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"$32,500 and still counting" The case for surgical rejuvenation

Article-"$32,500 and still counting" The case for surgical rejuvenation

Dr. Hamra
I was hardly surprised by the October, 2006 article in Cosmetic Surgery Times entitled, "HA Augmentation: Natural Persistent Rejuvenation" concerning the use of Restylane (Medicis Aesthetics) for periorbital hollows. This article is similar to an article published in Plastic and Reconstructive Surgery 1 in November, 2005 which caused me to write a rebuttal letter that appeared in the September, 2006 PRS 2 entitled "$25,000 and Still Counting." Allow me to change the title for this column of polite dissent to "$32,500 and Still Counting."

It is simply a fact of life that simple, hyped, noninvasive, marketable procedures are here to stay.I daily use Botox (Allergan Medical) and Restylane and I fully appreciate the advantages of both products in a cosmetic practice. I also fully understand the fact that the vast majority of physicians in a cosmetic practice are not fully trained plastic surgeons, and that that percentage is growing daily.

The November 30, 2006 issue of The New York Times ran a front page article entitled, "More doctors turning to the business of beauty," describing injection procedures used by untrained physicians in the unregulated practice of cosmetic surgery and spas.

My only objection is that the authors of both of these articles make statements condemning true surgical procedures in order to make their point, totally ignoring published articles including confirmatory articles demonstrating the proven advantage of surgical rejuvenation.

Having been involved with lower eyelid/cheek surgery since 1992, and having had several articles published3,4,5,6, I disagree strongly with Drs. Born and Airan's statement in their October CST article, both being consultants to Medicis, that "HA filler has consistently resulted in favorable cosmetic outcomes that are equivalent to or surpass those seen with more invasive procedures for periocular rejuvenation." This is similar to Dr. Robert Goldberg's statement in his PRS article that, "the more we can avoid open surgery, the better we can do in avoiding the inevitable backsliding from surgery." Hopefully these respected physicians speak for themselves, not others.

The fact is that well done surgery is aesthetically superior to injection techniques, as any objective observer can see when examining the published results in the October CST article in which the lower eyelids still appear hollow. Judging from the disappointed patients I have seen done in Dallas, there is usually a "mushy" consistency of the lower eyelid to palpation and appearance.

I have followed patients closely since 1992, and for the sake of accurate documentation, offer three patients who have been published showing both the one-year and long-term results. The patient in Figure 1 is a primary facelift patient shown with an eight-year follow-up photograph. The patient in Figure 2 is a secondary facelift with hollow eyes from a previous excessive orbital fat removal shown with an eight-year post-operative view, and the patient in Figure 3, one of my earliest patients, is seen with a 13-year follow up cheeklift and fat preservation procedure.

Not only is the lower eyelid contour superior to published injection results, but these patients, typical of patients who have undergone surgical techniques are still, "waiting for the inevitable backslide." Assuming the cost of yearly Restylane to be about $2,500 a year, the patient in Figure 3 would have spent $32,500 and "still counting" as the years pass. Miss an injection, and the lower eyelid falls back to emptiness with nothing to show except cancelled checks.

Somewhere in the mushrooming boom of cosmetic procedures, the long-term interest of the patient must be considered. Unfortunately, the prevailing world of managed care, physician overproduction, and poor training is creating a scenario that may reverse years of progress in rejuvenative surgery since the promotion and adoption of non-surgical procedures could eventually diminish the use of surgical procedures which are best for the patient.

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