Plastic Surgery vs. Cosmetic Injectables: Pros and Cons

In my practice, I am often asked, “What do I need, Botox, filler or plastic surgery?”  The short answer is you don’t need any of it; it is more a matter of what distracts you when you look in the mirror and what you want to do about it.  We have more choices than ever before when it comes to looking more rested, younger and even more attractive and rarely is there ever a single “Silver Bullet” that accomplishes everything we may want.

It is important to understand the overall effects of facial aging when we are making our decisions.  I always thought that our skin just became looser as we got older, it was like the sack that holds us together got bigger and it’s contents got smaller.  I now realize that not only do we have a loss of collagen and elastin causing sagging of the skin, we also have loss of the facial fat, muscle mass and demineralization of bone that actually causes a breakdown of the scaffolding and support that holds the skin up.    

So, lets start with the skin.  Your skin is your body’s largest and fastest-growing organ. Skin is your body’s coat. It helps you stay warm when it’s cold, and cool when it’s hot. Your skin keeps all your insides in and it is your barrier to keep germs, and environmental toxins out. You also feel things through the nerves in your skin.  Skin is AMAZING!  I always start with skin care, it can be basic and simple and if you do nothing but cleanse your skin every evening and wear a broad-spectrum sun screen every day we are off to a good start.   We can go from there to address specific concerns.  A good skin care regimen can give a youthful healthy glow to the skin and creates a nice canvas for the rest of your treatments.  You wouldn’t buy a Rolls Royce and never protect the paint or condition the leather would you?  Your skin needs constant maintenance to help it do its work.  We live on a planet with gravity, a sun and a barrage of toxins that the skin is fighting off every day.

When your mama told you, “If you keep making that face, it’s gonna stick like that,” she wasn’t all together wrong!  Facial animation and repeated expressions create lines on our faces that left untreated become deep and etched into our skin.  Enter the neuromodulators; Botox, Dysport and Xeomin.  They actually temporarily weaken the muscles that create some of the lines on the face so that the skin can eventually repair itself and soften or even eliminate those lines.  Many of my facelift clients continue to use neuromodulators to address the frown lines between the brows, the crow’s feet, and forehead lines.

And while we are on the subject of saggy skin, there are several non-invasive skin tightening modalities including lasers, ultrasound and radio frequency.  For the right client, these can be very helpful, but it is important to remember that as we age we lose collagen and these treatments work to stimulate collagen production. The facial plastic surgeon that I work with in Portland uses the analogy, “if I take a quarter inch off the putting green, it can be significant.  If I take a quarter inch off the rough, who’s going to notice?”  The younger client with nice thick, healthy skin may see a 1-2 mm lift with a noninvasive treatment.  When there is mild to moderate laxity, this can be significant, but if the laxity is significant, 1-2 mm may be indiscernible. Most of us over the age of 50 will have a less robust response to these treatments and may require several costly treatments for minimal results.  These are great preventative treatments for those in their late thirties into the mid to late 40’s, but for those of us of a “certain age” with an excess of loose skin, plastic surgery is the only real answer.  It just needs to be cut off!  The areas I see most often that fall into this category are saggy eyelids and excessive neck skin.  I can give minimal improvement in these areas with bulk heating, neurotoxins and fillers, but plastic surgery is the only definitive answer especially after the age of 50.

Dermal fillers address the fat, muscle and bone loss that can accompany aging.  We use several types of fillers to address the volume loss that accompanies aging.  Most folks over the age of 40 will begin to show the effects of that loss.  I usually address the midface first.  Often by just revolumizing the cheeks, improvement can be seen in the tear troughs, nasal labial folds and marionette lines.  Once we see the improvements we can then assess the areas that we may want to fine tune.  We can use fillers in the afore mentioned areas as well as enhancing the jaw line, filling sunken temples, enhancing chin projection, and correcting small deformities of the nose.  Several dermal fillers are available on the market.  Many hyaluronic acid fillers (the Juvederm family, the Restylane family and Belotero), calcium hydroxypeptite (Radiesse), poly-L –lactic acid (Sculptra) is the most commonly used in the U.S.  I personally prefer the more temporary fillers because the side effects and complications are minimal and what looks good on a face today, may not in five years or more.   Face lifts, brow lifts and blepharoplasty can lift the tissues and remove the excess skin but do nothing to address the loss of volume.  Most face-lift clients look more natural and refreshed with a little volume replacement once or twice a year.

Thread lifts have reemerged on the scene recently.  While there were a lot of complications with the previously used products, the new threads are made from an absorbable suture that is fully absorbed by the body.  The results look natural and last up to a year.  The procedure is minimally uncomfortable and works well in conjunction with neuromodulators and fillers for a more youthful and refreshed look.  Again, if the sagging is significant and the skin texture is poor, the threads may pucker the skin and have minimal lifting capacity.

So, are you catching the common “thread” here?  All of these treatments can have impressive results, but I have yet to find a nonsurgical treatment that can rival a surgical result for loose and sagging skin.  Nonsurgical treatments are a great option for mild to moderate issues and can help you look your best if you want to delay plastic surgery or you are not a surgical candidate.

So there you have it, so many options, and so many more on the horizon.  A good clinician can help guide you and help you set realistic expectations, be very wary of one who promises you surgical results with non surgical treatments.  A good treatment plan should be ongoing and even if you opt for plastic surgery, often times you will want to continue some nonsurgical treatments to continue to look your best.

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