Think you know your way around the hills and valleys of an aging face? Think again, urges one plastic surgeon who is using 3-D photos of faces to challenge assumptions about how our appearances change over time.  

The nose gets larger and its tip plunges over time, right? Wrong. Lower eyelids sag as we get older? Nope. The nasolabial fold grows because our cheeks slide down? Not really.

Dr. Lambros"If we’re going to be the people who understand the face the best, we need to understand how the face ages. But we don’t," says Val Lambros, M.D., FACS,  a Newport Beach, Calif., plastic surgeon. "The goal here is simple: To show true, valid pictures of facial aging."

Dr. Lambros spoke about his facial research earlier this year at Plastic Surgery The Meeting 2016 in Los Angeles and in a conversation with Cosmetic Surgery Times.

In 2005, Dr. Lambros began using a 3-D camera to take photos of about 1,400 plastic surgeons and about 450 others. The photos can be averaged to reveal how typical people age over time.

"One then can see, for example, the average face of all the women from 20 to 30 and all the women from 68 and up," he says. "I then made an animation of the two so you can see the average aging pattern of young to old faces," he says. "It is not an artist's conception. It is the true real way that faces age." 

Here are some of the findings reported by Dr. Lambros:

The nose recedes.

"I had seen evidence that the nose recedes in earlier studies of mine, but this research shows that the effect is universal enough to be in the averages," he says.

The tip of the nose doesn't plunge with aging.

This is an illusion created by the shortening of the lip and changes in the posterior nose, he says.

NEXT: The Lower Eyelids Don't Fall

The lower eyelids don't fall.

The eyes appear smaller as we get older, he says. But don't blame the lower eyelids.  "All of us think lower lids fall down because those are the kinds of patients we see. In fact, the average lower lid rises."

Instead, he says, it's the upper lid aperture that gets smaller, helping to explain some of the smaller appearance of the eyes. 

There's more to the nasolabial fold than just the cheek.

Procedures to improve the nasolabial fold are among the hallmarks of cosmetic surgery. But why does the fold become more prominent — and endlessly aggravating for many people — as we age?

"Everyone has thought that the nasolabial fold comes from the cheek sliding down. That's because pulling on the cheek makes the fold look better," Dr. Lambros says. "What this research shows is that the nasolabial crease gets partially formed by the lip thinning as well."

Men age similarly... and differently.

Men's faces behave in similar ways to women's faces during aging, but there's an important exception: Older men's heads are about 5 mm bigger than when they are younger.”

Changes in bone aren't that significant.

Changes in bone aren't as important as you may assume. "Soft tissue alone can explain lip and nasal base changes, not bone," he says. “Soft tissue changes are big, and hard tissue changes are small. That occurs all over the face, although hard tissue does make a difference in the posterior mandible." 

Why does all this matter? "When you can see the change of the tissues and have a picture of that in your mind from studies like this," Dr. Lambros says, "you have a complete view of how the face has changed, and you make different decisions."

Disclosures: Dr. Lambros reports no relevant disclosures. 

Cosmetic surgeons can use relatively low volumes of a 20-mg/mL, smooth, highly cohesive, viscous hyaluronic acid (HA) filler to correct mid-face volume loss, with high rates of patient satisfaction — even at 12 months after injection, according to a newly published study. 

Dr. Wilson“The study findings suggest that, in daily practice, physicians can provide appropriately selected patients with long-lasting, cost-effective correction using small volumes of this HA filler,” the study’s lead author Monique Wilson, M.D., a dermatologist at Cosmetic Laser Dermatology in San Diego, tells Cosmetic Surgery Times. For reference, the pivotal aproval trial used mean injection volume of 6.65 mL, a large and perhaps unrealistic volume in many practices.

Dr. Wilson and colleagues conducted a two-center, retrospective study of 61 adults (including 58 females) being treated for mild to severe facial volume loss. They used an average initial treatment volume of 1.6 mL, and write at 12 months that 42 of 51 patients, or 82%, reported very much or moderate improvement; 84% were satisfied with their results. At one year, 29 patients, or 48%, elected to have touch-up treatments, for which the researchers used an average HA filler volume of 1.4 mL.

There were no significant differences in initial injection volume or likelihood to get touchup treatment among the eight patients who were dissatisfied at 12 months and those who were satisfied.

Most patients reported that they would elect to have the procedure again, at all time points studied (one, three, six and 12 months). Adverse events were mild, and all resolved spontaneously within 14 days. At the two-year follow-up, there were no reports of delayed adverse events. Patients experienced only mild adverse events — all of which resolved on their own within 14 days. The researchers found no reports of delayed adverse events at the study’s two-year follow-up.

NEXT: Pivotal Trial Comparison

Pivotal Trial Comparison

Researchers in the pivotal approval trial for a smooth, highly cohesive, viscous, 20-mg/mL HA filler used a mean injection volume of 6.65 mL. But to inject such large volumes in daily practice often isn’t realistic, according to the paper.  

“While the efficacy, satisfaction and safety results of the pivotal trials examining the 20-mg/mL, smooth, highly cohesive, viscous HA filler were remarkable, it wasn’t always clear how those results would translate to daily clinical practice, where most patients do not need, or cannot afford, large volumes of HA filler,” Dr. Wilson says. “This study sought to bridge the gap between those pivotal trials and what is happening in the office every day. Other information gathered in the study, including need for touch-ups, adverse events, and willingness to undergo the procedure again, lends us evidence with which to better counsel our patients.”

Whether what these researchers found translates to other filler types is unclear, according to Dr. Wilson.

“Our study only examined the 20-mg/mL, smooth, highly cohesive, viscous HA filler which has unique rheological properties that make it particularly well-suited for mid-face volumization. It would be difficult to generalize these findings to all HA fillers; thus, studies examining the efficacy of low-volume correction with other HA fillers are certainly warranted,” she says.

Disclosures: Dr. Wilson reports no relevant disclosures.

Botox still boasts the biggest name in neurotoxins, but competitors have added a new wrinkle for cosmetic surgeons and their patients: Is Botox the best? Or should they try Dysport or Xeomin instead?

Dr. GutowskiKarol A. Gutowski, M.D., FACS, a plastic surgeon based in Chicago, says there aren't many clinical reasons to choose one over the other. "While there are minor differences between them, these products seem to be much more similar than different," he says. "I'm not going to say they’re interchangeable, but they’re pretty close to it."

But this doesn't mean the three drugs are all the same, says Dr. Gutowski, who spoke in a conversation with Cosmetic Surgery Times and at a presentation during Plastic Surgery The Meeting 2016 in Los Angeles. Doses and costs differ, he says, as do the ideal patients for each medication. And other factors may play roles too.

According to Dr. Gutowski, there are issues to consider when prescribing a botulinum neuromodulator for cosmetic purposes.

Is Faster Onset Better?

In Dr. Gutowski's experience, Dysport has the fastest time to onset — one to three days. "It kicks in a few days earlier, but most people don’t come in and say 'I’ve got to look good this weekend,'" he says.

Does the Patient Have a Favorite Brand?

Dr. Gutowski says he educates his patients about the three options and doesn't stand in their way if they express a preference that is appropriate for them. 

"They may have been getting Botox for a long time; they may have an account that gets them a rebate; they may get points. If they like that, that’s fine," he says. "I have one patient who likes Dysport, and some like Botox because it's the brand everybody knows."

NEXT: Is the Patient Price-Sensitive?

Is the Patient Price-Sensitive?

"Some are willing to pay a little bit more for a brand they know, but others don't care as long as it will work," Dr. Gutowski says. "They'll say, 'Give me the one that's most cost-effective.'"

According to him, Xeomin is the least expensive of the three drugs. Dysport is in the middle, and Botox is as expensive or more expensive than Dysport.

He recommends keeping an eye on the usage of the drugs at your clinic. If volume is lower, it may not be financially wise to offer more than one or two of the three drugs because of the risk of waste, he says.   

Is One Brand More Appropriate for the Patient?

"There are some people who get excellent results with all three products," Dr. Gutowski says, but there may be exceptions.

Dysport, for example, is not appropriate for people with cow's milk allergies, and it may cause more injection pain. It also seems to have a wider diffusion area, he says, "but how much it matters clinically is a little harder to say."

NEXT: Does the Patient Need a Duration Boost?

Does the Patient Need a Duration Boost?

Dr. Gutowski says he hasn't noticed a difference in the duration of effects between Botox, Dysport and Xeomin. Research backs him up: A 2016 systematic review examined use of the drugs as treatments for wrinkles and found "there is insufficient evidence demonstrating an increased duration of benefit of any one medication relative to its competitors."

But Dr. Gutowski has seen the effect of neurotoxins wear off in less than three months in some patients. What to do? One option is to try to increase the duration of wrinkle relief through the use of zinc supplementation.

Dr. Gutowski points to a double-blind, placebo-controlled 2012 study that found the effects of the toxins lasted longer in 92% of subjects who took a zinc and phytase supplement; the average increase in duration was almost 30%.

The phytase product — which claims to provide "nutritional support to enhance the effectiveness of botulism toxin injections" — costs $40 per treatment. It is also known as Zytaze.

Disclosures: Dr. Gutowski has a speaker relationship with Suneva Medical.

The FACE-Q Eye Module, a patient-reported outcomes measure, is a promising practice, research and quality improvement tool for surgeons who perform cosmetic eye treatments, according to an original investigation, published online September 15, in JAMA Facial Plastic Surgery.

Surgeons, including FACE-Q developers, at plastic surgery clinics in the U.S. and Canada reported on 233 cosmetic eye surgery patients who had completed the FACE-Q cosmetic eye treatment section before and after their surgeries. FACE-Q is a patient-reported outcomes measure that includes more than 40 independently functioning scales and checklists measuring appearance appraisal, care process, quality of life and adverse effects for areas of the face, including the eyes. The four scales in the FACE-Q Eye Module measure (1) appearance of the eyes, (2) upper and (3) lower eyelids and (4) eyelashes. The module also includes a checklist measuring post-blepharoplasty adverse events.

Related: Kaolin and eyelid surgery

The module takes only minutes to complete, according to an accompanying commentary on the paper by Lisa E. Ishil, M.D., MHS.

The 233 patients in the study represented an 81% response rate. The researchers found higher scores on the eye scales correlated with fewer adverse effects, including eyelid scars, dry eye and eye irritation, according to the study’s abstract.

According to the FACE-Q scales, participants reported notably better scores on the appearance of their eyes overall, as well as specifically on the upper and lower eyelids, post- versus pretreatment. And, in the pretreatment group, older age patients tended to report lower scores than younger patients on scales measuring appearance of the eyes and upper and lower eyelids, according to the study’s abstract.

This and other patient-reported outcome tools let surgeons learn from patients about patients’ perceptions of their outcomes. Use of the tools for gathering patient feedback is a growing opportunity in medicine — the data from which can be incorporated into the ultimate evaluations of surgical outcomes, according to the commentary.

“One can imagine a time in the not too distant future when prospective patients inquire about surgeon [patient-reported outcomes measure] data for procedures in the same manner they now inquire about before and after photographs,” Dr. Ishil writes. “We surgeons will be best served by having these data available proactively.”

Decades ago, plastic surgeons helped patients understand the size of their future enhanced breasts by placing bags of rice in their bras. We've come a long way since then. But plastic surgeon Kevin Small, M.D., says more progress is still needed to help women accurately understand how breast implants will affect their busts.

"They aren’t coming back disappointed. They’re just not getting the correct picture," says Dr. Small, assistant professor of Plastic Surgery at Weill Cornell Medicine.

So what's the solution? Three-dimensional imaging, says Dr. Small. He estimates that it's now used by only 5% or fewer of plastic surgeons who perform breast implant procedures.

"It's a better estimation tool to show the patient," he says. "It's becoming more common as an educational tool that allows patients to see what their bodies will look like in a three-dimensional picture."

Dr. Small told an audience at Plastic Surgery The Meeting 2016 in Los Angeles about the weaknesses of pre-operative "bra sizing" and the potential for 3-D imaging.

NEXT: Implant Sizer Shortcomings

Implant Sizer Shortcomings

"When you're putting an implant in a bra, you’re overestimating the total volume because the bra has volume itself," he tells Cosmetic Surgery Times. "The bra artificially displaces the implant medially and superiorly. That’s what a bra does: It's supposed to move breasts to create more cleavage."

Current pre-operative bra-sizing techniques also distort volumetric distribution, Dr. Small believes. 

So should breast-implant "sizers" no longer be used to assist women in understanding how implants will affect them? According to Dr. Small, studies suggest that many women are satisfied with their breast implants. Still, the inaccuracy is a problem. "It's not only that they’re not selecting the right volumes," he says. "They also can’t visualize it."

He suggests that plastic surgeons need to be upfront with patients about the limits of traditional pre-operative bra sizing. "The most important thing is to tell patients that it overestimates the bra volume and also distorts the shape."

He also recommends 3-D imaging because he believes it offers accurate and reproducible perspectives on how implants will affect patients. Through 3-D imaging, he says, patients "can see what their breast will look like with the implants in. It temporarily puts the implants underneath the breast envelope and simulates what the breasts will look like."

However, Dr. Small cautions that even with 3-D imaging it's just a prediction. “Patients have to know that beforehand. It doesn’t account for how the tissue envelope changes over time. As people get older, their breast shape changes and starts to sag."

Still, he says, "It's another tool."

And in the future, he says, 3-D printing technology may allow the creation of torso models that plastic surgeons can use in the operating room "to remind them of what the patient wants to look like." This is especially important, he says, "since patients look different when they’re lying down versus sitting up and standing."

In addition, he says, patients could take the miniature torsos home so they can assess them with their families prior to surgery.

Dr. Small has no relevant disclosures. 

There are many ways to carve a turkey (and as the household surgical pro, we’re betting the honor falls to YOU), but what’s your preferred approach to treating turkey neck? Given the holiday, we thought it would be an appropriate time to take a look back at our most popular neck treatment stories of 2016:

Non-surgical neck tightening: What works best? 

Surgical options, such as the neck lift, facelift or platysmaplasty, still reign for optimal outcomes in neck tightening. But there’s good news. Nonsurgical options are getting better and better results, according to Jason D. Bloom, M.D., a facial plastic surgeon in Ardmore, Penn. » Read More

Neck contour: Open vs closed technique

Somebody with a sense of humor created the “#turkeygobbler” Twitter hashtag for a session about optimizing neck contouring at The Aesthetic Meeting earlier this year in Las Vegas. Funny stuff. But ridding patients of their troublesome wattles is a serious, difficult and potentially dicey business for plastic surgeons. Many aren’t comfortable with “opening the neck,” often because of concerns about safety. On the other hand, some surgeons feel excessive caution can lead to suboptimal results. Bottom line: Experts disagree on the answer. » Read More

NEXT: Can we offer patients a no-knife neck lift?

Can we offer patients a no-knife neck lift? 

“We can’t treat the neck as aggressively as the face … but I think we’re broadening the number of things we can do nonsurgically." ~ E. Victor Ross, M.D.

Read More of Dr. Ross' perspective on skin tightening, fat removal and heat.

Rethinking complete platysma transection

In a recent study, Mario Pelle Ceravolo, M.D., a plastic surgeon practicing in Rome, Italy, critically looked at his own series of 150 consecutive complete platysma transection necklift patients and suggests the specialty should reconsider what the most appropriate procedure might be for correction of the anterior neck. » Read More

Dr. UmarSanusi Umar, M.D., a clinical instructor of medicine in the Division of Dermatology at University of California at Los Angeles, describes a series of 122 patients in which he used body hair transplants to treat baldness. Results from the series, published November 2016 in the Aesthetic Surgery Journal, suggest that using follicular unit extraction (FUE) to harvest body hair to treat baldness is a viable option if one chooses the right patients.

Dr. Umar, who has a U.S. patent for the UGraft and UPunch technologies (Pro-Dex) used in the study, documents the experiences of patients at his practice from 2005 to 2011. He preselected these patients for having adequate body hair from the beard, trunk and extremities to transplant to the scalp. He also reports on what the patients who responded to an emailed survey had to say about their outcomes.

Body hair transplant candidates often are those who lack head donor hair to treat scalp baldness and must have a lot of good quality hair in the beard or on other body areas. Dr. Umar writes that shorter and finer leg hair can be used to treat hair loss at the hairline and temples. Beard hair, which is coarser, is better for creating density and repairing surgical scars.

Something to keep in mind: Body hair tends to retain its characteristics after being transplanted. As a result, it’s important to adequately match follicle diameter, hair color, curliness, texture, growth rate and shaft angle to the recipient site, according to Dr. Umar.

NEXT: Hair Transplant How-To

Hair Transplant How-To

Dr. Umar used the previously described follicular unit extraction, which generally involves transplanting about 1,500 to 1,800 grafts in an eight- to nine-hour operation, divided into graft extraction and placement.

He performs graft extraction with a hypodermic needle with a modified tip, called the UPunch Rotor. Dr. Umar describes it in the paper as having a circumference that is flared outward to form a punch-like instrument mounted on a rotary tool — a modification that minimizes graft damage and lessens follicle injury.

When it comes to extracting gray hairs, Dr. Umar uses only 18-gauge needles because using smaller punches could increase the risk of disrupting follicle integrity and viability. He hydrates grafts with a piece of wet gauze, using a two- to three-minute interval between scoring and follicle removal. Dr. Umar automated this process with his UGraft Revolution.

Because some grafts separate from all tissue attachments following UPunch Rotor scoring, Dr. Umar uses a the “FUE swipe maneuver” to quickly identify and remove the follicles, as well as store them in physiologic media, separately ahead of attached grafts. This involves rubbing wet gauze over donor areas soon after scoring 50 to 100 follicles.

Dr. Umar leaves postoperative non-head hair donor sites open and coats them with bacitracin or Neosporin ointment (Johnson & Johnson Consumer) for seven days post-op, twice daily. He also uses triamcinolone lotion 0.1% once daily, the first three days post-op.

NEXT: Patient & Peer Input

Patient & Peer Input

There were 79 patients who responded to the survey, an average 2.9 years after their last surgeries. On a scale of 0 to 10, with 10 being the highest, patients reported an average 7.8 for healing status, hair growth in recipient areas and overall satisfaction with surgery.

Dr. BaumanHair transplant surgeon Alan J. Bauman, M.D., medical director of the Bauman Medical Group, in Boca Raton, Fla., says he uses body hair transplants in appropriate candidates.

“In my practice, body hair is used when scalp donor follicles are limited by previous surgery or other factors. Patients who want more density but have limited scalp donor are typically excited with the prospect and the results of using body hair to accomplish their hair restoration goals,” Dr. Bauman tells Cosmetic Surgery Times. “I’ve successfully used FUE to extract body hair follicles for implantation into the scalp for density and for scar coverage. Mainly, we use beard hair because it is the most robust and has long anagen (growth) cycles. However, FUE harvesting of follicles from the chest, abdomen, extremities… even pubic and axillary harvesting is also possible.”

According to Dr. Bauman, transplanting mixed scalp and body hair into the crown area is effective. He says patients who have old-style linear scars from strip harvesting are the most thrilled with the use of body hair to camouflage those telltale scars.

“My experience with FUE since 2001 has led us down this path, and I have also found that patients, when selected properly, are quite happy with the results as Dr. Umar has described,” Dr. Bauman says. “My caution to hair transplant novices is to be careful to explain to patients the differences in hair quality of scalp versus body hair follicles and to avoid areas where these differences in the transplanted hair quality might be more noticeable, like the hairline for example.”

A plastic surgeon critically looked at his own series of 150 consecutive complete platysma transection necklift patients and suggests the specialty should reconsider what the most appropriate procedure might be for correction of the anterior neck.

In a recent study, Mario Pelle Ceravolo, M.D., a plastic surgeon practicing in Rome, Italy, and colleagues studied the use of a major neck rejuvenation procedure, combining full neck undermining with complete platysma transection and midline platysma approximation.

The prospective study was conducted between 2010 and 2014, evaluating patient satisfaction and recurrence rates of anterior skin laxity and platysma bands. The researchers reviewed 138 of those patients at three months and 96 cases at one year. During those reviews, patients completed questionnaires designed to gather their input on the procedure.

They found that 100% of patients were satisfied at three months, but that dropped to 76% of patients at one year. Results, according to what the surgeons saw, began to decline at one year, when 48% of patients appeared to have anterior neck skin excess and, in 45%, the bands were recurring.

While the results from the major cosmetic procedure were satisfactory in most patients, the authors note the technique’s many downsides, including that “… it is time consuming, there is the risk of iatrogenic deformities unless it is carried out precisely, the postoperative recovery is often very long, and there is a significant failure to maintain long-term correction.”

NEXT: Alternative Approaches

Dr. Jacono

Alternative Approaches

Facial plastic and reconstructive surgeon Andrew Jacono, M.D., says that he has witnessed the same things in his practice with the complete platysma transection necklift.

“My way of avoiding those problems was to abandon those techniques that I was taught and to start doing a different procedure,” says Dr. Jacono, who practices in Manhattan and Long Island, New York.

According to Dr. Jacono, when surgeons do face and neck lifting surgery, the most common place to have failures is in the neck.

“The complete platysma transection necklift is one of the more aggressive procedures that has been popularized among plastic surgeons during the last two decades. The theory behind it is that if you cut from the center of the platysma in the middle of the neck, all the way across to the lateral part of the neck, you’ll deactivate the muscle so that the muscle won’t droop as much,” Dr. Jacono says. “Anybody who does a lot of face and necklifts, and that’s primarily what I do in my practice, sees that oftentimes after two years or more, the results of a necklift might not be as long as we’d like and other deformities can show up as a result of all the maneuvers we do on the muscles.”

As a result, Dr. Jacono published a paper in 2011 on his minimal access deep plane extended vertical facelift approach, which includes an extended lateral platysmal flap elevation, to prevent the need for anterior platysmal plication and platysmal myotomy.

Dr. Ceravolo also dramatically changed his approach to the surgical necklift, and his results will be published February 2017 in Plastic and Reconstructive Surgery (PRS).

Dr. Ceravolo“After many years of carrying out very aggressive procedures on the neck, I realized that very few of our patients accept to be away from social [activities] for four to eight weeks, and even [fewer] of them accept some of the risks linked to complete neck undermining ( i.e., long term skin induration, irregularities of the contour, etc.),” Dr. Ceravolo says. “For this reason, I have dramatically changed my approach to neck rejuvenation [for the last] six years. I am now using a technique, which I call Lateral Skin-platysma Displacement (LSD), which can obtain similar or even better results than the most aggressive techniques and still avoid any submental incision, anterior neck undermining and many of the risks that these maneuvers entail.”

The result of the revised approach, according to Dr. Ceravolo, is patients are more willing to undergo a procedure in which they achieve tightening of the skin laxity over the anterior neck and diminished platysma bands, in a shorter recovery time and with fewer side effects.

Disclosures: Drs. Ceravolo and Jacono report no relevant disclosures. 

With six advanced medical degrees between them, Alexa Nicholls Costa, NP, and Alexandra Rogers, NP, share a passion for education and aesthetics.

As co-founders and co-owners of LexRx, a boutique aesthetic practice in two locations in the Boston area, they offer treatment limited to “Lips + Lines + Lashes." Their interactive website (www.lexrx.co) features an illustrative menu of services and before-and-after photos, which are creatively trademarked as The LexRx LineUp.

“We found that millennials, in particular, are interested in both preventative and corrective procedures,” Costa tells Cosmetic Surgery Times. “However, it can be difficult for new clientele to understand appropriate indications for Botox and fillers. With the help of our graphics team, we created a collection of face illustrations with service descriptions, making it easy for our clientele, both men and women, to self-identify with a desired treatment.”

Costa and Rogers have similar backgrounds, with years of plastic surgery research and clinical training at institutions including Massachusetts General Hospital, Beth Israel Deaconess Medical Center and Rhode Island Hospital. The NPs first met in graduate school at Regis College in 2012 during their accelerated BSN/MSN training.

“We take a lot of pride in our academic background, and we want that to reflect in the way we practice,” Rogers says. “Therefore, when clients visit our website or they reach out with questions, we always support them. We encourage our clients to ask about the procedures, process and any potential side effects.”

Consistency Is Key

Because LexRx specializes in Botox and dermal fillers, “our clients can expect the same exceptional results every time,” Rogers says. “A qualified and certified nurse practitioner is always performing the injections. As we look to expand LexRx, the providers will always be trained through the LexRx method of injection. We have set ourselves up for success with an approach that is consistent.”

Before individuals arrive for therapy, they are sent pre-treatment instructions by either email or text image. These instructions include what to expect, who should and should not be given a particular procedure and recovery.

“Although we advise patients to do their own research before committing to a provider, we encourage them to ask questions and be curious,” Rogers says. “Post-treatment, we review all instructions with the client and follow up within 1 to 2 weeks to ensure continuity of care,” Rogers says.

LexRx clients maintain approachable and confidential communication with the NPs through email, text and phone. “This offers a personalized and avante-garde experience for our clients,” Costa says.

NEXT: Differentiate and Standout

Differentiate and Standout

The duo prides themselves on their conservative and focused approach to aesthetics, differentiating LexRx from popularized MedSpas. “We encourage clients to come back in 2 weeks for a touch-up,” Costa says.

LexRx is aware that potential clients may consider medspas or elsewhere for services, including places that offer discount promotions. “While our prices may be higher than others, we provide consistent and quality results every time,” Costa says. “We set ourselves to a standard of excellence and we feel that our results demonstrate that.”

Costa and Rogers are also strong advocates for other advanced practice providers engaging in a more rigorous training program, “especially in an industry where there is a lot of variation and inconsistencies,” Rogers says. “Taking a step back and having a focus on education is really important for practice.”

With the support of medical leaders in the Boston community, including Harvard-trained, board-certified plastic surgeon Richard Peinert, M.D., LexRx is developing a training program within its practice for clinicians interested in becoming certified in injectables.

“We believe this will be the new standard in the industry,” Costa says. 

When he describes the state of hair restoration today, Atlanta-area plastic surgeon Dr. Keith Jeffords doesn't just talk about the wonders of modern follicle transplants. He has another message too: Your scalp won't have to pay the price.

"There's new technology, new devices, new ways to do this that are less painful and less invasive but still satisfactory," says Jeffords, M.D., D.D.S. "No one goes to get their gallbladder out with a 12-inch scar like they used to. That's what we should be doing: We shouldn't leave a 12-inch scar on the back of somebody's head."

Dr. Jeffords, who's in private practice in Smyrna, Ga., spoke about adding hair restoration to plastic surgery practices at Plastic Surgery The Meeting 2016, the annual gathering of the American Society of Plastic Surgeons. In a conversation with Cosmetic Surgery Times, he talked about technological advances, competitive advantages for plastic surgeons and the market for reconstructive hair restoration. 

Restoration Technology Changes the Game

Years ago, Dr. Jeffords refused to get a hair transplant himself because he didn't want to be sidelined from working. Why? Because he wouldn't be able to perform surgery for several weeks in order to prevent the hair-grafting scar from widening, which would happen by moving his head during procedures. 

Technological advances have since allowed Dr. Jeffords to undergo two hair transplants. "Follicular unit extraction doesn't create a scar," he says. "Instead, you remove a follicle at a time to reconstruct the hair line." 

Now, new automated follicle removal devices allow physicians to harvest 600 to 1,000 grafts per hour, he says. "I just did a 3,000-graft case, and finished harvesting in 2.5 hours," he says. "It's much quicker, much safer, with no scars."

The new grafting technology can even allow scar revision procedures, Dr. Jeffords says, such as graft hairs into scars. It's even possible to use the grafting devices to improve the appearance of scars without adding hair. "If you have a white scar that shows through dark hair, you can make holes in that scar so it will revascularize, turning a white scar into a flesh-colored scar." 

NEXT: Plastic Surgeons Can Stand Apart

Plastic Surgeons Can Stand Apart

While there's plenty of competition from chain clinics that specialize in hair restoration, Dr. Jeffords says plastic surgeons have a major role to play because of their expertise. "If a consumer knows that a plastic surgeon is doing hair restoration, they'll prefer them over someone who doesn't list their credentials," he says. 

And a plastic surgeon shouldn't find hair restoration to be a huge challenge, he says. "If a plastic surgeon wants to do hair, it's an extension of what we already do," he says. "I do brow lifts almost every day. I'm cutting in scars. I'm moving hair around. We do the same kinds of things all the time."

Making a Difference for Those in Need

Not every hair restoration patient is an adult who's balding. Through referrals from other physicians, Dr. Jeffords has become a go-to hair restoration specialist for people of all ages who have lost hair due to surgery scars and devastating burns. 

Dr. Jeffords recalls meeting a 12-year-old boy who'd suffered severe burns and hoped to get his eyebrows restored: "The little boy came out to see us, and we talked to him and his parents. He was nervous since he'd been through hell with burn surgery. But he got his nerve up, and they let him call us back to say he wanted to do this."

When it came time for the surgery, Dr. Jeffords recalls, "We made it a big day for him with his favorite food, and we brought him toys and videos. He was really brave and he did a great job. We made him very secure. That's the nurturing business that plastic surgeons are in."

While this kind of success is possible, Dr. Jeffords says it's not likely that a plastic surgeon will be able to turn reconstructive hair restoration into a main line of work. Still, he says, "It's an extension of what hair restoration can be."  

Disclosure: Dr. Jeffords has a speaker relationship with NeoGraft.