Good Plastic Surgery

Why don't you ever see tabloid headlines about "Good Plastic Surgery" or "Great Botox"? Or maybe "Fantastic facelift" or "Tremendous Tummy tuck"?

Well, besides the fact that 1) sensationalist headlines sell papers, and 2) we all have an excessive sense of curiosity about all things related to celebrities, regardless of their actual talent level, good plastic surgery should be basically undetectable. It shouldn't be the first thing you notice when you look at someone for the first time.

Good plastic surgery is about restoring or enhancing what is known as "the beautiful normal" - that is, the attractive end of the bell curve distribution of normal anatomy. A good facelift, for example, should smooth the cheeks, eliminate the jowls and correct the neck, but without obvious scars, or any peculiar "pulled" appearance, so everything looks like it did five or ten years earlier.

"Good" botox should just soften the expression lines of the face, and not leave the person looking frozen, or devoid of expression. Nor should it drop the eyebrows, creating an appearance reminiscent of Mr. Spock. (the Vulcan, not the author-pediatrician!)

"Good" lip fillers make female lips look young and luscious, and not like two sausages next to one another.

"Good" breast implants do not look bolted on, or like two cantaloupes. There should be a soft-looking, flowing shape that is proportional to the woman's frame.

"Good" eyelid surgery doesn't make you look permanently surprised, gaunt, or feline. It merely removes overhanging skin or puffy fat, letting the natural beauty of the eye show through.

And none of it should be obvious. It should be a "Did she or didn't she?" and not "OMG! Look at her!"

Bad plastic surgery distorts a feature so that it stands out from the rest, but not in an attractive, harmonious way. As one of my professors used to say, "Bad plastic surgery shouts, but good plastic surgery only whispers..."

As for the answer to the enduring mystery of why so many Hollywood celebs get some bizarre-looking work done - well, I'm as stumped as you are. One would think that these celebs, with their money and connections, would know which plastic surgeons are the good ones in town...

When Bad Lips Happen to Good People

One of the hallmarks of unfortunate plastic surgery in many celebrity photos is the overdone lip augmentation. The lips in these photos generally appear overstuffed, like two tubes, or two sausages lying side by side.

The real reason that these results are bad is that the idea of creating a beautiful normal lip has gone out the window! Real lips have many subtle features in their shapes - and beautiful lips maintain these features. Unskilled practitioners just "pump in" fillers without regard for the details of the anatomy. Skilled practitioners shape and enhance the underlying forms.

For example, the upper lip and lower lip are not the same size. Usually, the lower lip is about twice the height of the upper lip. It's important to maintain this 2:1 ratio when enhancing lips. If the lips are made to be the same size, this will make the upper lip appear excessively large, which is not desirable.

Secondly, lips have subsections or segments to them. The upper lip has three segments, the lower lip has two. It's important to recognize these segments and maintain their individual shapes when performing lip enhancement with fillers. For example, since the lower lip should have two symmetric halves, with a slight depression in between - the plan for the filler treatment should be designed this way too.

The central portion of the upper lip and the adjoining skin is particularly unique, with features known as "cupid's bow" and the "philtral columns". A well done lip augmentation preserves and enhances these normal contours, rather than obliterating them through excessive filling. Plastic surgeons have a unique understanding of the anatomy of the lip, as the surgical repairs for children with congenital cleft lip problems also require the restoration of these same anatomic features with careful attention to subtle anatomic details.

In addition to enhancing the outline of the lips, adding volume to the lips is also helpful to restore a loss of lip fullness that happens with aging, or to enhance the look of lips that were naturally thin. Once again, respect for the segmental lip anatomy is key to getting a good result. So is restraint.

Excessively sized "pillow lips" will not look attractive, no matter how you do them. Sometimes patients get carried away with their desires for lip fullness... and the results may look peculiar. In these cases, a responsible physician will have to tell the patient, "No - that won't look good."

The bottom line:
1. Careful communication about the desired result with your practitioner is essential.
2. Start small / be conservative at first, using a more subtle approach.
3. Avoid long-lasting or permanent fillers, such as silicone, radiesse or artefill, in the lip. If there is an unsatisfactory result, you could be stuck with it. The options for correcting lumpy looking permanent fillers are very limited.
4. Look at lots of before and after photos when evaluating the previous results of your practitioner. Your injection specialist should have a light touch and an artistic eye. If you see some of the problems we've discussed here, go elesewhere!

Happy Father's Day!

Celebrity Plastic Surgery

Recently, I got a e-mail from a former employee, an attractive young nurse who had moved out to the West Coast. In it, she comically mentioned "not wanting to look like some Hollywood-style bad plastic surgery victim", and asked me for some recommendations about who to see out there. But it got me thinking...

I spent some time looking at "bad celebrity surgery", and started to notice some patterns. I think it boils down to a combination of facial distortion, loss of one's distinctive initial appearance with reduction of recognizability, and the "stigmata" of poorly performed or ill-advised work.

Here is my highly opinionated list of "problems to be avoided", if at all possible.

1. Excessive botox - particularly in the glabella and medial forehead area, when it can drop the position of the inner portion of the eyebrows, giving a diabolical or "vulcan" look.

2. Excessive lip fillers. While a full, pouty lip can look youthful and pretty - there is a limit. The upper lip should certainly not be larger than the lower lip. Respect the anatomic details of the lip - the lip should not look like a sausage. In general, straight men should avoid lip augmentation, as it can feminize the appearance.

3. Facial fat removal. As we age, we naturally lose our facial fat. Removing it surgically with liposuction or direct excision, in order to give a more "sculpted" appearance, can be a set-up for a skeletal, gaunt appearance in the future. And it's hard to fix.

4. Cheek implants - are not a substitute for a facelift, and do not make a good replacement for loss of facial fat. Poorly performed cheek augmentation can distort the facial width, or look like a chipmunk storing nuts in its cheeks. Cheek & chin implants can work wonders for people that don't have good underlying bone structure - if they are properly sized, and meticulously placed by an expert.

5. Overdone rhinoplasty. An excessively thinned, pointy nose, with distortion in the nostril area or visible irregularities. Celebrity gossip pages are full of these.

6. Unfortunate facelift results. We'll talk more about this in future posts - but "pixie ears", loss of hair in the temple area, peculiar direction of cheek wrinkles, visible scars, the "tight face-loose neck" combination....these are all tip-offs that a facelift didn't work out very successfully or had some technical problems.

7. "Tan-orexia" - when your skin tone is the color of pumpkin pie from the over-use of self-tanning products, it's not good.

8. Too much of everything / too young / too many operations. Trying to slow aging is one thing. Starting to look like someone else is another.


Best wishes for 2009!