Can Restylane help me stop drooling?

Dr. Dean Kane Q & A. 

Q. Because of a downturn on one side of my mouth, I experience drooling, can this downturn be sufficiently filled with a Resatylane type product? Or am I most likely to need surgery, I realize a precise answer is not possible. But a general consensus would be nice.

A. ​Drooling from the corner of the mouth may be due to over production of saliva and / or the physical changes from injury or aging around the mouth.

​The downturned corner of the mouth is a complex region of tissues created by muscles, fat and skin.
​
​Like a "spoke on a wheel", 8 muscles come together to lift, pull up, pull down, purse and pull tight the lips at their corners.
​
​On each side of the muscles lies a layer of fat which thins with muscle use and tissue folding or creasing.
​
​On the skin and mouth surfaces, the superficial tissues will crease or fold as well due to expression, skin, fat and muscle laxity.
​
​Depending on the depth of the crease at the lip vermillion corner, the thinning of the fat underneath the crease or fold and the descent of the spoke, will the inverted edges create the opportunity for wetness, chafing, drooling and frowning.
​
​Restylane, Silk, Juvederm Ultra or similar gel fillers maybe used to thicken the skin crease and stiffen the crease from folding. Improved resistance to folding is provided with thicker soft tissue fillers such as Perlane, Juvederm Ultra Plus and Voluma injected in the fat layer. If the jaw is "weak" (ie., small or retruded) a bone-like filler like Radiesse or stimulatory agent like Sculptra may be considered.
​
​If you notice jowling with significant  marionette folds, you should consider surgery to lift the modiolus (ie., the spoke of muscles,) the descending fat tissues and the skin.
​
​It is best to consult with a well experienced, Board Certified Plastic Surgeon or ENT facial surgeon to examine you and review with you your best options.
​
​I hope this has helped. All the best!

 

Sincerely,

Dean Kane, MD, FACS

Which filler (Sculptra, Radiesse, Voluma, etc.) for jawline?

Dr. Dean Kane Q & A.

Q. I decided to get Sculptra treatments to create a more angled, masculine jawline as sort of very, preliminary 'try out' before thinking of jaw augmentation down the line. While the volume and width are very good after seven months and three treatments, is there any other filler (short of augmentation) that may more of a sharp, angled contour to the haw as opposed to a slight of amount of a bloat from Scupltra? Would I have to wait until the current Sculptra effect dissipates?

A. ​The use of Sculptra as a trial is a good idea particularly if injected under the dermis and along the bone as it will stimulate firming of the skin and growth of the bone.​

​During the next few months as the effects of Sculptra continue to stimulate and improve, Radiesse may provide the sharper, more angled contour you are looking for.
​
​Any one of these fillers can be used BUT as notice, they will not provide the same effect.
​
​For this reason, it is best to be evaluated by a well experienced and Board Certified Plastic Surgeon or ENT facial surgeon to examine and review your concerns.
​
​Considerations along the jawline include:

1. ​Skin,soft tissue and fatty laxity creating an uneven jawline with jowling and / or weak angle.
2. ​Lack of teeth causing the bony jaw to resorb providing less projection
3. ​Angle of the jaw and balance of the jaw, maxilla-zygoma and temple regions
4. Level of placement, action and projection from each filler
5. Duration of each filler before your investment dissolves
6. And other considerations

Each injectors skill levels and understanding of anatomy is different. Consider different opinions.
​
​All the best!

Does Botox improve smoker's lines and chin lines?

Dr. Dean Kane Q & A.

Q. Does Botox improve smoker's lines and chin lines? I am going to have Voluma in my cheeks on Monday and Botox on my forehead. Would Botox help smoker's line above lips and wrinkles on chin? Can Voluma be used on chin wrinkles?

A. ​White patients of northern european descent have the most 

trouble with lines around the lips and chin. This is due to:

1. ​Thinning aging lip skin
2. ​Thinning aging peri-oral fat
3. ​Inversion of the "pink" lip vermillion
4. ​Thickening (hypertrophy) of the lip and chin muscles

Depending on the findings at consultation, a well versed and competent Plastic Surgeon, Facial ENT or Dermatologist Injector may consider:

1. ​Botox or Dysport to relax the tightened lip and chin muscles
2. ​Various fillers to the fatty soft tissues under the skin or the thinning lip skin itself
3. ​Thicker gel fillers like Perlane and Juvederm Ultra Plus have worked very well for me in the pink lip
4. ​Silk has worked very well in the lines around the lips and chin in my hands.
5. Voluma may be to stiff and projecting in the chin unless you have a weak chin and wish more projection
6. For other improvements of the lip and chin lines, consider:
7. Retinoids to exfoliate the epidermis and stimulate thickening of the dermis
8. Chemical or laser peels to exfoliate the skin and stimulate collagen formation

I hope this has been helpful! All the best!

Will Botox get rid of my wrinkles under the eye?

Dr. Dean Kane Q & A.

Q. Will Botox get rid of my wrinkles under the eye? I am 26 and have very tired looking eyes. I was looking into getting blepharoplasty in the next year or two, but before doing a drastic surgery, are there other options for me?

A. ​Without photos it is most difficult to comment. It is best for you to consult with a well experienced Board Certified Plastic Surgeon or Facial ENT surgeon.

​There are so many considerations for wrinkles under the eyes such as:

1. ​Sun damage,
2. Skin thickness,
3. ​Eye shape; where the eyelid corners meet,
4. ​Bone shape and projection,
5. ​Bags, fat, swelling,
6. ​And others

Botox under the eyelid except in special circumstances may create worsening of eyelid wrinkles and relaxation bulging of the fat bags.
​
​Consider:
​1. ZO Obagi Skin Health using retinoids,
​2. Chemical and laser peels,
​3. Superficial filler,
​4. Deep filler,
​5. And finally blepharoplasty.
​
​I hope this has been helpful. All the best!

What are the emergency signs to look out for after a surgery?

Dr. Dean Kane Q & A.

Q. What are the emergency signs to look out for after a surgery? 

A. This is a very complicated question and requires pre-operative education and counseling from your surgeon.  While uncommon to rare, there are general post-surgical concerns and side-effects or complications. Ask your surgeon what other issues you should consider consistent with the surgery you have planned.

In general, you should call 911 for emergency care following surgery if any of the following occur:

1. Fainting
2. Lack of urine output with or without dizziness
3. An obvious red rush of bleeding from an incision or body opening
4. Chest pain or difficulty breathing
5. Chest pain with radiation of pain to the neck, either arm, back or upper tummy
6. A severe and acute headache or loss of vision
7. Palpitations
8. And any other concern that makes you physically or mentally unstable.
9. Alert your surgeon you are going to the emergency room but let the EMT's evaluate you and take you, not a care-giver or family member.

Urgent concerns for which you should contact your surgeon for urgent evaluation include:

1. High fevers
2. A sudden change in pain at the surgical site
3. Sudden pain in an area not operated on such as the calf, thigh, pelvis, abdomen, chest or head
4. A sudden change in shape or symmetry of the surgical site and / or increasing drainage from a incision or drain site.
5. Increasing redness, heat  or tenderness at the surgical site
6. Separation of the incision

This is not a complete list of concerns. You will need more instructions regarding the surgeons expectations of your post-surgical care and recovery. The vast majority of surgical and minimally invasive procedures go smoothly but this is a good beginning question to review with your physicians.

All the best!

Sincerely,

Dean Kane, MD, FACS

How much does running (daily, 4+ miles) affect the longevity of a facelift? Also, how does menopause affect the face?

Dr. Dean Kane Q & A. 

Q. How much does running (daily, 4+ miles) affect the longevity of a facelift? Also, how does menopause affect the face?

A. A facelift is a personal investment. To make it last longer, maintenance of weight with exercise including running and diet like other lifestyle improvements will maintain the quality your surgery.

​

​Running per se, is not the issue as it up-regulates the repair and anabolic pathways of our immune system. It is other factors which accelerate the passive aging of our skin, organs and glands. These include:

1. ​Dry  and harsh weather environments
2. ​UV light (sun and tanning lights)
3. ​Dehydration
4. ​Low protein, high carb diets
5. ​Lack of essential fatty acids
6. Menopause (due to lack of proper hormone stimulation including: estrogen, testosterone, thyroid, growth hormone and many others)
7. ​Many other factors.

Beyond the obvious reversal of the above list, you should consider a skin stimulation regimen such as the ZO Obagi Skin Health systems provided by a qualified and Board Certified Plastic Surgeon, Facial ENT Surgeon or Dermatologist. The use of retinols and non-retinols, hydroquinones and non-HQ's along with its anti-oxidants, UV blockers and many other protective plant compounds will assist in stimulating proper skin regeneration and rejuvenation. Sculptra injections has also been the most recent advancement in non-surgical firming and maintenance of facial skin and soft tissues.
​
​I hope this has been helpful. All the best!
​
​We often come to your most interesting and beautiful part of the world!

What is the downtime after a facelift?

Dr. Dean Kane Q & A. 

Q. What is the downtime after a facelift? I am doing a facelift on a Monday and need to return to work on a Thursday. I have long hair so my stitches will be covered. My doctor said I should be ok, but would like other opinions. I work as a receptionist and my job is not strenuous. I am worried my co-workers will notice that I had a facelift.

A. This is a universal concern and very reasonable question for all patients to understand.

​There is a dynamic and similar course of healing everyone goes through following surgery or an injury.
​
​Physiologically, any incision or puncture of the skin will cause bleeding and bruising. The length of the incision and amount of lift or undermining determine the magnitude of the healing to occur. More surgery means more bruising, swelling and potential side-effects or complications but the healing time is similar and that is because the "army" of healing cells and scar formation is the same for any injury.
​Please anticipate:

1. Swelling and bruising for 10 days to 3 weeks
2. ​Potential bleeding complications and incision concerns during the first 3 weeks
3. ​Under the skin firming, lumpiness and irregularity during the first 3 months

I separate 2 levels of activity for my patients.

1. ​ADL: activities of daily living; what you need to get by with daily rituals such as hygiene, breathing exercises and mobility. No stooping or bending and no lifting over 2 pounds as any increased activites may generate more swelling or bleeding. ADL's for the first 3 weeks.
2. ​Exertion: starting to do more than what is required such as exercise, sex or pulling and lifting suitcases. After 3 weeks.

In general, I have found scar formation and tightening to the point of restrictive movement and some skin irregularities for the first 3 months.
​Different and changing levels of massage as the healing process progresses such as:

​1 gentle pressure

​2 gentle lymphatic or "squeege" motion

​3 firmer lymphatic or "squeege" motion

​4 "rock and roll" or firm deep massage for lumps

Emotionally, patients go through a "roller coaster" of concerns and presentations. You can expect:

• 1-5 days: ​initial surprise: "I didn't expect this"
• 1-3 weeks: ​concern and a feeling of "did I do the right thing"
• 2-4 weeks: ​worry: "when is this swelling, bruising going to go away"
• ​4-12 weeks: more worry: "why am I forming lumps and irregularities"
• ​2-4 months: depression: "I have to look socially acceptable and I look deformed"
• ​3-4 months: sunlight: "it's getting better"
• 6 months: ​elation: "wow, I look good"
• 9-12 months: ​super-elation: "wow, I look hot!"
• 3-10 years: ​eventual disappointment: "where did it all go?"

Each patient and each physician interpret their changes and findings differently.
​
​Return to your treating physician and discuss what is best for you.

​All the best!

Is it possible to combine Sculptra and fat grafting?

Dr. Dean Kane Q & A.

Q. Hello doctors ! My question: is it possible or profound to combine Sculptra and fat grafting for tightening and revolumizing the face?

A. ​The idea of volumizing and firming is the next page in the rejuvenation / regeneration story.

​For decades, many molecules have been added to fat to improve its survival. Maybe Sculptra will be that molecule.

​So far there have been no research articles on this idea but there should be. I use both injectibles and both stimulate the immune repair system to send signals to the fibroblasts either via a stimulator molecule, poly-L-lactic acid (Sculptra) or as stem cells (fat) to regenerate blood supply and produce collagen, elastin, hyaluronic acid and other youthful skin components.

Both injectibles do not work simultaneously so at this time, I recommend beginning with Sculptra to begin the revascularization and scaffolding. 1 to 3 months later inject the fat with anticipated greater survival and volumizing rejuvenation of the tissues.

Thanks for this question!

All the best!

Can I have Fraxal and Botox?

Dr. Dean Kane Q & A.

Q. I had Fraxal around the eye area but can I have Botox as well 9 days later when I'm booked in for Botox.

A. ​Botox is a protein than can be denatured and therefore lose its potency with heat. The fractionated CO2 laser penetrates the skin to heat the tissues and can therefore reduce the effects of Botox or like muscle relaxers. Current understanding is that Botox has linked irreversibly to the nerve ending and performed its job within an hour of injection.

​The swelling associated with laser therapies will also increase swelling in the area performed. While I know of no studies to the effect, I can anticipate that the added fluid in the area may dilute the muscle relaxer and possibly cause diffusion effects depending on injector technique.

If you do plan to have both a laser procedure like Fraxel and Botox performed, I prefer they be separated by a day with Botox on the first day followed by laser the next day. ​ Your best results when combining such procedures would be inject Botox and wait for its maximal effects 10-14 days later, then have Laser.

​Please discuss this concern with your injector / laser specialist.

​I wish you well.

Any treatment suggestions for deep marionettes lines and jowls?

Dr. Dean Kane Q & A.

Q. I have a heart shaped face which is slim. I'm 47 and do not want a facelift. What are my best options to smooth out deep marionette lines and jowling. Had Juverderm late last year and some Voluma added to cheeks to try and lift and plump my mid face a little. Right now my face looks miserable even when I'm not, because the corners of my lips drop downwards. I exercise a lot too. Which treatment would be most economical? Any advice would be greatly appreciated. Thank you!

A. Various options for facelifting, minimally and non-invasive facial enhancements and skin texture improvements are available according to the skin laxity and areas of lift or tightening you wish or need.

​Your question centers over the use of fillers yet your description sounds as though you have a significant amount of skin laxity. Fillers do a wonderful job up to a point but if you can "pinch more than an inch of skin along the jawline in front of the earlobe" I recommend you consider surgery to redrape the underlying soft tissue descent and skin lift with skin excess removal.
​
​Please consult with a Board Certified, well experienced Plastic Surgeon or ENT Facial Surgeon for your best evaluation and recommendations.
​
​A patient with significant skin laxity may note some improvement with facial fillers alone but the value is in lifting the tissues and removing the skin excess first and then filling in volume loss thereafter. Don't forget skin tightening therapies like ZO Obagi Skin Health.
​
​Both surgical and minimally invasive / non-surgical options are listed below.

Surgical lifts would be likened to pulling the bedspread and or top-sheet of your bed up to the head-board and removing the excess material.

Minimally invasive procedures such as fillers provide volume such as adjusting a pillow under the bedspread. Botox and Dysport act by pulling the top-sheet which drags the bedspread upwardly. If the bedspread (or skin) continues to fall to the foot of the bed despite fillers, Botox or Dysport you will need to consider a facelift.

Non-invasive options such as laser and light therapies, skin tightening products and technologies perform their tightening and smoothening of the skin similar to sending your bedspread to the dry cleaners. A more refreshed, even colored, glowing smoother and tighter spread covers the surface of the bed.

The most popular of the fillers, Restylane and Perlane, a jelly-like clear skin filler is used to fill lines, wrinkles and folds. Juvederm and its longer lasting "cousin"Juvederm Ultra Plus are similar skin fillers, used to soften and fill the nasolabial ("parentheses") and marionette folds, the brow ("number 11") lines and fill and lift the cheeks and lateral brow or chin.Voluma is the longest lasting, up to 2 year duration HA filler. Each one is used to expand or volumize the loss of tissue associated with expression, weathering or aging. All the fillers come with numbing anesthetic!

Non-surgical facial contouring is possible with fillers such as Radiesse, a bone mineral for the nose or cheeks, jaw and chin as well.

Sculptra is the latest of the injectibles stimulation collagen at different levels of the skin adding volume but primarily firming and adding resistance to the formation of wrinkles, folds and descent.

Botox and Dysport too have been found to rebalance excessive facial expression, provide a non-surgical brow lift and lip lift and reshape the nose, as well as reducing wrinkles!

Dr. Obagi's new, second generation ZO Skin Health programs may be added to personalized chemical peels, light and laser resurfacing and tightening and will, smoothen and even the color of your skin.

IPL and fractionated lasers such as CO2 and erbium and now RF (radiofrequency) are additions to smooth the texture of the skin, tighten and reduce red and brown uneven pigmentation.

Face lift and / or neck lift or any of the other procedures and their combinations should be discussed following a proper examination by a Board Certified Plastic Surgeon who performs all of these options so you will not receive a biased approach because he or she is limited in their skills.

​I hope this has helped! All the best!

What do you think? Facelift/neck lift? Fillers and Botox or fat transfer?

Dr. Dean Kane Q & A.

Q. I'm 43 but feel like I'm 23. The past few years I've noticed less volume, for the record I think I already have a thin face. The upper eyelids stand out along with the tear trough. My dermatologist told me no on the face/neck lift but I submitted my photos to a plastic surgeon. He also said I wasn't a candidate for the lifts. He suggested an upper eyelid surgery and fat transfer! I don't want to spend thousands on that if in a few years I will need a facelift. Please help with your opinions. Thank you!

​A. Thanks for sharing your photos! You will notice that your best appearing presentation are the photos in which your cheeks are the most prominent and your jawline is most angular. This is due to a "heart-shape", convex presentation where there are more highlights then shadows.
​
​You, like many patients may achieve these features with facelifting options, injectibles, peels and laser. Each has its own advantages and disadvantages, onset and duration, recovery and cost. Your personal needs must be evaluated with a well experienced, Board Certified Plastic Surgeon or Facial ENT Surgeon that provides all options so they are not biased based on a lack of skill level.
​
​I have many patients choose fillers, retinoids, peels / lasers when they won't consider surgery, have the funds or recovery time for surgery.  Others, recognize the advantages of surgery to reduce / lift the jowls, widen and fill the upper cheek and redrape the lax skin while maintaining a thinner facial appearance and obtaining a longer duration of results.
​
​Both of these and other combinations are options you will determine with a trusting physician.
​
​I hope this has helped! All the best!

Why do some patients have great outcomes after a non-invasive treatment & others only have little improvement w/same procedure?

Dr. Dean Kane Q & A.

Q. When looking at before & after photos of patients who have had identical treatments, same treatment locations, same number of treatments & post-photos take the same number of months post-treatment of coolsculpting or thermage (& similar non-invasive treatments), you can see that some patients have dramatic results and others seem to have almost no change. Is it patient age or treatment location or body size or post-treatment diet/lifestyle or doctor's skill or length of treatment? Thanks.

​A. This is a very perceptive question requiring a very complex answer. The simple answer is every patient is different and needs to be matched to their best option to achieve a particular result.
​
​The more complex answer is based on the following and many other individual factors:

1. ​Age: younger patients will tend to have thicker firmer dermis, thinner epidermis and more fat with rounded contours in more pleasing places
2. ​Aging: the physiologic changes associated with skin laxity, shifting / thinning / separation of soft tissues accelerate in your 30's.
3. ​Environment: more weather and UV exposure will oxidize tissues, injure skin and age the tissues faster.
4. ​Metabolism and disease: each of us carry a unique set of genes which will accelerate or decelerate and repair aging and damaged tissues.
5. ​Familial and ethnic quality: you inherited these traits.
6. ​Personal care: use of retinoids, care for acne, tobacco, alcohol, etc
7. Patient perception on what they hope to achieve based on exposure or education to any / all available options

​I have observed the following general trends in how patients respond to rejuvenation procedures.

1. ​Individuals with thicker dermis, oilier skin and more pigmentation will tend to age slower but may present with more pigmentation damage. They will tend to take longer for scar thickening to reduce.
2. ​Those with thinner, northern European thinner, less resistant (to folding and creasing) dermis, drier more reactive skin will age earlier and show more aging skin changes. They will tend to "heal" faster with less scar thickening.
3. Patients with more reactive red tones in their skin (due to more active histamine and inflammatory response) such as a ethnic history with Irish and American Indian backgrounds will swell more but may also respond better to technology which creates redness and inflammation.

In addition, each individual should choose or be selected for particular procedures according to:

1. ​Cost
2. ​Recovery, onset of effect and duration
3. ​Amount of involvement in the procedure or after-care
4. MD, RN, aesthetician skills
5. Availability of differing procedures, technology
6. ​Desired results

I hope you can now better understand why a patient responds to different rejuvenation options differently.
​
​All the best!

What would your advice be if I walked to your office? Botox?

Dr. Dean Kane Q & A. 

Q. I have this horrible lines on my neck (deep ones) and I am so young I shouldn't have to be worrying about it... I think its genetics so... there is only so much I can do, but I definitely will proceed on something against them since I'm fairly slim and I just want them to get toned out and vanished as much as possible. Ive tried aloe vera, collagen pills... etc. you name it; I've tried it. I feel hopeless... Oh, and when I was 15-18 I was a bit chubby but not anymore. Thank you in advance.

A.  ​​​​Thank you for sharing your photos!
​
​As advancements are made in surgical and non-surgical cosmetic improvements, concerns not previously addressed are now facing (no pun intended) the limelight.
​
​Neck creases or necklace lines may now be more apparent as the computer-cam generation and "selfie" revolution highlights these and other personal concerns including the weak chin, the open nose and facial asymmetries not previously appreciated. The necklace creases may be created by the more repetitive flexion of the neck looking down toward these devices.
​
​While there is a sheet of muscle called the platysma under the neck creases, it produces vertical folds more than horizontal creases. Botox will relax the muscles creating "dynamic" lines like those of the crows feet and not easily reduce the visibility of neck creases.
​
A continuous evolution of heating technologies (laser, ultrasound and radio frequency) to produce collagen thickening and skin tightening by combining the body’s own natural healing process to tighten loose skin has been less than overwhelming.
​
​I have experienced a greater improvement in "necklace" line reduction and thickening of dermal thinning with resistance to creasing with an off-label use and dilution of the injectible "filler" called Sculptra. This is very injector dependent and not for routine use but illustrates how technology and technique are helping enhance our personal lives and aging’s consequences.
​
​Please consult with a Board Certified, well experienced injector specialist to examine you and review with you, your options.
​
​I wish you well!

Could I be a Restylane Candidate?

Dr. Dean Kane Q & A.

Q. I am so over these eye bags. I'm only 30, but I feel 100! Help! Should I get Restylane fillers, or should I go with a lower blepharoplasty? Thanks.

A. Thanks for sharing your photos. ​Yes, Restylane is an alternative to mask the bags by elevating the folds. It takes special skills so choose your injector wisely.

​It would also be important to have your thyroid hormone levels checked and a proper evaluation of your eyes, lids and boney structure. Eyelid surgery is a possibility but in your photos, I detect some eye bulging and asymmetry. This may indicate an overactive thyroid gland or other anatomic concerns regarding your options.
​
​Consult with a well experienced and Board Certified Plastic Surgeon, OculoPlastic Surgeon and  / or Facial ENT Surgeon who perform eyelid surgery regularly.
​
​I hope this is helpful. All the best!

Three respected plastic surgeons had different opinions. Any suggestions?

Dr. Dean Kane Q & A. 

Q. Three respected plastic surgeons each had different opinions. 1. Facelift, neck lift, upper eye lift both eyes, fat grafts/transfers and dermabrasion around mouth. 2. Facelift, neck lift, upper eye lift on right eye only (said not enough extra skin on left eye), lower eye lift on both eyes and full face laser, 3. Facelift, neck lift (with very small incision under chin to liposuction), fat grafts and temple plasty for right eyelid. We did not discuss laser or dermabrasion. What should I do?

A.  ​​​​Various options for facelifting, minimally and non-invasive facial enhancements and skin texture improvements are available according to the skin laxity and areas of lift or tightening you wish or need. Both surgical and minimally invasive / non-surgical options are listed below and offered according to your anatomy, recovery time, budget, skills and availability of services offered by the surgeon.

​The 2 basic foundations to rejuvenation include:

1. ​Lifting  and suspension (with removal of skin excess if needed), and
2. ​Texture improvement (lines, pigment, laxity).

Surgical lifts would be likened to pulling the bedspread and or top-sheet of your bed up to the head-board and removing the excess material.

Minimally invasive procedures such as fillers provide volume such as adjusting a pillow under the bedspread. Botox and Dysport act by pulling the top-sheet which drags the bedspread upwardly. If the bedspread (or skin) continues to fall to the foot of the bed despite fillers, Botox or Dysport you will need to consider a facelift.

Non-invasive options such as laser and light therapies, skin tightening products and technologies perform their tightening and smoothening of the skin similar to sending your bedspread to the dry cleaners. A more refreshed, even colored, glowing smoother and tighter spread covers the surface of the bed.

The most popular of the fillers, Restylane and Perlane, a jelly-like clear skin filler is used to fill lines, wrinkles and folds. Juvederm and its longer lasting "cousin "Juvederm Ultra Plus are similar skin fillers, used to soften and fill the nasolabial ("parentheses") and marionette folds, the brow ("number 11") lines and fill and lift the cheeks and lateral brow or chin.Voluma is the longest lasting, up to 2 year duration HA filler. Each one is used to expand or volumize the loss of tissue associated with expression, weathering or aging. All the fillers come with numbing anesthetic!. Fat grafting is a wonderful option but consistency in survival of the fat and need for multiple procedures to achieve your "filling" results may disappoint.

Non-surgical facial contouring is possible with fillers such as Radiesse, a bone mineral for the nose or cheeks, jaw and chin as well.

Sculptra is the latest of the injectibles stimulation collagen at different levels of the skin adding volume but primarily firming and adding resistance to the formation of wrinkles, folds and descent.

Botox and Dysport too have been found to rebalance excessive facial expression, provide a non-surgical brow lift and lip lift and reshape the nose, as well as reducing wrinkles!

Dr. Obagi's new, second generation ZO Skin Health programs may be added to personalized chemical peels, light and laser resurfacing and tightening and will, smoothen and even the color of your skin.

IPL and fractionated lasers such as CO2 and erbium and now RF (radiofrequency) are additions to smooth the texture of the skin, tighten and reduce red and brown uneven pigmentation. Dermabrasion is a older but tried and true technique to improve lines and tighten skin.

If you can pinch more than an inch of skin along the jawline in front of your earlobe, you should consider a surgical option to redrape and remove extra skin.

You may consider: a traditional face and neck lift, short scar face and / or neck lift.

The recent resurgence of the S-Lift (created in the early 1900's), also called by other names as the Quick-Lift, Lifestyle-Lift, Swift-Lift, Soft-Lift, MACS-Lift and others; are a single modification of the S-lift targeted to elevate sagging lower cheeks jowls and lateral upper neck.
​
​SMASplasty of the face and platysmaplasty of the neck will further enhance the suspension of deeper tissues.
​
​The 3 opinions you have received are very close in recommendations. Asymmetry or anatomic variations between one side and the other are adjusted for by well experienced surgeons.

Face lift and / or neck lift or any of the other procedures and their combinations should be discussed following a proper examination by a Board Certified Plastic Surgeon who performs all of these options so you will not receive a biased approach because he or she is limited in their skills. Choose who you trust will deliver a level of care you wish to receive.
​
​I hope this has been helpful. All the best!

Which filler would you recommend and which is more effective between Botox, Dysport, and Xeomin?

Dr. Dean Kane Q & A. 

Q. Right now in my life for being 43 years old I feel great and I think I look pretty good but, of course, we all have things we"d like to change. The thing that bothers me most is the tear trough area, and the upper eyelid. I know in the near future I will be getting an upper and lower eyelid lift, along with a face/neck lift. Until then can I get a filler that will last in the tear trough area, and botox/dysport in the upper eyelid area to lift a little. Is this possible without surgery?

A.  ​​​​Every patient is unique. Your bony and soft tissues, their symmetry and aging, your personal and perceived appearance and how it bothers you are just a few of the factors to review with a well experienced, Board Certified Plastic Surgeon or Facial ENT Surgeon who offers ALL these and other options.

​Since the effects of aging, weathering, sun-damage, ethnic background affects everyone differently, you may consider filler for the tear trough and Botox for the brow elevation and / or stage your surgery at this time when healing is better, scars will usually be smaller and skin elasticity is at its best.
​
​Consider more than one well experienced, Board Certified surgeons for evaluation as you may find that their Botox and Filler skills as well as their surgical skills and results will vary.
​
​One consideration come to mind and that is you may wish to have the upper and lower lids improved at the same time. Using access gained by both incisions, a mid-face lift may rejuvenate your cheeks, eliminate the tear trough, possibly elevate your jowls and bring you a longer duration of satisfaction.
​
​If you are a candidate for a short scar face lift (or MACS lift and other named procedures) you may improve the jowling and upper neck while younger and gain more youthful appearing years.
​
​Regarding which Fillers or Muscle Relaxers; the options are getting so numerous that each filler or muscle relaxers have their own peculiar niche of use.
​
​I happen to like Botox in the brow area for precision and Dysport in the lips for a softer relaxation.

​Hyaluronic Gel fillers such as the Restylane Family or Juvederm Family each have their nuances. Depending on each gels production and artificial molecular linking will determine:

1. ​their duration,
2. ​their projection,
3. ​their volumization (ie. water attraction).

​This determines where they provide the best "fill" you desire.
​
​Noting your tear trough example, some injectors have only superficial injector skills and will inject immediately under or within the skin (ie. dermis). Others, may feel comfortable injecting under the deeper muscles of the cheek next to the bone with a variety of techniques.

1. ​You may wish to use Restylane or Juvederm superficially but it has the side-effect of radiating a "tindel" bluish coloration or lumpiness on eyelid skin.
2. ​Silk in this location superficially may swell the tissues too much.
3. ​I achieve my best appearance under and over the deep muscles of the cheek with a more linked, longer duration filler such as Voluma or Perlane.

Yes, the possibilities are endless today and so you must find and trust a surgeon with a lot of experience using each option selected for your anatomy, concerns and budget.

​I hope this has been helpful. All the best!

Would you recommend Botox, Juvederm, or both for eye area?

Dr. Dean Kane Q & A.

Q. I was initially considering Botox for my crow's feet but now I'm thinking that Juvederm may be a better option for the under eye area. Or should I consider both - Botox for the crow's feet and Juvederm for the under eye area? What would you suggest and how much do you think would be needed?

A.  ​​​​While:

1. Botox for dynamic lines (such as the crows feet), and
2. ​Fillers for folds (such as tear troughs)

is not 100% true, it is a guideline.
​
​Dynamic lines are those created by active underlying muscles such as those around the eyes. Botox is great for crows feet relaxation but will not fully erase the etched dermal skin lines and a fine filler such as Silk works well synergistically with Botox at this site.

​Botox for the lines along the lower lid should be used very judiciously. Relaxing these muscles will soften the lines but eventually weaken the lower lid tone, "rounding" the eyelid.

​Separation of the soft tissues and muscles between the cheek and eyelid creates the tear trough. This passive process will not be helped with a muscle relaxer (and may worsen it) but must be filled. Depending on the skill of the injector, different layers of the tissues will fill out the depression of the fold. I have used and recommend deep tear trough filler using Voluma, Perlane or Juvederm Ultra Plus. More superficially, consider Restylane or Juvederm Ultra. Silk that may migrate onto the lower lid skin may create too much swelling and if used must be injected very sparingly.
​
​With so many choices, it is best to consult with a well experienced, Board Certified Plastic Surgeon, Facial ENT Surgeon, OculoPlastics Eye Surgeon or Dermatologist.
​
​I hope this has helped. All the best!

​

Facelift six-hour surgery with local and oral sedation?

Dr. Dean Kane Q & A.

Q. I am planning to have a facelift, cheek lift, fat transfer, and laser in one operation. The doctor favors local with oral sedation. I am concerned that a six-hour procedure may have me aware and exceed my tolerance level. I'd love to hear from others who have gone through six-hour facial procedures under local with only oral sedation.

A.  ​​​​​I prefer local anesthetic and intravenous sedation with monitoring by a anesthesia provider. Most surgeons request general anesthesia provided by an anesthesia provider too.

​Local anesthesia with oral sedation does not provide you the same level of monitoring or anesthetic risk / benefit ratio.
​Due to the length of the procedure, under local / oral sedation, the surgeon must perform the procedures during which he / she is also monitoring your vital signs ( heart rate, blood pressure, respiratory rate, oxygen saturation and level of consciousness). Longer procedures will expose you to greater levels of local anesthetic risk whereas a "cocktail" of mixed sedatives or inhalant anesthesia reduces this concern.

In the December 2014 article “Local Anesthesia and Plastic Surgery: Marketing or Reality?” (http://drdeankane.com/ok-conduct-open-rhinoplasty-local-anesthesia/) , Heather J. Furnas MD states:

“An increasing number of patients ask to have their surgery done with local anesthesia   “because it’s safer.” Guess what? That isn’t always the case.
​
​The Mayo Clinic has weighed in on the use of general anesthesia, explaining it should be considered if your operation:

1.  Takes a long time
2.  Exposes you to a cold environment
3. Affects your breathing, such as chest or upper abdominal surgery.
4. They also state that: “Most healthy people don’t have any problems with general anesthesia. Although many people may have mild, temporary symptoms, general anesthesia itself is exceptionally safe, even for the sickest patients. In general, the risk of complications is more closely related to the type of procedure you’re undergoing, and your general physical health, than to the anesthesia itself.”
5. ​She also notes the increasing concern amongst properly trained surgeons and patients alike that MD's offer this marketed advantage at the disadvantage of the patients health.”
6. It is also noted in another physician comment, that such an option should raise flags of concern that the facility in which the procedures are performed may not be fully accredited / certified by a state / or national regulatory agency and the physician may not have been properly credentialed. I desire to provide my full concentration on the performance of the procedure and not distracted from this which is the full time job of a anesthesiologist or certified nurse anesthetist.
7. Or more hours of potentially listening to others conversing or should there be a concerning occurrence during the procedure, become aware of and develop anxiety from correction of this event, restlessness or discomfort / pain; I believe is not in your best interest.

I hope this is helpful. All the best!

Are under eye filler/Botox/ Restylane permanent?

Dr. Dean Kane Q & A.

 

Q. Are under eye filler/Botox/Restylane permanent? If not, how long does it last? I'm thinking about getting my under eye bags/dark circles done. The dark circles under my eyes constantly make me look tired. I want to know if injections is something you do once or if I will have to keep getting injections.

A.  ​​​​Pigmentation or dark circles under the eyelid may come from any combination of the following.

1. Eyelid bags and laxity with shadowing
2. Cheek laxity and shadowing
3. Thin eyelid skin with a reflection of the underlying muscle
4. Eyelid veins.
5. A separation of the eyelid structures from the sagging cheek structures
​6. Pigmentation and fine lines

Many options are available depending on the problem above.
1. Eyelid lift
2. Injection of fillers, either into the skin or deep under the fat for volumizing using Restylane, Perlane, Juvederm, Voluma or fat
3. Vein ablation
4. Mid-face lift, a lift of all the structures of the cheek with a eyelid lift
5. Facelift
​6. Exfoliation, ZO Therapeutic Skin Health
​
​No option is permanent as the body continues to age. Each option has its advantages and disadvantages and must be weighed upon your findings at consultation with a well experienced, Board Certified Plastic Surgeon, Facial ENT and / or Ophthalmologist.
​
​Botox, Dysport and any other muscle relaxers will last on average 3-4 months and worsen bags and dark circles if you are not the right candidate.
​
​Hyaluronic acid gel fillers may also worsen eye bags and shadowing if not performed correctly. Depending on the "linking" of the molecule, HA's are rated to last 6-24 months.
​
​Surgery maybe the best option in the correctly selected patient but may have a longer recovery.
​
​I hope this has been helpful.

All the best!

​

This is my first time using Botox. Is this normal?

Dr. Dean Kane Q & A.

Q.  I just had Botox for the first time. I am 37 with minimal wrinkles. I wanted to try Botox in the "crows feet" area and asked if it would help with slight wrinkling under my eyes when I smile. Injector asked me to smile, made a couple of marks and injected me 3x below each eye (25 units) and said "you're done". She didn't inject anywhere near the "crows feet" area and I'm wondering if my injection site is normal?
A. Botox is a muscle relaxer which when injected properly will help many but not all active (directly created by a muscle) lines and creases.
​Crows feet are the radiating lines created by the thin, circular muscle (called the orbicularis oculi) under the skin surrounding the upper and lower eyelids, upper nose, brow, lateral orbit and onto the upper cheek. Since this muscle attaches to the inner corner of the eye next to the nose (called the inner canthus), it contracts and:

1. Closes the eye,
2. Pulls the brow inward and downward,
3. ​Creates lines radiating from the inner canthus onto the nose,
4. ​Creates lines radiating from the outer eye called crows feet
5. Will lift the upper cheek

When properly injected along the outer radiating lines, Botox will relax the downward pull of the outer brow allowing it to raise and soften the crows feet.
​
​If placed under the 4:00 position of the left eye, or 8:00 position of the right eye, side-effects due to relaxation of the orbicularis and other muscles in this area include:

1. Creation of swelling and fat bags
2. Rounding of the lower eyelid margin
3. ​Loss of ability to drain tears
4. Passive lowering of the upper cheek
5. ​Possible drop in the upper lip

Botox or like muscle relaxers are science and art.
​
​It is best to discuss your concerns with your injector. You may also consider a second opinion from a well experienced, Board Certified Plastic Surgeon, ENT Facial Surgeon, Dermatologist or Ophthalmologist.
​
​I hope this was helpful.
All the best!

​

Could something like CoolSculpting or cryosurgery treat Gynecomastia? Can the cold kill glandular tissue? I'm not worried about fat.

Dr. Dean Kane Q & A.

 

Q.  I know cold at a certain temperature for a certain time can cause cell death in fatty tissue. I imagine it could do the same with any living cell. At what temperature would cells in your mammary glands die?
A.  ​ ​​Great question! ​CoolSculpting's cooling endpoint is just above freezing where well perfused tissues retain the heat to remain alive and where superficial fat is stimulated to die via apoptosis.
​
​Male breast tissue includes non-active tubules (which transfer breast milk) and no lobules (which make breast milk). This tissue is not easily penetrated by the cooling and appears to retain enough heat not to undergo a programmed cell death.
​
​If the endpoint goes below freezing, frostbite occurs and all tissues die within this frozen zone. This concept is used in cryotherapy for debulking or killing tumors in many areas of the body.  It is for this reason that the feed-back relays on the CoolSculpting machine are so important.
​
​There are several ways to remove such tissue depending on the amount of residual breast mass and the skills of the surgeon. These include:

1. ​Lipocontouring with a unique cannula used for breast tissue
2. ​Areola incision with a "grasp and cut" or full excision
3. ​Breast mound excision with breast reduction techniques

Please consult with a well experienced Board Certified Plastic Surgeon to consider your options.
​
​All the best!

What can I do to take years off my face?

Dr. Dean Kane Q & A.

Q.  After ten years of a very stressful life, I have decided to invest in me! I lost my only child at age nine to brain cancer medullablastoma then 13 months later lost my husband to a brain aneurysm then my brother passed with liver cancer and last March loss my dad. The toll on me is self evident, it is written on my face, please tell me what can be done to take away the imprint these losses have left me with. Not happy with what I see, I'm ready to write the rest of my story.

A.  ​​​I am sooooo sorry for your losses! Congratulations on pulling yourself up and moving on! Thanks for sharing your photos with us.
​
​Your best initial option will be a face and neck (with platysmaplasty) lift. Depending on the skills of the surgeon, a modified face and neck lift without platysmaplasy will be less expensive and give you a great new start.
​
​Thereafter, consider extending the outcome of your surgery with minimally and non-invasive options. I have added a long winded discussion....
​
​Various options for facelifting, minimally and non-invasive facial enhancements and skin texture improvements are available according to the skin laxity and areas of lift or tightening you wish or need. Both surgical and minimally invasive / non-surgical options are listed below.

Surgical lifts would be likened to pulling the bedspread and or top-sheet of your bed up to the head-board and removing the excess material.

Minimally invasive procedures such as fillers provide volume such as adjusting a pillow under the bedspread. Botox and Dysport act by pulling the top-sheet which drags the bedspread upwardly. If the bedspread (or skin) continues to fall to the foot of the bed despite fillers, Botox or Dysport you will need to consider a facelift.

Non-invasive options such as laser and light therapies, skin tightening products and technologies perform their tightening and smoothening of the skin similar to sending your bedspread to the dry cleaners. A more refreshed, even colored, glowing smoother and tighter spread covers the surface of the bed.

The most popular of the fillers, Restylane and Perlane, a jelly-like clear skin filler is used to fill lines, wrinkles and folds. Juvederm and its longer lasting "cousin" Juvederm Ultra Plus are similar skin fillers, used to soften and fill the nasolabial ("parentheses") and marionette folds, the brow ("number 11") lines and fill and lift the cheeks and lateral brow or chin. Voluma is the longest lasting, up to 2 year duration HA filler. Each one is used to expand or volumize the loss of tissue associated with expression, weathering or aging. All the fillers come with numbing anesthetic!

Non-surgical facial contouring is possible with fillers such as Radiesse, a bone mineral for the nose or cheeks, jaw and chin as well.

Scuptra is the latest of the injectibles stimulation collagen at different levels of the skin adding volume but primarily firming and adding resistance to the formation of wrinkles, folds and descent.

Botox and Dysport too have been found to rebalance excessive facial expression, provide a non-surgical brow lift and lip lift and reshape the nose, as well as reducing wrinkles!

Dr. Obagi's new, second generation ZO Skin Health programs may be added to personalized chemical peels, light and laser resurfacing and tightening and will, smoothen and even the color of your skin.

IPL and fractionated lasers such as CO2 and erbium and now RF (radiofrequency) are additions to smooth the texture of the skin, tighten and reduce red and brown uneven pigmentation.

If you can pinch more than an inch of skin along the jawline in front of your earlobe, you should consider a surgical option to redrape and remove extra skin.

You may consider: a traditional face and neck lift, short scar face and / or neck lift.

The recent resurgence of the S-Lift (created in the early 1900's), also called by other names as the Quick-Lift, Lifestyle-Lift, Swift-Lift, Soft-Lift, MACS-Lift and others; are a single modification of the S-lift targeted to elevate sagging lower cheeks jowls and lateral upper neck. The shorter scar, limited undermining and second layer lift achieve the "quicker" procedure but not necessarily the quicker recovery or the improvement you desire.

Face lift and / or neck lift or any of the other procedures and their combinations should be discussed following a proper examination by a Board Certified Plastic Surgeon who performs all of these options so you will not receive a biased approach because he or she is limited in their skills.

​
I wish you the very best!​