Making a beautiful belly-button

It seems like a small thing, but many of my prospective tummy tuck patients mention how they like our photos, especially the nice looking belly buttons.

During a full abdominoplasty, we re-use the original umbilicus, but we have to make a new cut-out in the skin for it, once the upper abdominal skin has been shifted downwards and pulled snug. It's much like making a new button-hole for a button on a shirt.

Here are some of my "surgical secrets" for making pretty belly-buttons:

1) the right size: when you trim the original umbilicus, and when you make the new cut-out, the sizes must match. Don't make the new cut out either too large nor too small...

2) the right location: the umbilicus needs to be in the midline, at the correct height, which is on a line at the top of the so-called "iliac crest" - that bony bit on the top of the hip you can feel on your side. Try it for yourself, and see. By putting the skin incision at the correct location, you avoid tension on the closure, which could lead to a distorted shape later.

3) the right shape: don't make the new umbilical cut-out perfectly round - or else it will tend to shrink / scar down later. There are multiple techniques for this; I prefer the "tulip" or "pac-man" methods, in which the pre-existing umbilicus is converted to a "tulip" or "pac-man" shape. A small V-shaped flap of tummy skin is designed to fit neatly into the top of the "tulip" portion of the umbilicus, re-creating the hooded configuration of the upper part of the belly button. This method looks nice, and reduces the risk of a scarring problem known as umbilical stenosis.

4) tailor the underlying fat: After all, you don't want to have any puffy fat around the umbilicus...

5) Perform a tidy layered closure.

And now you know most of how it's done. It's really not magic, after all. Just like schoolwork, points are awarded for neatness!

The SoCal "Boobie Bandit"

And now, one of those "News of the Weird" stories...

Allegedly, a woman in Huntington Beach, CA, recently used a stolen identity to open a line of credit, which was then used to finance a breast implant exchange and liposuction surgery, worth $12,000. The woman lied to her doctor and the staff of the surgery center about her name and personal information, but when she didn't show up for any of the post-operative appointments, the staff became suspicious.

The shapely criminal might have gotten away with this theft - except for one minor detail. Her old breast implants had a registered tracking number, as many implanted devices do. This was used to track down her true identity...

The woman turned herself into custody last week, one day after the story and her photo were made public on the national news and internet.

No news yet on whether the upcoming trial will be televised, or if the stolen property will be repossessed!

Herbal Supplements and Surgery - Safe or not?

Herbal supplements are everywhere. And cosmetic surgery patients love them - in a recent survey, 55% of cosmetic surgery patients surveyed took 2 or more supplements, compared to only 24% in the general population. The most commonly used supplements in the survey were: chondroitin, ephedra, echinacea and glucosamine.

Some supplements have some serious side effects that may be problematic, if you are having general anesthesia and surgery.

Here's a quick guide to which supplements should be stopped, and the reasons why. The general recommendation is to stop these supplements two weeks before surgery.

These supplements can cause bleeding problems:
Chondroitin / Glucosamine --- can also cause low blood sugar
Fish Oil
Garlic
Ginger
Gingko
Ginseng --- can also cause low blood pressure under anesthesia
Saw Palmetto
Vitamin E

These supplements affect drug metabolism and can cause excessive sedation:
Echinacea
Goldenseal --- can also cause photosensitivity reactions from laser light
Kava
St. John's Wort --- can also cause low blood pressure under anesthesia
Valerian

Ephedra ("Ma-Huang") - can cause cardiac arrhythmias, stroke, heart attack, low blood pressure under anesthesia


Since the whole idea of cosmetic surgery is to have a wonderful outcome and to minimize the risk of complications, the problems these seemingly-innocent supplements can cause are just not worth it. Please avoid them - and have a smooth recovery!

A Hero Passes

Last week, we lost a very special person here in the Orlando area, when Mark L. Parker passed away.

As a rookie Correctional Officer full of promise at age 19, Mark was seriously wounded in the line of duty, at a shootout at the Orlando courthouse some 25 years ago. Two other officers were killed. The gunfight left him a quadraplegic...and Mark spent the rest of his life in a wheelchair.

Now for most of us, this injury would be as mentally and emotionally devastating as it is physically devastating. Most of us would never really smile again, being endlessly angry at the world for the terribly unfair thing that had happened.

But not Mark. Mark's true greatness was in his positive, "can-do" attitude. I don't think I ever saw him "down" or feeling sorry for himself.

Not only did he continue to lead an active life - enjoying Sci-Fi conventions, NASCAR races, rock music, Civil War history and computer games, he volunteered at the local school, sharing his life experience and his time with the youngsters. Always positive and genuine, always upbeat and smiling, Mark made a habit of looking forward, not backward.

I got to know Mark and his family when I helped Mark with some reconstructive surgeries a few years ago for the inevitable pressure sores that occur from time to time, despite all the fantastic care that Mark received 24/7. While the surgery itself is completed in a few hours, the recovery and rehabilitation from these procedures takes weeks - so Mark and I had plenty of time to visit each day and get to know each other. I chuckle when I remember Mark saying, "Doc, let's get this thing (his wound) healed up - I gotta be ready to go watch the Daytona 500!" And sure enough, we got it done.

There are some people you meet in life that make a lasting impression - people you never forget. That's true for us surgeons, too - we have a few very special patients that stand out in our memories. Mark was definitely one of those people. The capacity crowd at his memorial service in Winter Garden last week shows that many, many other people shared my high opinion of Mark, too.

Godspeed, Mark Parker. I'm proud that you considered me your friend.

How to scrutinize Before and After Photos

Patients love to see "before and after" photos. I agree - it's one good way to see the quality and artistic vision of a plastic surgeon.

Unfortunately, photographs can be manipulated to look better or worse. And I'm not talking Photoshop here. Simple tricks of timing, positioning, and lighting can be used by the unscrupulous.

So - here's a quick guide to analyzing surgical photos, to make sure they are honest.

1. There should be plenty of photos. If a surgeon has no good photos to show you of your procedure - that's a big red flag.

2. Photos should be taken with the exact same body position, both before and after. For example, watch out for face and neck lift photos where the "before" photo is taken with the patient looking down (making the before neck look worse), and the "after" photo is taken with the patient looking up (making the after neck look better).

Facial photos should be taken with a calm expression on the patient's face - no raising of eyebrows, smiling, or trying to pose. Breast lift photos should be taken with the arms in the same positions both before and after - no lifting of the arms in just the post-op shot!

3. Photos should be taken with the same camera, using the same technique. No black and white "before" photos compared to color "after" photos, please. Before and after photos should be the same size, too.

4. Make-up and hair should be consistent in both photos. For facelift photos, the hair should be pulled back, so you can fully see the ear area, and relevant incisions around it. If someone is showing you facelift photos and every single one has the bangs hiding the ear - they are intentionally hiding the surgical scars. Go somewhere else!!

5. Timing of photos: As we all know, initially the area that has had surgery is swollen. If a photo is taken during this time, certain features will be artificially emphasized. For example, breasts will look fuller and rounder, faces will look smoother, forehead lifts will look less wrinkled than what they will look like once the swelling has resolved. Therefore, it's important to know when the photos were taken. We take our post-op photos no sooner than 3 months post-op for this very reason. It's more honest.

6. The lighting should be consistent. For example, "before" photos of facial scars should not be lit tangentially (from the side) to exaggerate the scars with harsh lighting, while the post-treatment photos are taken with soft frontal lighting, to make the face seem smoother. This kind of trick is sometimes seen on laser resurfacing sites.

If you know these basic guidelines, it's amazing just how many sub-standard photos you will be able to spot on various websites. If somebody tries to "con" you with a bunch of these kinds of questionable photos - then go somewhere else.

It's really all about honesty - this time in photography.

Double-Board Certified Plastic Surgeon?

Some doctors are calling themselves "double-board certified" or "triple board certified" surgeons. This terminology seems to be especially common on the Internet, and, in my opinion, is a bit of a pretentious marketing ploy. Since the whole board certification thing can be a bit confusing for consumers, let's talk about it.

As you probably already know, being board-certified in a specialty means you've completed an approved residency in that area, then completed the written and oral examination process set up by that Board, including case reviews and time-in-practice requirements. It's a thorough method - and anyone who passes any of the board exams of the American Board of Medical Specialties (ABMS) should be proud to call themselves a specialist in that area.

A physician who has completed training and passed the board examinations in two different areas of surgery or medicine can legitimately call themselves "double-board certified", if they wish. For example, many plastic surgeons, including myself, have trained in General Surgery, as well as Plastic Surgery, and have completed both examination processes. A background in Otolaryngology (ear, nose & throat) as well as Plastic Surgery is another common combination. Parenthetically, I don't know anybody who leaves Plastic Surgery to go into ENT - it's always the other way around!

In addition to the American Board of Plastic Surgery (ABPS), the Royal College of Physicians and Surgeons of Canada also has a very rigorous examination process in Plastic Surgery, and their certification is widely accepted in the U.S. as being completely equivalent in quality to the ABPS' process. Other than Canada, medical training diplomas and certificates from other countries are not commonly accepted here.

What makes matters more confusing for consumers, though, are the plethora on non-ABMS organizations, that call themselves "Boards" of this or that. They are not part of the official group of 24 medical and surgical specialties that make up the ABMS, and are not generally considered as being equivalent to an ABMS certification by the majority of States in the U.S. (You can read more about this at the ABMS website - www.abms.org)

For example: You or I could quite legally start up our own corporate organization, and call it, say, the "American Board of Blogging". We could then issue certificates to our friends which proclaim that so-and-so is "board-certified" by the American Board of Blogging. And we could have meetings, and give courses about blogging from our affiliated "American Institute of Advanced Blogging".... but, of course, our fictional American Board of Blogging wouldn't be any kind of officially-sanctioned ABMS Board. Except for one loophole - if we can somehow persuade our State legislators to pass a law to make us legally "equivalent" to those other Boards.

Well, here in Florida, certifications by the non-ABMS "American Board of Liposuction", the "American Board of Laser Surgery" or the "American Board of Cosmetic Surgery" are not legally considered by the State of Florida as being equivalent to certification by the American Board of Plastic Surgery, which is the one-and-only official ABMS board which certifies Plastic Surgeons.

However, the State of Florida does recognize the American Board of Facial Plastic Surgery (ABFPS). So, if you are having surgery above the collarbone , you can choose between an ABFPS surgeon and an ABPS surgeon. The major difference between Plastic Surgeons and Facial Plastic Surgeons is, of course, that Plastic Surgeons are trained to do both reconstructive and cosmetic types of surgeries from head to toe. Facial Plastic Surgeons are not - they are limited to the head and neck, and don't receive any training in breast surgery or body contouring, for example. So, I wouldn't recommend a Facial Plastic guy to do your breast augmentation, but they may be a reasonable choice for a rhinoplasty.

One last note for today: the "Truth in Medical Education" law here in Florida means that, if a physician claims to be board-certified, he must tell you what Board gave him his certification. For example, if you find out that your so-called "cosmetic surgeon" is only certified by the American Board of Psychiatry, you may wish to reconsider having him or her do that liposuction!

Does Vitamin E help the appearance of scars?

From time to time, people ask me about Vitamin E...and whether rubbing some of it on their incision will make it heal and look better.

It's an interesting "urban legend". The belief that Vitamin E helps scars seems pretty widespread.

First of all, what is Vitamin E? It's a fat-soluble vitamin that was discovered in 1922. It acts primarily as an antioxidant, helping to protect the membranes of cells from what is known as oxidative stress. It also seems to have anti-inflammatory effects, and adversely affects platelet aggregation (which is why we have our patients stop taking it prior to surgery, as it can cause more bleeding at surgery!)

As I always say, "Let's look at the science."

Although there have been a few animal studies where Vitamin E seems to have helped wound healing, the outcomes in human volunteers have been very disappointing.

There are two very good studies on the use of Vitamin E as a scar treatment.

In the first study, published in Dermatologic Surgery in 1999, researchers compared the use of twice-daily application of Vitamin E in Aquaphor ointment versus Aquaphor alone, applied for a twelve week period. They then had the patients and independent observers rate the appearance of the wounds. There was no difference and no improvement in the appearance of the Vitamin E treated incisions.

Unfortunately, 33% of patients developed a reaction to the Vitamin E, with a contact dermatitis rash - so the appearance was actually worse with Vitamin E treatment. Not only did the Vitamin E fail to help the scar look better, it actually had a side-effect problem.

In the second study, published in 1986, researchers from the well-known Shriner's Burn Institute in Cinncinati investigated whether the use of topical Vitamin E cream or steroid lotions would help the appearance of the skin grafts that are often necessary in the treatment of burns. Once again, there was no beneficial effect on the scar appearance with either Vitamin E or topical steroid. Side effects were again a problem - 16% of patients had reactions to the Vitamin E.

Despite the science, the myth persists. In a recent questionnaire of physicians, nurses, medical students and pharmacists, nearly 68% incorrectly thought that Vitamin E would improve scars, and 21% had tried it on themselves.

But now, you know better. Don't bother with putting Vitamin E on your scar. We have other products that work much better....and that actually been scientifically proven to work! We'll talk about these options in an upcoming blog.

Isn't myth-busting fun?!

Do breast implants prevent breast cancer?

It sounds hard to believe...but a new study published in the January issue of International Journal of Cancer found a 27% reduction in the number of breast cancers in women who have breast implants. The researchers compared the incidence rates of breast cancers in 6,200 Scandinavian women with breast implants, compared to the number of breast cancers that would be expected in the normal population. The women with implants had fewer breast cancers, over the 16 year time period of the study. The difference of 27% less in the implant group was statistically significant.

Is this a fluke? It could be. But this is not the first study to find this surprising finding.

In 1997, a study from Los Angeles published in Plastic and Reconstructive Surgery showed a similar finding, with a 37% reduction in the incidence of breast cancer in a group of 3182 women with implants followed over a 14 year period.

In 1992, a report from Alberta, Canada, published in the New England Journal of Medicine found a 53% decrease in the expected breast cancer incidence, over a 10 year follow-up period.

There are several other reports as well.

So why does this happen? Well, I don't think it's because that breast implants have some sort of special protective properties when it comes to breast cancer, although some investigators are looking into this possibility. It's more likely that the women who get breast implants are drawn from a low-risk population. Most plastic surgeons, for example, wouldn't put implants in a patient with a strong family history of breast cancer....but this only partially explains the findings of these studies. Further research is needed to come up with the full explanation.

It's good to know, that at the very least, breast implants do not increase your risk of developing a breast cancer.

Another myth "busted" (no pun intended!)

Do the FDA recommendations for MRI's after breast augmentation make sense?

When the FDA re-approved the general use of silicone breast implants in 2006, there were some "strings" attached. One of these was the recommendation for follow-up testing of the breast, using an MRI scan, at years 3, 5, 7 (and so on) to look for clinically "silent" implant leakage.

This was a new recommendation - and a change from the earlier FDA policy of 1992, which had not recommended any screening tests at all for asymptomatic women with silicone implants.

So, does this new FDA recommendation make sense?

Well, let's look at the science, shall we? It really breaks down into two different questions:
1) Is an MRI scan a good way to look at the breast - or would a breast ultrasound be a reasonable, inexpensive first-line alternative?
2) What are the odds of having a leaking silicone implant at 3 years, or 5 years?

This is going to get a little technical, but please, bear with me.

Question one: MRI or not.

Prior to the 2006 ruling, MRI was not in routine use as a "screening" exam for women with silicone breast implants - it was used if there was a specific reason, such as a mammogram or ultrasound that was indeterminate, or a clinical situation that required investigation.

An excellent paper published in 1998 by Chung and associates, from the University of Michigan, actually developed an algorithm for decision-making for women with suspected silicone breast implant rupture, based on a statistical method called Bayes' theorem.

They found that in asymptomatic women, if they had a "normal" result on a screening ultrasound test (i.e. no rupture reported), the probability of an actual rupture was low - 2.2%. If the ultrasound reported a rupture, and this was confirmed by MRI, the likelihood of a true rupture rose to 86% - a reasonable threshold to operate.

So, Chung et al. recommended breast ultrasound as their first-line test, since ultrasound is widely available, relatively cheap, and doesn't involve radiation. They only used the expensive MRI if the ultrasound was abnormal. Makes sense to me - I like this idea because the patient saves money, and is more likely to actually get the test done, because of the lower financial barrier.

In a separate paper published in 2001, Cher and associates did a meta-analysis of MRI results in 1039 women. They found that when the MRI was used for women with specific complaints like breast hardness, shape change, etc., that it was reasonably accurate in detecting rupture - >80%. In women without these issues, the positive predictive value of an MRI was "insufficient to warrant use as a screening tool". They also recommended using the MRI to confirm the results of a screening ultrasound.

The Royal College of Radiologists (UK) echoed these views in their recently published guidelines on breast imaging. A normal ultrasound examination was highly predictive (91%) for an intact implant. Ultrasound was recommended as an initial investigation. According to the RCR, patients with an abnormal ultrasound examination should then proceed to an MRI examination, provided the more powerful 1.5 Tesla MRI machines are used with the specialized "breast coil" imaging device. Lower power MRI machines or those that don't have the breast coil are not nearly as reliable.



Question two: how often does leakage really happen?

The best way to determine whether there is implant leakage is to perform surgery, and look at the implant directly. But, as you might imagine, it's pretty darn difficult to convince a women who is feeling perfectly fine, without any symptoms at all, to undergo surgery - just so we can open her up to look and see whether her implants are OK!!

So, this data is hard to come by. Instead, we use MRI scans - to estimate the deflation rate. In Mentor's Core study, at 3 years out, just 0.5% of the 420 patients had a rupture in the primary augmentation group.

In other words, at the three year point, 199 women will have to pay to have an MRI that is completely normal, for one woman to find a rupture. That's probably not the best utilization of health-care dollars.

In the study by Sharpe and Collis (UK), no ruptures were noted until 7 years postoperatively.

Data like this really make me wonder whether it makes sense to insist on a scan at years 3 and 5, when not much is happening.

In summary: the screening recommendations of the FDA are certainly controversial. I feel that they are scientifically questionable, financially imposing, and a bit of a "CYA" move by the FDA, particularly at years 3 and 5. However, they are the "official party line", so I tell all my patients about them. The FDA rules were probably written more with political expediency in mind. I hope that, in time, they will be modified to better reflect the actual science!

Reloxin - a potential challenger to Botox Cosmetic?

"Reloxin", a form of botulinum toxin, and potential competition for Botox, could go on sale in the U.S. soon.

The FDA is currently evaluating the product, which has been sold in Europe for approximately 15 years under the name Dysport. It's a wrinkle-fighter, similar to Botox, and it also has a good track record of success and a good record of safe use.

Medicis, the U.S. distributor, said it is hoping for FDA approval of their application in early 2009.

It will be interesting to see how this situation works out. Will the newcomer try to under-cut the price of Botox? Will patients be willing to try the newcomer, or stick with the original? The dosing of Dysport and Botox is not directly comparable - so it wouldn't be a simple 1:1 substitution - but both have been shown to be effective for dynamic facial wrinkles.

Botox, made by Allergan, has been the No. 1 cosmetic medical treatment in the United States for the last few years, according to the American Society for Aesthetic Plastic Surgery (ASAPS) procedural statistics.

Silicone breast implants and breast feeding

Breast-feeding is known to be nutritionally superior to commercial infant formulas. Breast milk also has immune-boosting properties, and seems to reduce the chance of the baby developing common childhood conditions, such as eczema, otitis media, and iron-deficiency anemia. In other words, it's good for the baby.

Women who are considering breast augmentation with silicone gel implants often ask me whether their breast milk would somehow get "contaminated" from their implants, making the milk potentially harmful for their baby.

Well, let's look at the science. Quite a bit of research has been done on this topic at the Women's College Hospital in Toronto, Canada. The researchers there measured silicon levels in the breast milk of lactating women with silicone gel implants, and also in women who didn't have any breast implants. They also analyzed the silicon levels in cow's milk, and in 26 commercial infant formulas.

Silicon levels are used, since there is no satisfactory method of analysis of silicones. Silicon assays also include silica and silicate compounds, and are felt to be a reliable estimate of silicone levels. The samples were prepared in an "ultraclean" laboratory and analyzed using atomic absorption spectrophotometry.

Here are the results, in descending order:

Commercial infant formulas:..... 4402.5 parts per billion (average)
Cow's milk:......................... 708.9 parts per billion

Blood levels - no implants:...... 103.7 parts per billion
Blood levels - with implants:.... 79.29 parts per billion

Breast milk - with implants:..... 55.4 parts per billion
Breast milk - no implants:....... 51.0 parts per billion


Comparing women with breast implants to those without implants, the average silicon levels were not statistically different in either the breast milk, or in the blood.

Since lactating women with silicone breast implants are similar to women without implants in terms of levels of silicon in their breast milk, this would strongly suggest that women with silicone breast implants can go ahead and safely breast-feed their babies without any worries about having "contaminated" milk.

Silicon levels are actually 10 times higher in cow's milk and even higher in infant formulas, compared to breast milk. So, maybe it's time to avoid using commercial formulas, if you're worried about silicone !!

Does breast augmentation affect pectoral muscle strength?

Recently, a number of patients have asked me during their breast augmentation consultations whether the strength of the pectoral muscle is reduced after a sub-pectoral breast augmentation ("unders").

I can certainly answer from my patients' experience - very active patients (weight lifters, personal trainers, police women, wakeboarders and others) have not reported any problems to me whatsoever. The best way to answer the question, however, is to double-check the science. Has pectoral muscle strength been tested scientifically after surgery, and what did these tests show?

It turns out that there are two excellent studies on this very issue.

The first, published in 2003 in the Aesthetic Surgery Journal, tested strength performance on a computerized Biodex 3 isokinetic muscle-testing system. Twenty patients were tested preoperatively, and at 2 and 6 weeks postoperatively. At two weeks postop, 50% of the patients were back to pre-op measurements. At six weeks postop, 70% of patients were back to pre-op measurements. Long-term follow up measurements on 9 of the patients who agreed to return for a follow-up comparison showed full recovery in all 9 patients.

The second study, published in 2004 in the Plastic and Reconstructive Surgery Journal, tested both breast sensation and pectoralis muscle function. Again, a computerized system was used to acquire the strength testing data. There was no significant decrease in pectoral muscle strength at 3 months or at 6 months postoperatively in any of the tested movements (flexion, extension and adduction). Implant size did not have any adverse effect on pectoral strength, either.

So there you have it - two good scientific studies that show no permanent changes in pectoral muscle strength related to breast augmentation surgery, once the initial recovery period has been completed.

Another "urban legend" dispensed with!! :)

Over the hill at age 27....?

According to a report on the health page of the BBC news website, new research suggests that mental powers start to dwindle at age 27, after peaking at age 22.

Professor Timothy Salthouse of Virginia University tested 2,000 healthy people aged 18-60. Study participants were tested with puzzles, word recall and spotting patterns in letters and symbols.

In the majority of tests, top performance was achieved around age 22.

In tests of brain speed, reasoning and visual puzzle-solving ability, declines in performance began at age 27. Memory testing started to decline at age 37, while vocabulary and general information held steady until age 60. Yikes !!

In other words, we may need to start anti-aging treatments earlier than previously thought!

2008 ASAPS Procedural Statistics

Every year, ASAPS - the pre-eminent organization for aesthetic plastic surgeons - compiles statistics on common plastic surgery operations and trends in surgery. The latest report, on last year's surgical activity, was released today, and includes figures from Board-certified Plastic Surgeons, Dermatologists and Otolaryngologists (Ear, Nose & Throat).

Here are some of the highlights:

- In 2008, over 10 million cosmetic procedures (both surgical and nonsurgical) were performed. This was divided into 1.7 million surgical procedures and 8.4 million non-surgical procedures (botox, fillers, etc.)

- Not unexpectedly given the economy, these numbers are down somewhat compared to the previous year - by about 12 percent overall.

- The top 5 surgical procedures in 2008 were: breast augmentation (355,000), liposuction (341,000), eyelid surgery (195,000), rhinoplasty (152,000) and abdominoplasty (147,000).

- The top 5 non-surgical procedures in 2008 were: Botox injection (2.4 million), laser hair removal (1.2 million), hyaluronic gel fillers like Juvederm and Restylane (1.2 million), chemical peel (591,000) and laser skin resurfacing (570,000).

- Women had 92% of the total, men 8%.

- The most popular operation for women overall was breast augmentation, while the most popular for men was liposuction.

- 62% of women and 51% of men approve of cosmetic surgery. Forty percent of women would consider surgery for themselves, either now or in the future.

The full report can be viewed at www.surgery.org.

Twins Facelift study

New, in this month's issue of the Plastic & Reconstructive Surgery journal, is the 10-year update on the famous twins study, originally devised by Dr. Bernard Alpert at UCSF.

In this study, 2 sets of identical twins underwent facelift procedures, by four master surgeons, all using different facelift techniques. The goal was to see which facelift technique worked better.

For those of you who like the details, the surgeons and their techniques were:
Dr. Jack Owsley -- multi-vector SMAS-platysma facelift with neck liposuction,
Dr. Dan Baker -- SMAS-ectomy with anterior platysmaplasty,
Dr. Sam Hamra -- composite / deep-plane facelift with anterior platysmaplasty,
Dr. Oscar Ramirez -- subperisoteal facelift with anterior platysmaplasty.

(N.B. platysmaplasty is a necklift operation, done with an incision beneath the chin area, tightening the neck muscles together in the middle.)

Drs. Baker and Hamra were assigned the first set of twins, while Drs. Owsley and Ramirez worked with the second set of twins.

So, which facelift method was the best?

Well - the answer is not that easy. All four of the twins looked good. All four of the twins, at 10 years out, looked better than they did pre-operatively. So, great surgeons can probably get great results, even if they use somewhat different operative techniques to achieve that result.

Studying the pictures, however, my personal preference was for the results by Dr. Owsley and Dr. Baker. To my eye, these looked the most natural, and the most aesthetically pleasing. This did my heart good - as I use Dr. Owsley's technique almost exclusively for major facelifts. (Disclosure: I did my facelift Fellowship with Dr. Owsley, learning the technique from him personally, over the course of a year.)

Of interest to me was that the Owsley technique gave a nice result in the neck, without having to open the neck surgically using a platysmaplasty. Also, both Dr. Baker's and Dr. Owsley's methods gave excellent correction of jowls and lower facial laxity, and I felt that these methods "aged" better than the other two methods.

Of course, this is a comparison of only 4 patients, not a large, randomized prospective study...nevertheless, it's fascinating stuff for those of us interested in facelifts!