I was at a dinner party recently with several of my former medical school classmates where we were chatting about the various fields of medicine we entered.  At the table there was an emergency medicine physician, a cardiothoracic surgeon, a radiologist, a pediatrician, two family physicians, and myself.  As we traded stories about our lives and our practices, one of the spouses who (was not in medicine) commented how it seemed that all the doctors at the table gave back to society by caring for the medical problems of people in need.  He then quipped, “except for Dave who just shoots up botox in the society ladies.”  This got a little chuckle around the table, and heads turned to me to see what my response would be.  But, having been a plastic surgeon for a long time, this was not the first time I have heard such jibes from my peers.  And because I liked the guy who made the comment and placed it into the context of an attempt at humor after a few glasses of wine, I decided to let it go.

But what my friend and many others may undervalue is the good that aesthetic services can provide an individual beyond just the act of smoothing out a few lines or wrinkles to make one look a little younger.  I have said that my field is not about making one look better, but rather making one feel better about oneself.  It is a subtle distinction, but one that makes the difference between conceptualizing cosmetic services as procedures which are image driven, shallow, and trivial versus treatments which enhance self-esteem and wellness.

Here is an example.  Many times, I see an individual who comes in because he or she would like to appear more youthful or refreshed in anticipation of some upcoming life transition.  Often, a new job or job interview prompts this person to seek a “fresh start” or a “boost”.  And in most situations, after treatment, most patients will inform me that the changes aided them, whether in helping them land a job or some other benefit during the period of change.  I have always contended that our treatments have a positive impact by making patients feel better about themselves more than the fact that they look better.  It makes sense–the projection of greater self-confidence and positive energy will have more of an impact to those around an individual than a few less lines or wrinkles.  And if these enhancements in self-attitude can translate into real advantages in life, work, or love, then it is hard to refute that these services provide some real value to the health and wellness of people.

I realize it is easy to poke fun at my field as saturated popular culture is with images and ideas pertaining to plastic surgery and cosmetic treatments.  But I contend that I provide meaningful therapeutic benefit to my patients.  I may not be bypassing clogged coronary arteries or re-setting broken bones, but I know that I too am providing my patients with services that can make them feel better and live better.

By now, most cosmetically minded people have heard about aesthetic fillers—those magical injectable gels which plump up the lips or smooth out wrinkles and folds.  For years, “collagen injection” was the catch-phrase, as this naturally existing component of the skin’s dermis was the main option for filling.  But so much has changed in the world of injectable fillers.  And as more options have become available, there is more confusion about what is safe, what is effective, and what should be avoided.  To help shed some light on this topic, here’s a brief outline of the past, present, and future of cosmetic fillers:

1. It’s no longer all about collagen. Although collagen is appealing as a filler because it occurs naturally in the skin, the main problem is that it doesn’t stick around for very long.  Even with the newer human recombinant form of collagen which does not require allergy testing (the earlier versions came from cows and some people were allergic to the cow protein in the filler), the body reabsorbs the material in a few months.  The current most popular options for fillers which have largely replaced collagen are hyaluronic acids (HA) or hydroxyapetite fillers.  HAs such as Restylane or Juvederm or hydroxyapetite fillers such as Radiesse do not require allergy testing and they last longer in the body.  In addition there are different preparations appropriate for different depths for the HA fillers.
2. A shift from focused to global treatment—the liquid facelift. Fillers were initially used as a treatment of specific localized problems such as thin lips or deep folds around the mouth.  Increasingly there has been a shift in thinking about how fillers can be used.  Specifically, fillers have been used more and more to address the overall changes that happen with the aging process with loss of volume, deflation of the soft tissue, and overall sagging of areas of the face.  Larger volumes of fillers are now placed into areas of hollowing such as the under-eyes, cheek bone areas, and jawline to volumize, lift, and rejuvenate the face. Particularly for the patient who wishes to look younger but does not want to go through with the recovery or expense of surgery, the “liquid facelift” with injectable fillers can provide a dramatic improvement through an in-office procedure.
3. Fillers are still non-permanent and that’s a good thing! One of the few criticisms about injectable fillers is the fact that the effect goes away after several months.  Because most of the commercially available fillers absorbable, the volume that is introduced will recede after several months to a year.  And while this is viewed as an inconvenience for some, in my opinion, this is a good thing.  The reason is two-fold.  First and foremost, permanent fillers have the risk of creating permanent problems.  There is a greater risk of problems such as infection or adverse tissue reaction with permanent fillers because these materials are, by definition, non-biodegradable.  Second, the face and soft tissue is ever changing.  The aging process affects us all creating changes in the shape and anatomy of our facial features.  Thus a permanent filler may cease to provide an appropriate, cosmetically favorable effect over time if the anatomy around the filler changes.  So the fact that reapplication is needed every several months to a year allows placement of the filler to be adjusted to match the ever-changing needs and anatomy of one’s face.  With continued advancement of filler technology, longer lasting, non-permanent fillers are likely to be developed which hopefully reach that “sweet spot” of duration where a longer effect can be enjoyed, but not so long that the changes in the face cause them to become a problem eventually.  In my opinion that sweet spot would be 2-3 years of duration—a time frame which I suspect will soon be attainable as research progresses in this area.
4. Experience counts. The most important factor that predicts successful filler treatment is the experience and skill of the injector.  As aesthetic office procedures become more and more popular, more practitioners are getting into the game.  As a patient seeking treatment, one should seek a medical practice with treatment performed or overseen by a board certified physician with specific training and experience in the cosmetic field.  There are many skilled non-physician injectors who are capable of performing beautiful work.  But I believe it is safest if such non-MD injectors conduct their practice within the scope of safe, physician supervised, medical setting.

The same regimen we recommend for overall anti-aging skin care maintenance will also greatly augment the results of a facelift. In general, a facelift improves the structure and volume of the face. Skin treatments enhance the finish and surface.

A good physical sunblock is one of the key players. Reduction of UV exposure will greatly reduce progression of actinic damage, atrophy, loss of elasticity, and fine lines. Active treatment with a retinoic acid topical treatment can be instrumental in promoting collagen regneration and strengthening of skin.

This can result in wrinkle reduction, improved smoothness, texture and tone. Also, a Vitamin C based ferrulic product serves as a powerful anti-oxidant therapy that can tighten, brighten, and stimulate collagen production. We offer a customized protocol for each patient which can be modified based on skin type and individual needs.

It is a mistake to think that a facelift pulls the skin so tight that all the surface blemishes are smoothed out. Patients need treatment on a cellular level to effectively optimize the skin surface so the outer “canvas” matches the improvements to the inner “sculpture”.

Now that the weather is starting to get nice again, it’s natural for us to start to think about getting outside more…. BUT before we get out the swimsuits and golf clubs, we should all remember to protect the most “sun-vulnerable” part of our body….our skin! Not only is our skin our protection against the elements, it is also our largest organ (by mass and surface area).  And nowhere on our skin is the damaging effects of sun exposure more apparent than on our faces.

THE MOST IMPORTANT STEP in protecting our facial skin is a good, broad-spectrum physical sun-block. A physical sun-block provides a mechanical barrier to UV light, dispersing the damaging UV rays.  Zinc or titanium molecules in the physical sun-block provides the protection.  Chemical sunblocks are an alternative, but these work by actually absorbing the UV rays to prevent the skin from being exposed to them.  This has the side-effect of creating heat, creating free radicals (which can actually cause skin aging), and irritation to sensitive skin.  While a physical block does not cause these problems, some find the white pasty appearance and thick texture of the physical blocks to be unappealing.

We offer a great solution to provide the superior protection of a strong physical block without the thick white pasty consistency.  Our line of Dr. Kim anti-aging physical sun-block is zinc and titanium fortified and contains several powerful anti-aging anti-oxidants.  It is prepared as a soft, thin emollient preparation with a natural crème light matte finish rather than a thick goopy feel.  Our patients have been really happy with this product and find it easy to use on a daily basis in conjunction with their normal skin care products.  For more information about this product please contact our office at info@dwkimmd.com or at 415-773-0800.

Next blog….once your skin becomes sun-damaged, what can you do?”

Asked on RealSelf

Dr. Kim answers the question…

Q - What questions should I ask my doctor about Rhinoplasty?

A - The most important question is…. Can you reach my goals?

The past: Early in my career I thought that being a plastic surgeon was all about making people look better.  Face-lifts, nose jobs, cosmetic office procedures—I viewed these as tools to enhance a patient’s beauty.  After having had the privilege of treating thousands of patients, my views on this have shifted quite a bit.  In particular, this change occurred after I reconstructed the nose of a young woman who had much of the nose removed to treat an aggressive skin cancer.  Once she recovered after several stages of surgery, she thanked me for returning her back to her life.  That she was finally able to feel happiness and joy again.  That’s when I realized that I should be in the business of making people feel better about themselves and not simply to look better.

The present: So now every time I meet with a patient in my office, I am thinking what I can do to make that person feel better.  How I can make that individual happier?  This has made all the difference in the way I approach each patient.  I find myself listening more carefully to their goals and paying more attention to what it is that makes them tick.  I have tried to construct a practice that is patient-centric and not one in which the game-plan for treatment is dictated by me.  I find that I am now able to make such a connection with each patient beyond that of a cosmetic surgeon and client, but one that embodies a true doctor-patient relationship.  As a result, I believe I have happier patients and I myself have found much more personal gratification in my work.

One patient’s asks the question ….”I have an otherwise perfect nose, except for a huge dorsal hump that I developed after entering highschool. I am now 18 and looking to get a nose job.”

My answer….It is tempting to think that one can simply “chop off” a dorsal hump on the bridge of a nose. But there are several things that you must realize about this procedure.

1.  When you reduce a hump, you are lowering the height of the bridge of the nose.  Because the nose sits on your face like a triangular pyramid, lowering the bridge results in removing the narrowest part of the pyramid and you are left with a wider portion.  So there may be a tendency for your nose to appear wider on the front view after hump reduction.  The amount of widening depends on how thick your skin is, how much the bridge is narrowed, and how wide you were from the start.

2.  Once a hump is removed and the bridge is lowered, the skin must then drape down onto the reduced infrastructure.  For patients with thin skin and a small or medium hump, this is not a problem.  If you have thick skin, especially if a lot of reduction is done, the skin may not be able to drape cleanly onto the structures of the nose.  In these situation, the skin remains a bit raised above the bone and cartilage of the dorsum, and some outward fullness remains.  This is called a soft-tissue polybeak deformity.

3.  If the hump involves the cartilage part of the dorsum, removing it may lead to collapse of the cartilages that form the middle part of your nose.

So in summary there a lot of things to think about before going through a procedure like this.  Rhinoplasty is a complex operation with many variables and considerations, even for a change that you might think is simple.  the best thing to do is to do your homework and seek treatment from someone who has a lot of experience with rhinoplasty.