PLASTIC SURGERY

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INTRODUCTION

Some of the specialty services that we offer include BOTOX® Cosmetic injections, laser skin resurfacing and cosmetic blepharoplasty. We also offer other eyelid surgeries including repair of drooping or malpositioned eyelids and removal of benign and malignant lesions of the eyelids.

Two new technologies have emerged to make some of our surgical procedures much easier and with improved cosmetic results.

The Superpulsed CO2 laser removes facial wrinkles in and around the eyes. This laser has done such a good job of removing wrinkles around the eyes that we have extended its use to the full face. We also use the CO2 laser for cosmetic Blepharoplasty (removing excess upper lid skin and removing those unsightly bags beneath the eyes).

The Ellman unit is truly a technological marvel. It operates by allowing us to do what we call high frequency radio surgery. The Ellman unit helps us to shave lesions off the eyelids and face while maintaining a normal counter to adjacent tissues.

BOTOX® Cosmetic

Introduction

BOTOX® Cosmetic injections are a quick and simple treatment for the temporary improvement of moderate to severe forms of frown lines and crows feet. You laugh, you concentrate, you frown, and over time, those expressions leave their mark upon your face. Until recently, there was nothing you could do about it. Now, there is BOTOX® Cosmetic; a simple 10- minute injection procedure performed right in the office.

BOTOX® Cosmetic is a compound derived from the botulism bacteria, called botulinum toxin type A. It acts by blocking the nerve from releasing a chemical called Acetylcholine. As a result, frown lines on the forehead and crows feet around the eyes become significantly less noticeable. Although it's effects have been dramatic for many people, it's important to remember that BOTOX® Cosmetic is not a cure, and that re-treatment may be necessary every 4-6 months to maintain continuous results. Three to four months after initial treatment, the nerve will begin to recover from the injection and start to re-release Acetylcholine, allowing the muscle to again become overly active. It is at this point that re-treatment may be needed to provided continuous relief.

Anatomy

The muscles of facial expression above and around the eyes are arranged such that excessive contraction causes glabellar (frown) lines and crows feet to develop. Years of laughing, concentrating, and frowning leave their mark upon your face. These expressions cause the overlying skin to be thrown into folds or creases that make you look un-rested or older than you really are. An understanding of the anatomy of the muscles responsible will enhance your understanding of why this occurs and how we can treat it. There are two groups of muscles in the forehead that, under continual contraction, cause you to look tired, un-rested and angry. These muscles are called the corrugator and procerus muscle groups.

How lines and wrinkles form: Movement and contraction causes the overlaying skin to crease.

As skin becomes less elastic over time, repeated frowning may create visible lines and wrinkles.

The second group of muscles around the eye that can cause you to look tired and un-rested are called the orbicularis oculi muscle groups.

How lines and wrinkles form: Movement and contraction causes the skin
to crease to form what is commonly called crows feet.

The skin becomes less elastic over time, repeated laughing, concentrating and
squinting over time, create visible lines and wrinkles called crows feet.

How the Nerve and Muscle Units Work

Normally, your brain sends electrochemical messages to your muscles in order to make them contract or move. These messages are transmitted from the nerve to the muscle by a substance called Acetylcholine. When too much Acetylcholine is released, muscles become overly active and may spasm or tense up. The skin overlying these muscles is thus thrown into folds, resulting in those unsightly frown lines on the forehead and crows feet around the eyes. BOTOX® Cosmetic injected in and around the muscle blocks the nerve from releasing Acetylcholine, stopping or greatly reducing the muscle contractions or spasms, which in turn provides relief from those unsightly frown lines and crows feet.

The outlined blue represents the end plate of the nerve or the nerve ending. The blue round vesicles
contain Acetylcholine that is released upon electrical nerve impulses arriving at the nerve ending.
The released Acetylcholine diffuses across the membrane of the nerve ending
into the muscle and causes the muscle to contract.

BOTOX® Cosmetic acts by blocking the release of Acetylcholine in the vesicles. If there is no free
Acetylcholine to diffuse into the muscle, there is no muscle contraction.

The Procedure

First a short, general consultation is needed with the administering doctor. This one-time consult lasts just 20 - 30 minutes and will give you a chance to get to know the doctor, to discuss possible treatment options, and to just get a feel for what you could expect following a BOTOX® Cosmetic injection. After this initial consultation with the doctor, you are now ready for treatment.

BOTOX® Cosmetic is a very simple, non-surgical procedure which consists of a few tiny injections on or around the desired area, and usually takes about 10 minutes to administer in the office.

The injection relaxes the muscles that cause frown lines and other superficial wrinkles, keeping them relaxed for up to four months while allowing your skin to regain the youthful look you're after. Unlike surgery, BOTOX® Cosmetic is simple, fast, and minimally evasive, with no downtime or recovery required. Most people return to work or normal activity immediately following treatment and within days they report looking relaxed and more natural.

No general anesthesia is required, although the doctor may choose to numb the area using a cold pack or anesthetic cream prior to injecting. Discomfort is minimal and brief, with most patients comparing the sensation to a bug bite. It is highly unlikely that you will develop significant side effects, although some people develop temporary bruising at the injection sites, which can be easily covered by makeup. You're free to resume normal activity immediately! Although some people report immediate improvement, you can expect to see marked improvement within days and may continue to improve your appearance for up to a week. The effect should last up to three to four months, with most patients requiring just two treatments per year. If you decide not to continue treatment, your brows or eyes will not look worse than before treatment, as they gradually revert to their pre-treatment appearance.

Results

BOTOX® Cosmetic results are dramatic and apparent within days of treatment. In clinical trials, 82% of patients reported an improvement in appearance 1 week after treatment and nearly 90% reported an improvement after 30 days. For many, BOTOX® Cosmetic virtually "erases" these lines.

Before injection	After injection (1 week)
Before injection	After injection (1 week)

Who is a Good Candidate?

Any image-conscious man or woman who is concerned about the appearance of frown lines or crows feet can consider treatment. BOTOX® Cosmetic is an FDA approved procedure for the treatment of frown lines on those people under the age of 65. If you are considering treatment but don't know if it's right for you, call Grendahl Eye Associates at 561-1917 to schedule a skin consultation with one of our doctors. They would be happy to talk with you about treatment options that can best meet your individual needs.

Frequently Asked Questions

What is BOTOX® Cosmetic?

As we talked about earlier, BOTOX® Cosmetic is a formulation of botulinum toxin type A. It is derived from bacterium Clostridium botulinum, which produces a protein that blocks the release of acetylcholine and relaxes muscles. Type A is just one of seven different types of botulinum toxin (A, B, C1, D, E, F, and G) and each has different properties and actions. Today, BOTOX® Cosmetic is produced in controlled laboratory conditions and given in extremely small doses. It has helped over 1 million patients worldwide with conditions caused by overactive muscles, and continues to be used for various treatments, including cosmetic applications.

Is BOTOX® Cosmetic a New Treatment?

No. BOTOX® Cosmetic has been used for more than 11 years to treat patients worldwide, and is approved by health ministries in at least 70 countries. It has been endorsed by the American Academy of Neurology and the National Institute of Health, and is also FDA approved in the United States for uses including but not limited to cosmetic.

How is BOTOX® Cosmetic Different From Other Botulinum Toxin Treatments?

BOTOX® Cosmetic is Allergan's brand of botulinum toxin type A. A brand of botulinum toxin type B is also now available. The two toxins are different in several ways:

• They are different serotypes • They have different manufacturing processes • They work differently • They require different doses

How is BOTOX® Cosmetic Different From Oral Treatments?

When drugs are taken by mouth, they are distributed throughout the body by the blood system. In contrast, BOTOX® Cosmetic injections are administered directly into the desired site of action. BOTOX® Cosmetic is not expected to be present in the bloodstream at measurable levels following treatment, and typically remains in the injected muscle, although some spread to adjacent muscles may occur.

How Long Can I Be Treated With BOTOX® Cosmetic?

Each treatment typically lasts up to 4 months and can be repeated as long your condition responds to BOTOX® Cosmetic and you do not have any serious allergic reactions or other significant side effects. Although most people continue to respond to BOTOX® Cosmetic injections, some people have experienced a diminished response over time. There may be several explanations for this:

• Changes in your condition-sometimes the physician may need to inject new muscles and/or change your dose. • Setting appropriate expectations-you may believe your first BOTOX® Cosmetic injection was more helpful that subsequent injections. That's because your condition was perhaps quite severe when you had your first treatment. Subsequent injections are usually given before your condition becomes that severe again. • Antibody formation-when foreign proteins, like botulinum toxins, enter your body, antibodies may form. If antibodies to botulinum toxin develop, you may no longer respond to treatment.

Does the Injection Hurt?

Some people report minor, temporary discomfort from the injection. BOTOX® Cosmetic is reconstituted with sterile, preservative-free, normal saline for injection. The neutral pH of the injected solution, in combination with the fine-gauge needle your doctor will use, can help to minimize any injection-related pain.

Is There Anything Else I Should Know Before Having BOTOX® Cosmetic Injections?

Make sure your health care provider knows if you're pregnant, nursing, or taking any medications before receiving BOTOX® Cosmetic injections. Additionally, you should not receive BOTOX® Cosmetic if you have an infection at the injection site. BOTOX® Cosmetic should be used with caution if you have other neurological diseases or disorders, or if you are taking aminoglycoside or other drugs that interfere with neuromuscular transmission. Also be sure to tell your health care provider about any prescription or over-the-counter medications you are taking before receiving BOTOX® Cosmetic.


Restylane®

If you are considering a wrinkle or facial fold correction treatment, Restylane® might be your choice. The recovery time is minimal and the results are immediate.

What is Restylane®?

Restylane® is a cosmetic dermal (skin) filler composed of hyaluronic acid, a natural substance that already exists in the human body. Hyaluronic acid and collagen are the "ground substance" that makes up a major part of the packing substance of the body's tissues. It is found in muscle, cornea, skin etc.

The filler properties of Restylane® come from binding of body water to the hyaluronic acid. The injected Restylane® (hyaluronic acid) maintains its shape using the body's own water. Hyaluronic acid gradually dissolves over time with each molecule binding more water to maintain its skin fold filler properties.

Restylane® restores volume and fullness to the skin to correct facial wrinkles or folds. It is particularly good for treating the nasolabial folds (lines from the corner of the nose to the corners of the lips) as well as lines around the lips. Restylane® injections also restore fullness to the lips.

What to expect

After your injections of Restylane®, you will have some swelling and redness. This will last one to two days. After your injections, sunbathing and cold outdoor activities should be avoided until any redness or swelling disappear. If you are pregnant or breast-feeding you should not use Restylane®.

The following before and after photos demonstrate Restylane® treatment:

Before	After

Frequently asked questions

Q: What is Restylane®?
A: Restylane® is a safe and natural cosmetic dermal filler that restores volume and fullness to the skin to correct moderate to severe facial wrinkles and folds, such as Nasolabial folds.

Q: What is Restylane® made of?
A: Restylane® is a cosmetic dermal filler composed of non-animal stabilized hyaluronic acid. Hyaluronic acid is a natural substance that already exists in the human body and is used to provide volume and fullness to the skin. The hyaluronic acid in Restylane® is a crystal-clear gel called NASHA^TM. NASHA^TM is biodegradable and completely biocompatible with human hyaluronic acid.

Q: How is Restylane® different than other hyaluronic acid-based products?
A: Unlike rooster-derived hyaluronic acids and bovine collagen products, Restylane® is free from animal proteins. This limits any risk of animal-based disease transmissions or development of allergic reactions to animal proteins.

Q: What should patients do prior to treatment?
A: Restylane® requires no pretesting, but you should take a few precautions before being treated. Avoid using aspirin, non-steroidal anti-inflmmatory medication, St. John's wort or high doses of Vitamin E supplements prior to treatment, because these may increase bruising or bleeding at the injection site. Also, if you have previously suffered from facial cold sores, there is a risk that the needle punctures could contribute to another recurrence.

Q: Is Restylane® safe?
A: Yes. Restylane® has been used by dermatologists and plastic surgeons since 1996 worldwide. Restylane® has a highly favorable safety profile. It's composed of non-animal stabilized hyaluronic acid. Hyaluronic acid is a substance found naturally in the human body. Restylane® is fully biocompatible. There is limited risk of animal-based disease transmission or development of allergic reactions to animal proteins. No allergy testing is required before use. The most commonly reported side effects were temporary redness and swelling at the injection site. These effects typically resolve in less than seven days.

Q: Is Restylane® permanent?
A: No. Restylane® can last up to 6 months in some people. Others need more frequent injections to achieve the desired effect. Restylane® dissolves slowly over time once injected.


LASER SKIN RESURFACING

Our skin changes with age. Fine lines and wrinkles appear in the face where there was once soft skin. These lines and wrinkles are caused by age, hereditary factors, smoking, alcohol, stress, pollution, sun damage, and the pull of the earth's gravity. Abusing one's skin by overexposure to the sun, smoking, and alcohol consumption increases these changes. Although a facelift can help tighten loose skin and muscles, it is not effective in removing fine lines or wrinkles. Facelifts are considered skin stretching procedures. The CO2 Laser skin resurfacing procedure is considered a skin contracting procedure.

Sun exposure, squinting, and smiling all contribute to wrinkles. You may have noticed them around your eyes or mouth. You may have realized how they alter your appearance, making you look tired, sad, unrested, or older. Fine skin wrinkles are a fact of life. Now, so is treating them with theCO2 laser. Physicians around the world are using the NovaPulse laser and a technique called "cosmetic skin resurfacing" to reduce wrinkles without scalpels or stitches. Instead, the doctor guides a laser beam over the wrinkled skin. This removes the outer damaged layers. The healing process results in a firmer, smoother appearance to the skin.

A laser is a device that produces high-energy light waves of equal wavelength that are temporarily and spatially in phase. The laser light can be focused to produce high energy in very small spots. The CO2 laser has been used in medicine for almost two decades, making its debut in the early 1960's. However, recent advances, including the superpulsed CO2 laser mode, higher power version CO2 lasers, radiofrequency excited sealed laser tubes, and hollow fiber delivery modalities have made aesthetic surgery more viable and the results more predictable and desirable.

Application of the laser to the skin removes the outer layer of skin called the Epidermis; it contracts the collagen fibers in the inner layer of your skin, called the Dermis. More applications in some cases are needed to affect the deeper dermal reticular layer in order to affect more wrinkle removal. The primary goal in resurfacing is to affect the collagen of the reticular dermis (the outer portion of the dermis). This rejuvenation process is a progressive one that may take as long as 6 months to complete.

Patients are treated with the NovaPulse laser right in Grendahl Eye Associates office based outpatient surgical suites under local anesthetic. The treated area will be red for some time after treatment and one of our doctors at Grendahl Eye Associates will provide directions on how to care for the area as it heals. Steps may include application of ointment and/or creams, avoidance of sunlight, application of sunscreen, and other appropriate measures. (During the healing phase, you are not to "pick" at the dry crusts. You will be instructed in the use of vinegar soaks to soften any crusts so that they are easily removed). After the soak you will apply special lubricants to keep the surface lubricated. Vaseline is also applied. Additional follow-up visits allow the doctor to monitor progress.

After the CO2 laser treatment your skin will transiently appear red (much like a sunburn). This redness is a normal part of healing response. The redness means more permanency of the fine wrinkle removal. The redness is really your friend. Remember that no wrinkle removal procedures are completely permanent and some fine wrinkles may recur.

Patients are given a special makeup to cover this temporary redness of the skin. This makeup can be worn starting one to two weeks after the CO2 skin treatment.

Patients need to avoid direct sunlight after the surgery and must apply sunscreen with SPF 40 to the skin involved in the treatment. This risk is especially important in the first year after the procedure. The exposure to sunlight can cause the skin under treatment to become too light or too dark in color. We simply don't know in all cases how long you will have to stay away from direct sunlight exposure. In general, this affect diminishes with time.

A reduction in wrinkles is usually immediately noticeable. Resurfacing can modify periorbital (around the eye) and facial wrinkles. Remember that the operative word is modify, not eliminate. Furrows, frown lines, and crows feet generally are too deep to be removed with the CO2 laser. The use of BOTOX® Cosmetic injections is useful for some of these cosmetic blemishes.

Many times, the CO2 Laser Skin Resurfacing is combined with surgical procedures. The surgical procedures are used to take out excess skin and/or fat pads above and below the upper lids. These surgical procedures are called Blepharoplasties.

Your doctor may use the CO2 laser for the treatment of a variety of other skin conditions including the removal of moles, blemishes, and acne scars. In each case, your doctor will determine whether the laser treatment is appropriate for you. Since results can vary depending on age, skin type, and condition, your doctor will also discuss how much improvement might be expected.

The presence of laser technology in this office is your assurance that your doctor is providing the most advanced care available.


BLEPHAROPLASTY

Blepharoplasty is plastic surgery of the eyelids. This is a common procedure, in which excess skin and fat are removed from around the eyes. This is done with scalpels, scissors (cold steel), or with the CO2 laser.


WHY IS BLEPHAROPLASTY PERFORMED?

Blepharoplasty is performed to improve both visual function and cosmetic appearance. Excessive upper eyelid tissue can block the upper field of vision. Correction of overhanging skin folds will improve the function of the upper eyelid and improve peripheral vision. Even if vision is not affected, blepharoplasty may be performed to improve a sagging, tired, unrested appearance.

Sagging, drooping eyelids can interfere with vision and appearance. Removing the sag can improve vision and dramatically change a person's appearance, making them look younger and more energetic.


WHAT CAUSES THE EXCESS EYELID TISSUE TO FORM?

As part of the normal aging process, the connective tissue and skin around the eyelids begins to loosen and relax. This causes excess skin to develop around the eyelids. Over time, sagging occurs from the force of gravity pulling on the eyelid tissue. Changes also occur in the skin causing the skin to weaken and stretch. These changes involve a loss of collagen and elastin in the skin. Changes also occur in the fatty tissue located just beneath the skin. These normally firm pads begin to protrude, causing bulges or "bags" to form under the eyes.

The skin below the eyebrow sags, causing a loss in the definition of the eyelid and a tired look. Tired sagging eyes can have a negative effect on appearance and one's self esteem. After removal of excess tissue, the eyelids regain their definition, resulting in a younger more energetic look.

Blepharoplasty is a common procedure for both men and women. Most often Blepharoplasty is a cosmetic procedure and is done to restore a more youthful, rested appearance. Occasionally, it's done for functional reasons. Excess eyelid tissue can also cause physical discomfort. The weight of the excess eyelid tissue may cause brow ache and fatigue. In some cases, excess skin may cause the eyelashes to turn in and irritate the eye. After healing, incision lines are hidden in the natural skin folds of the upper lid and are virtually unnoticeable in the upper lid.


HOW IS BLEPHAROPLASTY PERFORMED?

The first step in the upper lid Blepharoplasty procedure is to determine the amount of skin and fat to be removed. Upper incision lines are marked along the natural skin folds of the eyelids. The incision lines usually extend to the "crow's feet" at the outer edges of the eye so that the incisions are hidden during and after healing. Finally the excess skin and fat are removed with the CO2 laser and the incisions are closed with stitches. Incision lines, which are hidden in the natural skin folds, may initially appear as small red marks which fade over time. Ultimately, the fine scars become virtually unnoticeable.

The lower lid Blepharoplasty is done by turning the lower lid outward and making a fine incision on the inside of the lid (through the conjunctiva) with a CO2 laser. The fat pockets of the lower lid are isolated and excess fat is removed with the CO2 laser. No suture is required in the lower lid Blepharoplasty. Any bleeding is controlled by the CO2 laser because it cuts and cauterizes at the same time.

Blepharoplasty is usually performed on an outpatient basis. Blepharoplasty is performed under local anesthesia in our office based outpatient facility.

Quiet rest with the head elevated is usually recommended after surgery to relieve any soreness and discomfort. Cold compresses in the form of frozen peas may be applied to reduce swelling and bruising which may last several days to weeks.

Temporary blurred vision and excessive tearing may occur after the procedure. Although Blepharoplasty is a common plastic surgery procedure, possible complications include bleeding, infection, and, rarely, loss of vision.


WHAT ARE THE RESULTS OF BLEPHAROPLASTY?

The results of reconstructive eyelid surgery are generally successful. However, the final outcome depends on many factors including the extent of reconstructive work required, the patient's skin structure and age, and the healing process. Many times it is desirable to combine upper and lower lid Blepharoplasty with CO2 skin resurfacing to tighten up the lax skin.

In most cases, Blepharoplasty can successfully improve visual function and physical appearance, restoring a more youthful, rested appearance.

These are just some of the oculoplastic procedures that we do at Grendahl Eye Associates. If you have questions, or would like more information, contact us and we would be happy to assist you.

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