Turning Back Time

After a difficult couple of years, Cleveland-area cosmetic surgeons are seeing an increase in patientsready to invest in their appearance.

The 43-year-old woman appeared more than ready when she arrived at Beachwood Plastic Surgery and Medical Spa in early 2008 for a consultation with Dr. Steven Goldman. She told him she wanted breast implants, but then never made a follow-up appointment.

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Some people, he explains, are just on a fact-finding mission. Others hold off because of fear or an unexpected change in their finances. When the woman finally returned for a second appointment with Goldman in early 2010, he learned that she'd just returned to her computer-sales job after a year-plus layoff.

Cleveland-area cosmetic surgeons tell stories like these over and over. Many doctors are beginning to see an increase in patients, many of whom put off procedures until the economy regained its footing.

"People now have a lot more confidence in the future," says Dr. Bahman Guyuron, chairman of the department of plastic surgery at University Hospitals and Case Western Reserve University School of Medicine

And the surgical and nonsurgical procedures these Clevelanders are booking mirror those being scheduled throughout the country, according to 2009 statistics provided by the American Society for Aesthetic Plastic Surgery.

For example, breast augmentation — the nation's No. 1 cosmetic procedure, according to ASAPS — is the hottest enhancement at many practices around town. Dr. Jason Leedy of the Cleveland Plastic Surgery Institute in Mayfield Heights says most of his patients are women who just want to restore the firmer, well-contoured bust line they enjoyed before it was ravaged by weight fluctuations, pregnancy and breast-feeding, or menopause.

"The mammary glands can atrophy after childbirth or menopause, so they end up with smaller breasts and loose skin." Leedy explains.

Another group of breast-augmentation patients, according to Westlake plastic surgeon Dr. Edward Levy, are young women who want a proportioned figure that fills out blouses and dresses.

"In Cleveland, women want to look normal, for the most part," Levy agrees. "They're not looking to win contests."

But Guyuron questions the popularity of breast augmentation over ASAPS' No. 2 procedure, liposuction. Even at his seven-surgeon department of plastic surgery, where people come from across the country to benefit from his considerable expertise in facial surgery, liposuction is still the most frequently performed procedure. And it isn't because locals have more saddlebags and love handles to remove.

"The national statistics [for breast augmentation] are skewed by the populations in New York and California," he says. "Many of those individuals are younger people who want to look better for self-image and jobs."

Innovations, Delayed Procedures Drive Demand

Expertise, like patient preference, plays a big part in determining the operations doctors perform. Goldman, for example, is board-certified in both plastic surgery and ear, nose and throat surgery, a fact he mentions in explaining the large number of rhinoplasties, or nose jobs, he does. (The procedure was No. 4 on ASAPS'
2009 list.)

Dr. Mark Foglietti of the Cosmetic Surgery Institute in Beachwood attributes the volume of patients who come to him for a facelift — an operation that wasn't even in ASAPS' Top 5 surgical procedures — to his trademarked Natural Vector technique.

"I redirect the tissues of the face — both the skin and muscle — in eight different directions to give a composite, natural look," he explains. "It's a reproducible result when the same sequence of steps is used." He calls it "one of the hottest procedures in the Cleveland area," one that reduces pain, bruising and recovery time and attracts clients from throughout the United States.

Almost every doctor we talked to mentioned the number of blepharoplasties, or cosmetic eyelid surgeries, they do. Leedy says he's seen a big increase in demand for ASAPS' No. 3 procedure as well as other facial surgeries, a hike he attributes to "a pent-up demand" created by older patients who put a lot of money in the stock market and delayed surgery until the value of those investments improved.

Levy adds that he's seeing a trend toward choosing a less-invasive surgical alternative that addresses a particular area of the face rather than undergoing a full-face rejuvenation requiring more recovery time. Dr. Gregory Fedele says the preferred alternative at his Center for Plastic & Cosmetic Surgery in Beachwood is a facial peel performed with the Pearl-brand laser. The peel improves the skin's appearance long term by evening out its texture, reducing wrinkles and producing a fresh, youthful glow.

"It's more gentle in terms of patient comfort, and you can see a result in one treatment," Fedele says of the laser. "Some other lasers require four or five treatments." The only drawback of the 15- to 20-minute procedure is a redness that requires three to four days of "social downtime."

Injectables Still Strong

Demand for injectables remains high at Cleveland-area cosmetic surgery practices. Even in recession-wracked 2009, when ASAPS statistics show surgical procedures dropped a whopping 17 percent nationwide, nonsurgical counterparts increased by almost 1 percent. "While big, invasive, facelift-type procedures are still popular, there's a move toward using more conservative procedures that are a little bit quicker, Goldman says. He notes that Dysport, recently introduced by Medicis as a competitor to pharmaceutical giant Allergan's Botox, is increasing interest in the popular botulinum toxin used to soften or eliminate frown lines by temporarily paralyzing the muscles that cause them. That interest, he points out, has been fueled by a rebate on Dysport.

Similarly, the appeal of fillers, used to plump up lips and smooth the nasolabial grooves between the corners of the nose and corners of the mouth, has been enhanced by the introduction of Juvederm XC, a version of the much-advertised lab-made hyaluronic acid (the gel-like substance found in connective tissue) that contains Lidocaine. Foglietti explains that the anesthetic numbs the discomfort of injection enough that dental blocks are no longer necessary in 90 percent of patients.

In his practice, the requests for such injectables are matched only by inquiries about Latisse, a prescription medication originally used to reduce eye pressure in glaucoma patients. The eye drops have the desirable side effect of increasing the growth phase of the eyelash follicle. A single drop applied eyeliner-style to each upper lash line every night starts producing longer, thicker, darker lashes in four weeks. Foglietti calls the results "absolutely extraordinary" at 16 to 20 weeks.

"I have at least a dozen patients right now who no longer have to wear mascara," he says. "The only patients who are not able to use it are those who have a contact dermatitis, or allergic reaction to it. When it's used on the skin of the eyelid, it has a negligible effect on the pressure of the eye itself. So it's extremely safe, even in patients with eye disease."

He stresses that although possible risks include increased brown pigmentation of the iris, he's never heard of it happening when the medication was used exclusively on the eyelid.

What's Next

Guyuron says discussions about fat injections — a filler forsaken for pharmaceutical counterparts such as Juvederm in some practices — once again dominate plastic surgery conferences.

Guyuron explains that researchers have discovered that fat is rich in stem cells — those precious, unspecialized cells that give rise to new, specialized counterparts that replace older cells. Guyuron uses a patient's own whole, live fat cells, harvested via liposuction and separated from undesirable elements such as water and oil with a centrifuge, to fill nasolabial folds, forehead lines, crows feet, even lips.

"It not only restores volume, but it also improves the elasticity of the skin," he says.

Guyuron and some of his colleagues have observed that injections of fat taken from the back of the body, including the buttocks, appear to be marginally more successful than injections of fat harvested from his usual go-to site, the abdomen.

"We are doing some studies to see if there's a difference in terms of the stem-cell count or population of cells," he says.

If those studies prove his theory, humankind will literally be sitting on the injectable of the future.

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