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About Face: Surgical and Non-Surgical Options

By Elaine Porterfield

Grace McNamara of Seattle epitomizes the face of cosmetic surgery and dermatology in the Northwest: After having surgery for skin cancer at 58, the admitted former sun worshipper went under the knife again—this time to get a face-lift. She has never been happier, freely telling anyone who asks where her fresh new look came from.

Puget Sound doctors say McNamara is not at all unusual: People, many of them baby boomers, are looking for a fresher—but still age-appropriate—look. For some, it’s about presenting a more vigorous or energetic appearance at work; for others, it’s about getting rid of acne scars or other issues that have always been a little embarrassing.

Recent advances in techniques and materials have made many procedures safer, easier and better than they’ve ever been. Many patients undergoing cosmetic surgery can be in and out in a day. Often (although not always), a local rather than a general anesthetic can be used. Some treatments can be done during the lunch hour with minimal or no initial discomfort; other treatments can be done on a Friday afternoon with visible results by the following week.

Of course, cosmetic procedures aren’t always as easy—or painless—as TV shows like Extreme Makeover make them seem. Complications, though rare for skilled medical practitioners, can and do occur, so prospective patients should fully educate themselves beforehand on possible problems. Recovery times vary considerably; it can take weeks before you’re fit to be seen in public after some surgical procedures, versus almost no time for the latest in injectables or lasers. Some procedures, such as face-lifts, can leave patients with temporary nerve numbness. And the effects of other procedures, like Botox injections, may not be visible for several days or more, making planning ahead for a big event important.

Here are some of the latest techniques, surgical and nonsurgical, that will tune up your look, from line, wrinkle and spot removers to tooth whitening and brightening.

Nonsurgical choices
Options here include injectables—such as Botox and the newer volume replacers—that fill in lines and wrinkles, and lasers that can treat acne scars, adult acne, redness, spots, scars, sun damage and more. The latest technology can create subtle, rather than extreme, changes.

PROCEDURE: Volume replacers
DESCRIPTION:
These relatively new types of injectables enhance the cheek, chin, nose and jaw line, as well the nasal folds, the corners of the mouth and those irritating “lipstick lines.”
WHO SHOULD HAVE IT DONE: Those interested in subtly reversing signs of aging or filling in unwanted facial hollows. Some fillers have been used to restore the faces of people with AIDS, who can sometimes suffer from gauntness and wasting.
PRODUCTS: Radiesse, Restylane, Juvéderm. Radiesse can give a “cheek lift” and fill in other unwanted hollows. Juvéderm, says dermatologist Brandith Irwin of Seattle’s Madison Skin and Laser Center, is preferred by her patients. “It’s smoother, it’s less puffy in the long term. It tends to lump less, and it’s less painful to inject.”
COST RANGE: $575–$650
TIME FOR PROCEDURE: One office visit
RECOVERY TIME: Virtually none, but some bruising and swelling is possible
HOW LONG IT LASTS: Three months to 1.5 years
WHAT THE PROS SAY: The new fillers are lasting longer and giving better results. “They’ve much reduced allergic reactions,” says Dr. Fredric Stern of the Stern Center for Aesthetic Surgery in Bellevue, “and the new fillers stay softer and can fill deep creases.”
ADVICE: Never use anything permanent in the face, such as silicon, says Irwin. Problems can arise up to 15 years later. “You may look great for a couple years, but if you have a complication, you can’t get rid of it, or you have to cut it out. … It’s like a Russian roulette sort of thing,” she says. Also, use a dental anesthesia block or topical numbing cream before having an injection in or around the mouth. “Believe me, it’s tender, even with topical numbing.”

PROCEDURE: Botox
DESCRIPTION: This popular injectable temporarily paralyzes facial muscles, easing wrinkles around the face, from forehead lines to crow’s feet to lines around the mouth.
WHAT’S NEW: Practitioners know better now how much is needed—and where. Too much, and you get that frozen, caught-in-the-headlights look of certain Hollywood stars. Stern—who is nationally known for training other practitioners in the use of Botox—injects all of his patients himself, using small amounts, artfully placed, for a much more natural look.
WHO SHOULD HAVE IT DONE: Anyone bothered by lines in the forehead, crow’s-feet or other wrinkling
COST RANGE: $300–$600
TIME FOR PROCEDURE: One office visit
RECOVERY TIME: None, but effects can take up to two weeks to be seen
HOW LONG IT LASTS: 4–6 months on average

PROCEDURE: Lasers
DESCRIPTION: High-intensity lights are used to treat brown spots, redness, age spots and blotchiness from sun damage, reduce wrinkles, even out skin texture and luster, tighten skin and even minimize acne scars.
WHAT’S NEW: Lasers continue to be refined, giving increasingly good results with less downtime. The new Fraxel laser creates numerous microscopic channels in the skin surrounded by healthy skin, says Stern. The treated skin stimulates the body’s production of collagen, smoothing and plumping the area. “It’s the first real advance in lasers in five years,” agrees Irwin, who has a new book on skin care, The Surgery-Free Makeover: All You Need To Know for Great Skin and a Younger Face (March 2008, Da Capo Lifelong Books, $24). “You can greatly adjust for depth, and that makes it even better for acne scarring.”
WHO SHOULD HAVE IT DONE: Those who don’t like the look of brown spots or age spots, who want to improve the overall look of their skin or reduce wrinkling.
COST RANGE: About $1,000
TIME FOR PROCEDURE: Typically 30 to 60 minutes
RECOVERY TIME: Varies depending on procedure, from little or no downtime to a few weeks
HOW LONG IT LASTS: Varies widely, depending on the initial number and type of laser treatments and skin issues. Collagen enhancement can continue for up to a year.
WHAT THE PROS SAY: “You can’t even tell you’ve had it done,” says Irwin of the Fraxel laser. “You’re a little red for a couple of days, then bronzy colored. Your skin texture feels like a cat tongue. Then that all resolves and you grow in new skin and look beautiful.”


Surgical Options
After a certain point, injectables or lasers often aren’t enough to achieve the more youthful appearance some people want, and it’s time to consider cosmetic surgery. Sometimes patients simply tire of coming in every four to six months for maintenance injections like Botox or Juvéderm, preferring a more permanent solution to lines and sagging, say Dr. Craig Murakami, a facial plastic surgeon at Virginia Mason Medical Center, and his colleague, plastic surgeon Dr. Keith Paige.

PROCEDURE: The numerous approaches to face-lifts and other facial surgeries break down broadly into the following categories:

• The mini lift: A less invasive procedure than a full-on face-lift, it tightens jowls and neck skin. The surgeon makes incisions in an “S” shape around the ears toward the bottom of the hairline, tightening and removing excess skin. Recovery is faster than with a regular face-lift, but results are also less spectacular. Often for younger patients with fewer signs of aging, such as people in their 40s.
• The traditional face-lift: This procedure nips and tucks sagging skin in the lower face and neck, reducing wrinkling and skin droopiness and raising the corners of the mouth. Liposuction can accompany it to remove excess fat.
• Other face-lift techniques include eye-lifts, in which a surgeon takes out excessive fat and/or droopy skin around the eyes, giving a more refreshed, alert look, and brow-lifts, to help take out frown lines and lift the brows.

DESCRIPTION: Surgeons draw upon a variety of surgical techniques. Excess skin is pulled and trimmed—think of tightening wall-to-wall carpet—muscles are tightened, and sometimes fat is removed. Most incisions are hidden within the hairline, behind ears or even within the mouth.
WHAT’S NEW: Combining precise liposuction and surgery for a more refined, natural and pleasing effect; mini lifts that require much less downtime; combining face-lifts with laser resurfacing for improved skin texture along with tightening.
WHO SHOULD HAVE IT DONE: This is an entirely subjective decision, say physicians. One person’s laugh lines, after all, are another person’s wrinkles. It depends on what you want to look like.
BOOMER TREND: Dr. Keith Paige says baby boomers are going to increasingly demand aesthetic procedures through old age. “As the whole population ages, 70- and 80-year-olds will be looking at doing cosmetic surgery. It’s a different ball game. The 70s are the new 50s,” he says.
TIME FOR PROCEDURE: Varies greatly, depending on procedure, from an hour or two to four or more hours. A surgeon may combine different facial surgeries, such as a brow-lift and a lower face-lift, which adds to the time needed for the procedure.
RECOVERY TIME: Recovery times vary greatly, but figure several weeks for most bruising, puffiness or swelling to subside. With less discomfort and bruising, a mini-lift is sometimes called a “weekend lift,” because patients can have it on a Friday and be back at work on Monday. But numbness in areas can persist for months.
HOW LONG IT LASTS: Varies depending on skin type and age at the time of the procedure, but 5 to 10 years on average.


Cosmetic Dentistry
Practitioners say that most patients are seeking a natural, cleaner-looking, more attractive smile—not a hyper-white grin full of freakishly even teeth. Veneers and whitening are great options. While over-the-counter whitening kits will help somewhat on the teeth in the front of the mouth, the fastest, most dramatic results come from a dentist.

PROCEDURE: Veneers
DESCRIPTION:
Veneers are very thin laminates made to cover teeth that are stained, misshapen or chipped.
WHAT’S NEW: Today’s veneer materials have a natural translucency, says Dr. Cynthia Pauley of Brookside Dental in Bellevue. The technique of placing veneers is improving too, says cosmetic dentist Shawn Keller of Redmond: “We can do more with removing way less tooth structure.”
HOW LONG IT TAKES: Veneers can often be placed within two visits, transforming discolored or misshapen teeth.
COST: $1,500 per tooth
WHO SHOULD HAVE IT DONE: Those with deep staining that can’t be fixed with professional bleaching or those with chipped or otherwise misshapen teeth.
RECOVERY TIME: None
HOW LONG IT LASTS: 10 or more years
WHAT THE PROS SAY: “We now can restore teeth to a very, very esthetically high level,” says Pauley, who has taught restorative dentistry at the University of Washington. “The future is only going to get better.” She adds, “The materials are really good, quite natural. The ability to cover up things like tetracycline staining is very, very good.”

PROCEDURE: Whitening
DESCRIPTION: There are several whitening methods, but in one common one, a bleaching solution is spread over the patient’s teeth in the dentist’s office. A special light is then applied. Some whitening procedures can leave patients with one to three days of sensitive teeth.
WHAT’S NEW: Whiteners are much gentler than they used to be, say Keller and Pauley.
TIME FOR PROCEDURE: One hour
WHO SHOULD DO IT: Those concerned with yellowing, dingy or dull-looking teeth
COST: $700
WHAT THE PROS SAY: “Our whitening materials continue to improve,” Pauley notes. “We have better whitening [materials] with less sensitivity. I think we’ll get to an area where we have whitening with virtually no sensitivity.”



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