronic migraine headaches, I encourage you to schedule a consultation today to start taking control of your life again.

n  Jason Mussman MD