admin on February 11th, 2009

As a Facial Plastic Surgeon, I have been asked to correct under eye circles more times than I can remember… unfortunately there is no uniform answer, so lets break it down by category.  The treatments have been addressed as treatments for the lower eyelid complex in a chapter I co-authored in Facial Plastic Surgery, Papel I, et al. - a Thieme textbook.

 
1. Under eye circles caused by skin pigmentation:
Can be genetic, and may present relatively early in life.  They can get worse as the lower eyelid complex looses fat and skin becomes loose and contracted.  Thereby leaving the melanin in the dermis (pigment in skin) contracted, more concentrated, and thus appearing darker.
Treatment for this includes skin bleaches such as hydroquinone, sometimes in combination with retinol (Retin-A), surgery to tighten skin - although we know that this has a limit due to pulling down on the eyelid, and a “refill” or augmentation of the volume of the lower eyelid complex.  A perfect segue to #2
 
2. Under eye circles caused by volume loss - this is a thinning of the skin and loss of fat in the area that leaves the inferior orbital rim (lower portion of the eye socket bone) in a shadow - the skin may be contracted but sometimes the pigment is just not the issue.  Treatment for this is based solely on augmentation of the “tear trough” and infra-orbital rim area.  This is done using fillers like hyaluronic acid, or fat, and has great results in my practice (www.noseandface.com - click on non-surgical treatments or fox news links.)  This refers to the Thirties Eyelift that is a quick in office treatment for the lower eyelid area that looks prematurely aged in the condition above.  Click to see results.
 
3. Under eye circles caused by thinning of the skin only - this is related to the unique anatomy of the area which leaves the thin layer of skin over the muscles surrounding the eye with no fat layer in between - the color of blood flow in the muscle shines through the skin…  This is tough to treat, but likely is the target of almost all of the under-eye topical preparations on the market.  I have heard success stories and disappointments with almost every single one of these products, and don’t support any particular one, but I do recommend starting one and continuing with it for several months before giving up.  Then if it does not work, a different product may be applied.  I generally recommend Teamine, or Hylexin, and people start with Teamine because we have samples and sell full size in our office - and it probably makes no difference which one you use - you just may get lucky with one of them.
 
4. Other causes include allergy - so called allergic shiners also result from the unique anatomy of the area and its tendency to swell more than other areas of skin in the face.  Allergy treatments such as antihistamines or avoidance of allergens may help with this.
 
Sara - I hope this helps you, and is in time for your use in your article.  If you referrence my quotes, please let me know.  I am in private practice in Beverly Hills, active staff member at Cedars Sinai, and Volunteer Clinical Instructor at UC Irvine.  Thanks.

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admin on January 28th, 2009

“Doctor, I like everything about my nose except the tip, can you just cut off this part right here?” said Mrs J. as she pointed to the tip.

 

“Lets just see what the problem is Mrs. J” I said as I examined her nasal anatomy up close.  “There may be something I can do about your tip, but Mrs. J. I cannot just cut it off!”

 

As a rhinoplasty specialist I have heard several requests for changes only in the tip of the nose, but it was the first time anyone had asked me to “cut it off”.  In recent years, both rhinoplasty surgeons and the general public have developed a sophisticated taste for results of rhinoplasty (nose job) surgery.  Gone are the days of “smaller”noses, “cute” noses, and “dainty” noses.  The most common request in my practice is to have the most natural looking nose possible – “I want it cute, and natural”.  But what defines “natural” in a rhinoplasty result?  What makes one person’s nose look obviously altered by surgical manipulation and another’s elegant, refined, and more balance with his or her facial features?

 

Historically, the Egyptians, and Greeks, followed by Rennaisance artists such as Michelangelo, and Da Vinci, have studied countless faces, and preformed countless cadaver dissections to derive the anatomic features most pleasing the human eye.  In recent times, several of my colleagues have attempted to answer this very question.  For example, Drs. David Pearson, and Peter Adamson of Toronto, Canada published such a study in the Archives of Facial Plastic Surgery in 2004, exploring what type of nasal profile the general public considers most aesthetically pleasing.  The study presented digitally enhanced photographs of Caucasian female volunteers in profile view (from the side) with their bridge, and tip depicted in five different variations.  The bridge was depicted as convex (with a hump), flat, or concave (with a scoop, or slope).  The tip variations were depicted as tips that were overprojected (too far forward) to underprojected (too close to the face), and overrotated (pointing up) to ptotic (pointing down).  The features that the survey returned were combined in order to draw the most beautiful nose as determined by the study’s participants. The results of studies such as this are not surprising. 

 

—A flat to slightly concave bridge, a subtle break or transition between tip and  bridge, and a tip angled slightly above the horizontal.—

 

As someone who doesn’t let a nose pass by without formulating a complete analysis and surgical plan, I can tell you that achieving a “natural and beautiful” nasal appearance after surgery is not as easy as studies like these would suggest.  This is why there are specialists, and so called “dabblers” in rhinoplasty surgery.  If you have been considering rhinoplasty, here are some tips and facts you should know to help you get your ideal result.

 

Have your own plan:

At the beginning of every consultation, I ask my patients some relevant medical history, then, I ask the patient “what would you do if you were me?”  Simply put, what do you think is required to give you a result with which you would be happy?  For some, a simple “shaving” or reduction of a hump on the bridge is enough, for others, a narrower tip, less visible nostril skin from the side view, so on and so forth.  In some cases, when the patient does not have a clear view of what they would change in their own, I would recommend using morphing software to digitally enhance and change features of the nose to facilitate discussions of the detailed changes they may and may not experience after rhinoplasty.  In this digital age, photos are easily obtained, and reviewing them is extremely helpful in the consultation with your doctor.  In fact, some patients notice new things they don’t like about their nose during this part of the consultation.  Whatever it is that you don’t like about your nose – the consultation with your potential surgeon is the time to put it on the table.  At this time you should hear a few confirming comments from your surgeon and a plan for how to execute the surgery to fit your needs.  

 

Know what you like:

When it comes time to look at the doctors before and after pictures, some offices have a patient coordinator, or consultant review the pictures with you, while some doctors prefer to review the pictures themselves.  Regardless of how it is done, you must see a fair number of before and after pictures from each doctor with whom you consult.  If the results you see are not to your liking, don’t have your surgery done there - plain and simple.  Although most rhinoplasty surgeons have a fair knowledge of the aesthetic ideals and know the measurements that comprise this ideal, each persons ideal that they consider beautiful is different.  The old cliché “beauty is in the eye of the beholder” holds true in regards to surgical results.  If there are any doubts in your mind that your bridge might be too scooped for your liking, or your tip may be to forward, etc… then continue shopping – you owe this much to yourself!

 

Selecting your Doctor:

The American Board of Medical Specialties, who overlooks all specialty boards, considers diplomates of two specialty boards qualified and capable of performing plastic surgery on the face and nose.  These are the American Board of Otolaryngology – Head and Neck Surgery, and the American Board of Plastic and Reconstructive Surgery.  Some diplomates of the former are also certified by the American Board of Facial Plastic and Reconstructive Surgery indicating that they have completed a special examination and review process for competency in Facial Plastic and Reconstructive Surgery.

 

Despite specialty training, board certification, and membership to professional societies, the real abilities of surgeons are generally determined by many other factors.  One factor you should include in your decision is the doctors overall experience with the nose.  Patients have repeatedly asked my staff “how many has he done overall, this year, this month, and this week.”  Of course, there are no magic numbers that can be used as a measure for experience, but you wouldn’t want to have surgery in a practice whose specialty is tummy tucks. 

 

In general, for elective procedures, I recommend that patients find a good personality fit for them.  You should be comfortable with your doctor, and he or she should be comfortable with you.  There should be no embarrassment, or hesitation for you to discuss problems with your surgeon.  He or she is committed to your best interest, and to getting you the best possible outcome.  This requires good communication, and overall personal comfort in the doctor-patient relationship.

 

 

 

Know your anatomy:

Prior to consultation with your surgeons, you should have a good knowledge of your nose.  Just as you should know what you would do if you were operating on your own nose, you should know if you have had fractures, breathing problems, or possible allergies.  One of my standard questions during a consultation is “which side is harder to breathe through?”.  It may be your right side, your left side, or even switch sides.  You may not have breathing problems at all. 

 

Because of the anatomy of the nose, its form and function are very closely related.  Any change in the appearance of the nose may translate into a change in its function.  If you are undergoing elective surgery to improve the appearance of your nose, you deserve your surgeon’s careful consideration of your nasal airway and nasal passages during your surgery.  After all, what good is it beautiful nose if you cannot breathe through it?

 

Know the risks:

As with any other surgery, there are some potential risks associated with rhinoplasty.  General risks include bleeding, infection, scarring, and blood clots under the skin.  These and other specific risks should be carefully reviewed prior to rhinoplasty surgery.  Not to scare you, but to inform you of things you should bring to your doctor’s attention in the postoperative period.  These may also help you decide if the changes you are requesting are worth taking the risk to improve.  Your surgeon should also honestly discuss the risk-benefit balance of your specific desired outcome during your consultation.

 

Recovering from rhinoplasty is generally not painful, but can certainly be uncomfortable due to nasal congestion within the first few weeks.  Bruises generally resolve within a week, and then there is the swelling.  Swelling can mask the true result of your nasal surgery for months.  It is generally thought that about eighty percent of your swelling resolves in the first six weeks, and the remaining twenty percent within one year from your surgery.  Depending on how you heal, and the thickness of your skin, you should see a nearly complete result by six months from surgery.

 

Taking the plunge into a surgery that will change the central feature of your face can be relatively stressful, but rhinoplasty is among the most common elective surgeries preformed today.  The key things to remember in choosing the right surgeon for you will also help you to feel more comfortable trusting your face to your doctor.  Also remember to keep your goals subtle.  Dramatic changes can lead to increased risk of an operated appearance, and a nose that is unbalanced with the rest of your face.  Train yourself to use the “–er” words like “smaller”, “cuter”, “flatter”, “straighter”, and you will be happier in the end.

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admin on January 28th, 2009

Dr. Torkian’s chapter Lower Eyelid Blepharoplasty, published in the 2008 edition of Facial Plastic and Reconstructive Surgery (Theime).

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admin on January 28th, 2009

Dr. Torkian will be included in an expert panel of rhinoplasty surgeons this weekend in Las Vegas.  The panel consists of experts in the feild of rhinoplasty at an educational conference of the Triological Society - The most prestegious society of Facial Plastic Surgeons, and Head and Neck Surgeons.

Did you know that the unsightly bags beneath your eyes can start as early as your twenties and thirties?

Dr. Behrooz Torkian MD has several patients in their early thirties who have complained about the unfavorable cosmetic appearance of their lower eyelid region.

Dr. Torkian beleives that most of these young people have decreased fat volume at the lower orbital rim (the bottom part of the eye socket). This leaves the relativley full lower eyelid fat appear to be bulging. In older patients the fat is frequently bulging in that area, and eyelid surgery may be necessary. For most young patients, however, surgery is neither desirable or necessary.

Dr. Torkian preforms the “Thirties Eyelift” in Beverly Hills with excellent results. Dr. Torkian uses the same “injectable fillers” (Restylane and Juvederm) used for lip augmentation and treatment of smile lines. These are safe and effective materials that are compatible with your own skin and tissues, and allow doctors to fill areas with volume loss giving you the “tired” and prematurely aging appearance.

You should also check out is before and after pictures of facial and nasal surgery.

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admin on January 21st, 2009

It seems that you cant go anywhere without seeing a sign that reads “Better Than BOTOX” promoting some type of topical (applied to the surface) skin cream. The first product to be marketed with this ingenious tag line is Strivectin. Strivectin is a skin cream made with plant derived extracts that may or may not help your skin look more youthful. The product was originally designed for treatment of stretch marks related to pregnancy or rapid weight gain.

Recently, I saw a booth at a local mall in near Beverly Hills with a sign reading the same text - “Better than BOTOX!” promoting another skin cream. I immediately had the same thoughts cross my mind as the first time I saw these words.

“They can’t say that!” I thought.

Here is why. In order to compare the type of products being called “better than BOTOX” to BOTOX itself you must first understand BOTOX.

BOTOX is a trade name registered to Allergan Inc. based in Irvine, CA. The BOTOX product comes in cosmetic and therapeutic formulations. BOTOX is a toxin that has long been known to cause paralysis if ingested in foods (canned foods or honey) contaminated by a bacterium called Clostridium Botulinum. In the very low doses used medically, BOTOX is an INJECTABLE (not topical) substance that is directly injected into the target muscles. It can also be used in nerve endings that cause sectretion from certain glands such as salivary or sweat glands.

The mechanism of action of BOTOX is directed against the passage of signal from nerves to muscles. When BOTOX enters the neuromuscular junction, it blocks the transmission of the signal from nerves to muscles for approximately 3-4 months. In order to acheive the same blockage causing temporary paralysis, BOTOX must be re-injected once its effects are noticed to fade away.

In most cosmetic patients, active wrinkles in the area of the forehead, and around the eyes are improved by partially paralyzing the muscles causing the wrinkles with BOTOX. In younger patients who use BOTOX regularly, the deep furrows in the brow, forehead, and crow’s feet areas may be prevented by decreasing the muscle activity under these wrinkle-prone areas.

Now lets compare the creams. Neither of these “Better than BOTOX” creams are injectable, therefore, none are directly applied into the muscles causing wrinkles in the face. Neither of the creams have any effect on the muscles at all. Neither of the creams have been proven by peer reviewed research to help prevent wrinkles in the areas that BOTOX can be used. Furthermore, creams and topical applications to the skin have very unreliable absorption profiles. We know that many medications / chemicals can be absorbed through the skin, but most of the skin creams have not been studied, and cannot be expected to have any effect on anything beneath the surface of the skin.

In summary, “Better than BOTOX” is a comparison of apples and oranges, and should not be taken to mean that any of the topical skin creams that you can buy at the mall will ever replace or supercede BOTOX. As always, you should consult your favorite Facial Plastic Surgeon, or Dermatologist prior to using any of these skin products.

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admin on January 21st, 2009

Finding a skilled surgeon is the most important task anyone seeking plastic surgery faces.

My patients always ask me questions regarding years in practice, track record (law suits), board certification,training, and “how many times have you preformed this surgery”. My primary goal during a consultation is to help patients find the right surgeon for them - as an individual. The truth is, no surgery is like the last one, and no patient is like the last one. Here are some signs of a “skilled surgeon” regardless of training, years in practice, or board certification. Read about the American Academy of Facial Plastic Surgery here.

1. Skilled surgeons should have an interest in what the patients specific goals are.
2. Should have an honest approach to the surgical task at hand and reaching the patient’s goals… does the surgeon think it would beeasy or challenging to reach the patient’s goals - does he/she tell you?
3. should have an honest approach to previous results - I always show patients before and after pictures myself - not in a book shown by anassistant or consultant. During the picture review - a skilled and confident surgeon will have “perfect” results as well as “imperfect”results - honesty about the uncertainties of healing, surgery and overall results is a sign that the surgeon will stand by his results, and usually improve upon imperfections - if there are any. Beware of the surgeon who does not discuss persona lexperience with complications, near-misses, touch-ups, or revisions. Everyone has complications and near-misses, and their honesty regarding these proves that they will have experience managing them, and improving your results.
4. a skilled surgeon will examine you with their eyes, hands, and “ears” - the consulting surgeon should not tell you what they would do or how they can improve your look until a formal examination is done.
5. “Less is more” - skilled surgeons should be able to advise their patients regarding the realities of their goals and wheather or not your goals will leave you with a “natural” or “unnatural” look.

In addition - when choosing a surgeon:
1. your sense of beauty and appreatiation for what is beautiful should match with your doctor - my rhinoplasty patients are advised - if you dont like the look of my patient’s nose jobs - find another doctor! If you see pictures of other doctors you dont like - do not commit to them.
2. you should feel comfortable with your surgeon and feel confidentt hat they will help you get through the tough times including healing and swelling periods, as well as adjustment to your new look.

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admin on January 21st, 2009

Fractures of the nasal bones are the most common fractures in the face. In the body, nasal fractures rank third after fractures of the collar bone (clavicle) and wrist. In general, fractures of the nose occur after injury sustained from a lateral (from the side) blow to the nose. Some occur from a straight frontal force, and rarely, fractures occur from a force from below or above. Fractures of the nose may involve bone along the bridge or back of the septum (wall in between the two sides of the nose), the cartilage of the bridge and septum, and rarely the cartilage of the tip or sidewalls of the nose. Most fractures of the nose are sustained in young individuals, and many are sustained during participation in sports.

When a nasal fracture occurs there is generally a loud noise, bleeding, bruising, and a significant amount of swelling that occurs both on the outside and inside of the nose. Although fractures should be evaluated as soon as possible after the injury is sustained, the treatment may not always be possible in the immediate phases due to swelling. Evaluation of the injury includes direct examination of the bones by feeling the integrity and shape of the bones, and internal examination to evaluate the septum for deviation. X-rays and CT (CAT) scans may be helpful in some cases, but are generally not considered specific enough for minor or simple fractures.

Septal fractures can occasionally lead to an emergent complication called a septal hematoma, or a blood clot that forms in the tissues of the wall in between the two sides of the nose. If a septal hematoma is not recognized or treated in a timely fashion, the blood flow to the mucus membrane and cartilage of the septum may be compromised. This compromise in blood flow may lead to a perforation, or hole in the septum. Septal perforation is a fairly common complication of nasal trauma that may lead to severe crusting, noisy breathing, and occasionally to nasal deformities of the external appearance that are difficlut to correct. Thus, septal hematomas should be detected early and drained promptly to avoid these complications.

Treatment of simple nasal fractures may easily be conducted in an office setting or in an operating room when sedation or general anesthesia is required. In general, numbing medicines are injected and fractured bones and cartilages are moved into their proper positions to allow appropriate healing of these skeletal structures. A splint may be applied to the bridge, and occasionally to the septum. Packing may be necessary in the event of a septal hematoma or heavy bleeding. The bones generally are “set” and begin to stabilize by about 7-10 days in adults and 4-5 days in children.

During the first few hours after injury, the swelling that appears externally may prevent your doctor from being able to preciscely replace the bones in their pre-injury position for propper healing. Thus, if you see a doctor after 2-3 hours of the injury, he/she may defer the initial treatment of the fracture for 2-4 days in expectation of some decrease in swelling that would enable you to have the best possible overall result.

Delayed repair of nasal fractures that have remained untreated, or healed inappropriately currently accounts for approximately twenty percent of my practice. Many of these patients have sustained injury in their childhood that have later led to problems with breathing and external deformites. In these cases, surgical correction is required to repair changes in the structure of the nose inculding cartilage and bone. The repair of bony structural defects usually requires re-fracture of the bones and stabilization of the bones using a splint. The cartilagenous components including the septum, sidewalls, and bridge may require alterations in the connections of these cartilages to eachother, and to the bony components with internal stabilization using internal stitches. The goals of these operations include improvement of nasal airflow, and restoration of propper form of the nose. These often go hand-in-hand, and may partially be covered by insurance when appropriate.

Recovery is considered speedy and usually with only a few days of pain. Most patients are able to return to school or work within one week. Breathing slowly improves within one month as internal swelling improves. External appearance generally improves slowly over the course of one year. The greatest decrease in swelling is seen within the first 6 weeks, then slowly thereafter for the next 10 1/2 months.

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