Editor's note

In addition to providing fresh clinical data and evolving surgical technique, Cosmetic Surgery Times seeks to present the most thought-provoking insights on the discipline from academe. In this piece, Dr. Philip Young elucidates his premise regarding the intriguing metrics of facial beauty. If you have a scholarly paper or concept you would like to share with your surgical peers, please e-mail us at TheEditors@cosmeticsurgerytimes.com
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Our understanding of facial beauty has not undergone any significant change since Leonardo Da Vinci developed the neoclassical canons. Some believe beauty is defined by the mystical number phi (1.618) that defines the proportions of the face. Others believe that "averageness" is beautiful. Many recent studies have now shown that these ideas are all incorrect. Other theories exist but the bottom line is that the answer has not been found.

Neuropsychologists have studied eye movements when people look at pictures of a face. They find that they concentrate on the eyes, nose and mouth and then other landmarks but return repeatedly to the eyes, nose and mouth. Specifically, the eye movements are centered predominately on the iris. When we think of how we talk to one another, we can come to the realization that we do indeed spend most of our time focusing on the iris from an everyday point of view.

Figures

SYMMETRY, BEAUTY The face is simply a collection of shapes within a larger oval with the eyes, nose and mouth as major shapes within the oval. When people are asked to judge whether a circle within a box is more aesthetically pleasing right in the center versus an asymmetric position, the majority will prefer the central location. This preference for order applies in the face as well. Because the eyes, nose and mouth are the main structures of the face, the distance between them should be separated symmetrically. Within these major structures, the iris, nasal tip and lower lip are the primary COP or centers of the eye, nose and mouth.

THE EYES Hence, the distance from the pupil to midline, from the horizontal level of the pupil to the nasal tip, from tip to lower lip, and from lower lip to the mentum should all be three iws (Figure 2).

The size of the iris also determines the distance between all structures. Within the eye there are four COP (Figure 3). The first and primary COP is the iris. The next COP is two IWs high and three wide.

The second COP is explained by the following: the distance between the limbus to the medial or lateral canthus is one IW; the distance from eyelid ciliary margin to palpebral fold is 1/2 IW, which is also the distance from the lower lid margin to the bottom of the shadow produced by the pretarsal muscle bunching. This creates the 2 x 3 IW dimension of the second COP.

A patient with problem-free saline implants wishes to replace them with silicone. What does a physician do?

"I personally don't believe doctors should be doing that. Surgeons in general like to perform surgery. If one's only tool is a hammer, all one sees are nails," says Amy E. Newburger, M.D.

She adds, "I'm sure many doctors will replace" such implants, assuming FDA approval assures the products' safety. However, Dr. Newburger notes, "That's not what FDA clearance means — it's not the Good Housekeeping seal of approval." According to Michael Rosenberg, M.D., "At the end of a very careful discussion with the patient about the risks and benefits of additional surgery and silicone, I would fall back to the old axiom that if it ain't broke, don't fix it."

"The basic rule of thumb is, leave well enough alone," states Mark Berman, M.D., F.A.C.S. "If one is going to revise implants, one must advise patients that it opens a bit of a Pandora's box. There's a risk of infection or capsular contracture subsequent to the treatment." But if the pocket is well formed, he says that, technically, "All one is doing is exchanging for size, which is potentially a 10-minute procedure." As long as the patient understands the risks, switching to gel implants wouldn't be unethical, Dr. Berman says.

"If a woman is self-conscious because her breasts feel like water balloons and she wants them to feel more natural, then it sounds completely appropriate as long as it's reasonable and safe," he adds.

Thanks to the FDA's ruling, "Now anyone for any reason — provided they meet the requirements — can simply switch from saline to gel," says Angelo Cuzalina, M.D., D.D.S. "That's going to happen more and more often."

For him, this presents an ethical dilemma. "One sees a patient who's had a very nice result, and one realizes that, by changing implants, one may create a problem. Most of the women in this category are probably going to have something they don't like about the saline" most likely the ability to see or feel a degree of rippling, he says.

"I've had several patients already — and I expect to have a lot more from years past — come in wanting to switch," he says.

Editor's note

CST takes you interactive! Here we present Part 1 of this two-part "how-to" on increasing the visibility of your practice's web site in search engines. Read Part 2 by clicking to http://www.cosmeticsurgerytimes.com/SEOPart2

Ms. Roche

Search engine optimization is the art of trying to make your site receive high rankings in search engines, such as Google or Yahoo. This process is an art not a science because search engines will not reveal the algorithms they use to rank sites in order to preclude firms from manipulating their search rankings. Still, there are some fundamental steps you can take to increase the chances that your site will receive a higher ranking.

PRIORITY ONE Getting the right people to visit your site is your chief online priority. To take advantage of the search engines that can lead patients to your site, first you'll need to make sure your site is laid out with search engines in mind. Then you'll be ready to register your site with search engines, as well as implement more advanced search engine optimization strategies aimed at ranking your site ahead of the competition. The most important step is to identify the keywords that will lead patients to your site most effectively.

SITE LAYOUT STRATEGIES Before registering your site or implementing search engine optimization techniques, you and your webmaster have some homework to do. Write down the following questions and their answers to help identify: What's the purpose of your site? Who are you trying to attract? What services are you trying to tout? What information are you providing of value to potential site visitors? What distinguishes your services and your site? Why would someone want to visit your site initially? Why would they want to return? Once you've determined the goals of your site, you should analyze it to verify that it's laid out to meet these goals. This is likely to be the first phase in making it as useful as possible to patients, as well as to search engines. Be prepared to make some changes on your site at each stage of the process.

WORDS THAT POINT Site layout strategy is a very broad topic, and so we're going to focus on some essential techniques to create a search-engine-friendly site. One of the most important things you can do is identify the topics of information — or "keywords" — that you want people to know your site includes. Your task is to identify and feature on your site, as strategically as possible, the all-important keywords that will drive patients to your site from search engines. Effective keyword placement includes the choice of words used for link text that point people to information pages on your site, the actual text in paragraphs, and the placement of those words on the page — both visible and hidden —inside something called "meta tags."

AUTO INDEXING Your site may be indexed in an automated fashion by search engine "spiders" or "robots" (often referred to as "searchbots"), by human-powered directories, or ideally, by both. In order to search and then index your site, searchbots need to be able to read your site pages.

National report The traditional medical patient — one who puts medical decisions and trust in the doctor's hands — is becoming the consumer-patient, an empowered decision-maker with demands for safe, quality, evidence-based outcomes, service and more.

It is but one of the trends that will either derail or propel cosmetic surgery practices in the years to come, according to Hani Zeini, former executive vice president of Inamed Aesthetics.

Mr. Zeini, who presented recently at the American Society of Plastic Surgery Industry Forum, watched the medical cosmetic industry blossom during his tenure prior to the Inamed/ Allergan transaction last Spring. In Mr. Zeini's view, patients are driving a transition in the specialty which he characterizes as "from where the patient would once say to the doctor, 'I have this problem; fix me,' to 'This is what I want. Give it to me according to my specific needs, or tell me what else you can offer and show me your demonstrated, evidence-based outcomes.'"

SHARED STAKES In Mr. Zeini's view, within this new ecosystem, traditional plastic surgeons, cosmetic dermatologists and cosmetic surgeons are all fighting for what they believe is the last fee-for-service bastion. But the fighting is unnecessary, he contends. In fact, true success will depend on their meeting the needs of today's patients, not beating the competition. For as good as the cosmetic surgery space is, he predicts it will be even better in the future.

"The opportunities and future are limitless in this space. But we have to re-orient our thinking and our approach," he says. "The first step is to stop worrying about the turf wars."

SHOW ME THE OUTCOMES Mr. Zeini refers to the old guard, versus the new guard, versus the progression of the market. All are affected by the market drivers in the new ecosystem, including the advent of the consumer-patient. Equally as important is the demand for evidence-based aesthetic outcomes. No longer an issue only in other medical realms, the call for evidence-based outcomes has filtered into cosmetic surgery. "We are now applying to our aesthetics needs how we act in our normal life as consumers. The consumer-patient no longer accepts promises; they want to see evidence," he says.

IN WITH THE NEW Those physicians who will struggle in the future are those who cling to the old-guard thinking that patients should simply trust and go along, Mr. Zeini says. He admits the dynamic of the consumer-patient and demand for evidence-based outcomes puts pressure on care delivery, but says that progressive practitioners will win.

"Those who understand that dynamic and offer what patients demand in a way that exceeds their expectations are going to reap the most benefit," he says.

Mr. Zeini projects that this goes far beyond what one traditionally thinks of as customer service. Consumer-patients are not merely going to a doctor to be treated well, he believes. Rather, they are pursuing results to correct what they perceive as deficiencies.

"The evidence-based clinical outcome must rule. Service is the icing on the cake," he explains.

EXPERIENCE TOUCHPOINTS According to Mr. Zeini, physicians can answer consumer-patient demands, in part, with "before care" — prior to service— when patients are still in the decision-making process. In this phase, the physician walks step-by-step through the patient's options, the procedure's value (outcomes proof), the process itself, and then appropriately describes what the patient's expectations, experience and outcome should and will be.

National report The cosmetic surgery arena became one of the darlings of Wall Street in 2002 when Botox (Allergan medical) hit the market with the U.S. Food and Drug Administration's cosmetic nod of approval.

Since then, cosmetic surgery has been looking better and better to investors. Thomas Gunderson, medical technology stock analyst, with Minneapolis, Minn.-based investment banking firm Piper Jaffray & Co., tells Cosmetic Surgery Times that Wall Street's view of cosmetic surgery has evolved right along with technology.

Mr. Gunderson

THE BOTOX BOOM As silicone gel breast implant manufacturers weathered years of lawsuits and the inability to fully market their technology, cosmetic surgeons were using Botox off-label to ward off signs of aging. It was the FDA's approval of Botox to treat frown lines which got Wall Street's attention.

"I think it surprised everybody how fast [Botox subsequently] took off," notes Mr. Gunderson. "Now that an American corporation could put its advertising and media clout behind it — the numbers and the excitement went up; it opened up a whole new technology area for investors to look at," he says.

TECH DOLLARS Botox preceded a line of technology-driven wrinkle fighters: Restylane, Radiesse, Juvéderm, Thermage™, Titan, Reliant and Apsala, to name a few.

"Restylane also had a very steep curve of adoption and revenue generation and created wealth," Mr. Gunderson says. "Investors who bought in early to the Restylane story did well, as those who bought in early to the Botox story." The technology floodgates in cosmetic surgery have opened, the analyst says, with a flurry of lasers, injectables and healthy competition. For the companies that have had a substantial revenue base in cosmetic surgery for at least the last two years, there seems an unquenchable thirst for product, according to Mr. Gunderson.

"This gets into the aging of America," he says. "The demographic — the boomers — who used to be hippies and did not seem to care too much about what they looked like. Now the front end [of this generation] is hitting 60 years old and they seem to have a bottomless desire to look good. That is very interesting to people who want to invest in new technologies." Another trend he predicts will impact cosmetic surgery is the obesity epidemic, the popularity of weight loss surgeries and the resulting need for massive amounts of skin removal.

DUAL SERVICE APPROACH The changing cosmetic surgery practice is on the front burner, according to Mr. Gunderson. Cosmetic surgeons who have reached professional pinnacles in their careers, earned by long years in medical school and training and experience, should take note that having high skill levels does not preclude the need to offer clients low-level services. Those ignoring low-end cosmetic surgery procedures might find that consumers look the other way for one-stop shops that help them look younger. Cosmetic surgery practices should offer both.

"If you want to be successful from a surgical career standpoint, that is up to the doctors," he says. "But business is what I know, and business would be better served by having womb-to-tomb [services]." Mr. Gunderson thinks that technology turf wars will also work to zap away some of the comfort of those highly trained cosmetic surgeons. High skill levels often translate to good surgical outcomes. But, today, he says, technology exists that allows just about anybody to achieve reasonable results.

"You end up with specialists who have to work harder to keep their territory because you have everybody from ophthalmologists to gynecologists to internists doing cosmetic procedures. Ten years ago, that wasn't the case," Mr. Gunderson says.

Chicago Chin augmentation is surgically achieved in one of two ways: an alloplastic implant or manipulation of the patient's own bone through sliding genioplasty.

"Genioplasty is a more versatile technique than an implant," Rodger Wade Pielet, M.D., tells Cosmetic Surgery Times .

Although the procedure has been talked about in the literature for decades, few plastic surgeons practice this technique. Dr. Pielet performs a genioplasty approximately twice a month and has performed the procedure in more than 50 patients to date.

Dr. Pielet

Although the implant procedure for chin augmentation is more straightforward, potential disadvantages of implants include long-term shift, infection, erosion, and problems with teeth. Furthermore, a deficiency in chin projection is often accompanied by a vertical deficiency and that vertical aspect cannot be addressed by an implant. An implant is more appropriate for someone who wants to effect a small advancement of the chin or for a patient whose oral hygiene precludes eligibility for sliding genioplasty. Implants may also be more appropriate following maxillofacial trauma.

Left, Figure 1: Pre-operative photo of 41-year-old patient with retrogenia and a vertical deficiency with mentalis strain. RIGHT: Digital simulation of expected results following sliding genioplasty procedure.

Because the procedure does not affect occlusion, overbite or underbite is not addressed. Dr. Pielet notes that issues related to oral surgery should be referred to an oral surgeon or an orthodontist.

Although bone resorption after genioplasty has been reported in the literature, Dr. Pielet has not seen this in his patients. In his experience, he has seen only one complication associated with genioplasty. Four to six weeks post surgery, an investigation of persistent swelling in the floor of the mouth revealed that the patient had actually experienced an injury that was not located at the site of the surgical cut for the genioplasty.

Figure 2: Three sets of pre- and post-operative photos of the same patient showing actual sliding geniopasty results (10 mm advancement and 3 mm vertical lenthening).

Typically, genioplasty is performed in combination with other facial surgery, such as rhinoplasty, to establish facial balance and harmony.

"Computer imaging helps the patient visualize the change in appearance that we think we can achieve," explains Dr. Pielet, who performs the procedure in as many men as women. The ideal candidate is healthy, has good oral hygiene, good teeth and bones, and takes an active part in pre-surgical discussions.

National report Big changes are in store in cosmetic surgery — changes fueled by evolutions in demographics, cultural factors, consumer and payer demands, technology and the transformation of the cosmetic surgery marketplace.

Dr. Morrison

POSITION FOR GROWTH There is typically a close correlation between medical care and age. The need for general medical services generally peaks at around age 75 and diminishes in the 85-and-older population, according to Dr. Morrison. However, that's not true in plastic surgery, he says. Peak usage in cosmetic surgery is in the 35-to-50-year-old age range.

Thus, the big message to cosmetic surgeons on the demographic side, advises Dr. Morrison, is to focus on procedures that will make aging baby boomers happy. He stresses the importance of establishing long-term relationships with cosmetic surgery patients, what he calls their "longitudinal management." In his view, the patients who come in for less invasive procedures in their 40's are the prime candidates for the more extensive cosmetic surgery which these same patients may seek into their 60's and 70's. The obesity issue in the U.S., too, is at a critical stage, he notes, and surgeons should position themselves for the rising demands of post-bariatric surgery patients for total body recontouring procedures following massive weight loss. Cultural drivers are also feeding the cosmetic surgery frenzy. "Our culture of celebrity, appearance and the fact that pornography has been mainstreamed to the point that often celebrities look like porn stars is fueling the general acceptance of cosmetic enhancement," he says.

BATTLING FOR SHARE Beyond cosmetic surgery, government, insurance and consumer purchasers are looking for value — not just quality and not just low cost, Dr. Morrison contends.

"The old premise was the more expensive, the better it was and the more you got. That is being challenged across the board in medical care. What we are seeing is quite the reverse: more is not better; more is often worse," he says.

The bad news for the field, according to Dr. Morrison, is that medicine is becoming retail, with physicians of all types hopping on the fee-for-service bandwagon rather than deal with reimbursement bureaucracy and costs within their own subspecialties. As such, many are eyeing cosmetic surgery services, so that cosmetic surgeons and dermatologists will increasingly have to battle for market share.

Technology, too, is fueling the increased competition, with the rising popularity of less invasive procedures that are easier to perform, he says.

"Botox is a classic example of something that doesn't require seven years of surgical training to do," he adds. The fact that the aesthetic marketplace is also shifting from local to global is adding lighter fluid to the competitive coals, says Dr. Morrison. As a result, tomorrow's cosmetic surgeons will not only be competing with other physicians who do what they do in the same city or town, but also with an ever-broadening spectrum of primary care and specialist doctors worldwide.

Mark A. Price, M.D., was drawn to medicine at a young age. He was fascinated by the character, Hawkeye Pierce, portrayed by Alan Alda on the television show M*A*S*H*, who handled trauma and dealt with potential devastation by bringing levity to life-altering events. But it would be his love for creating art and his desire for variety that would sway him to plastic surgery.

Dr. Price, who is published in the areas of facial trauma and fracture, says, "I try to make the experience as atraumatic as possible, with a laugh and a trusting relationship. This helps to get people through, whether it is a mastectomy reconstruction, major melanoma excision and reconstruction of the face or an elective cosmetic procedure," he says.

PLASTIC ATTRACTION While the T.V. Character, Hawkeye, inspired Dr. Price to pursue a medical career, his was a winding journey toward deciding on a specialty.

"Mind-brain issues always fascinated me, and I majored in neuroscience at Stanford, but I dismissed it because you just were not able to regularly and reliably take patients through an experience and get a great result in the end," Dr. Price says. "I also looked at trauma surgery — hoping to undo devastating acute traumatic events — but realized that it requires pretty routine protocols and does not have an enormously creative element to it."

LIFE SPECTRUM An only child who emigrated with his parents from England to the United States at age four, Dr. Price says he has always had a creative side, and has enjoyed drawing and painting since childhood. He was attracted to plastic surgery because it is a creative endeavor requiring practice over a lifetime.

"In medical school, I realized that plastic surgery was unlike any other surgical specialty in the breath and scope of what the surgeons did on a daily basis. It helps the full spectrum of patients — from infants to elderly — and includes the range of surgical possibilities, from microsurgery to taking the body apart and reassembling it on a macro scale," he says.

ON THE ROAD His desire to undo individual devastation is not limited to the work he does stateside.

Dr. Price first set out during his residency at Stanford to do overseas volunteer mission work with Interplast, a long-established group of plastic surgeons that originated at Stanford. In his chief year, he traveled to the Thai-Cambodian border, Peruvian Amazon and the coast of Brazil.

"[We were] primarily fixing cleft lips and palates on these three trips. We went to some of the poorest areas to find some of the unluckiest babies in the world — those who had been born with major facial disfigurement which is thought of in some of those cultures as a sign of evil or the devil. Sometimes, these children are ostracized or sent away from their families. So, to be able to dramatically impact these babies' lives in a matter of a couple of hours' of surgery and change lives in a positive way for no material incentive is tremendously rewarding," Dr. Price reflects.

Earlier this year, Dr. Price traveled on a charity medical mission with the Peruvian-American Medical Society to the High Andes in Ayacucho, Peru, which is at an altitude of about 9,000 feet. The Peruvian-American Medical Society estimates that there is one doctor for every 12,000 people in Ayacucho, the third poorest state in Peru.

National report — Early experience with a saline-filled implant (FulFil, Juva Medical) suggests it provides safe and predictable permanent lip augmentation with important advantages compared to existing alternatives, Miles H. Graivier, M.D., a plastic surgeon in private practice in Roswell, Ga., tells Cosmetic Surgery Times .

The device, currently approved by the U.S. Food and Drug Administration (FDA) for use as an intranasal splint, is being employed in an off-label capacity for lip augmentation and in other facial soft tissue augmentation procedures. Consisting of a very thin, outer expanded polytetrafluoroethylene (ePTFE) sheath with an inner silicone liner, the implant is filled intra-operatively with saline through a self-sealing tube.

Dr. Graivier

"With the introduction of the hyaluronic acid-based products, we currently have some very good injectable fillers for use in lip augmentation, but the improvement achieved with those materials lasts only for four to six months. Options for permanent lip augmentation have been less than satisfactory. For example, Goretex is firm, palpable and immobile. Implantation of a rolled Alloderm graft can result in a more natural appearance, but the outcome is unpredictable, especially in patients older than age 55 where there is a greater tendency for it to disappear over time," says Dr. Graivier. "In contrast to those latter modalities, the saline-filled lip implant is soft, pliable and stretches with lip movement to produce a cosmetic outcome that both looks and feels completely natural."

Figure 1: (left) Pre-operative view of 25-year-old patient. (Right) Patient is shown two weeks post implant. The implant in the upper lip is 5 cm in length and 4.5 mm in diameter and filled to 0.4 cc. The implant in the lower lip is 4 cm in length and 4.5 mm in diameter and filled to 0.3 cc. The implants are available in 4 cm and 5 cm lengths and 4.5 mm and 6.5 mm diameters for larger augmentations.

"These fill volumes are guidelines, but the surgeon can slightly under or overfill the implant to achieve the desired result," Dr. Graivier says.

To implant the device, once the incision is made, a dissection is performed above the orbicularis muscle, in the potential space between the muscle and subdermal plane, using a small curved scissors that is advanced across the midline to the opposite end of the lip. The deflated implant is placed into the pocket and filled with saline. After checking that the position and size are correct, the fill tube is removed and the fill hole seals itself.

After surgery, patients receive a short course of oral antiviral and antibiotic prophylaxis, and are instructed to apply ice and avoid excessive puckering movements of their lips.