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Ancillary Procedures
Botox is a new concept in treating facial wrinkles in the forehead, between the eyes, and in the "crows feet" areas (upper third of the face). Botulinum toxin, or Botox works by weakening the muscles of facial expressions. Once the resting tone of the treated muscles are weakened, the pull of the muscles relaxes and the overlying skin flattens. This approach is different than the other local treatments for the aging face. Silicone, Collagen, Autologous Fat Transfer, Alloderm, Softform, etc. all work by filling in wrinkles or depressions. These fillers are frequently not as effective as Botox in treating wrinkles in the upper third of the face. By physiologically weakening the muscles, wrinkles are lessened naturally.
Injection of this material into the small muscles between the brows, in the forehead, and at the corners of the eyes causes those specific muscles to halt their function (be paralyzed), thereby improving the appearance of the wrinkles. This paralysis is temporary, and re-injection is necessary within three to ten months. Options for alternative treatments include injection of either collagen or free fat, or the surgical excision of the muscles, usually through a brow lift.
Botox is freshly prepared on the day of injection. Once prepared, the medication needs to be used within 12 hours, as the potency diminishes with time. Because of the short shelf life and the cost, Botox is not available every day in our office. In order for the treatment to be cost effective, more than one patient must be treated on the same day. Using a very tiny needle, small amounts of Botox are injected into the muscles to be paralyzed. Depending on the areas being treated, 5-15 needle pricks (or more) may be required. Discomfort is minimal and lasts only a few seconds.
Although the surgical sequence varies depending on the needs of each patient, we will usually treat the belly first, by removing the excess skin from the belly button down to the pubic area. The abdominal wall muscle, which is deep to the skin and fat of the belly, is then tightened. The fat and skin above the belly button is then stretched down to the pubic area and sutured in place. A new opening is made to allow the belly button to be brought through, in its original position.
Occasionally, the needle may puncture a small blood vessel during the injection and a black and blue area may develop. Such an area can last 5-10 days and may require make-up to cover.
If any of the Botulinum toxin reaches a facial muscle not being treated, partial weakness of that muscle may last for several months. (For this reason, you are requested not to massage the injected areas for 12 hours following the injection.) If an untreated area experiences muscle weakness, the only "treatment" is to wait for the effect of the toxin to wear off in several months.
There are no recognized permanent side effects of Botox. Complications are rare but may include paralysis of a nearby muscle, resulting in its temporary loss of function (e.g., a drooping eyelid). Botox has been used safely in the treatment of muscular facial spasms for approximately 15 years.
Botox injected in conjunction with nearby facial surgery has caused unwanted facial weakness in at least one patient. For this reason, we will inject Botox only as an isolated facial procedure or treatment.
The specific risks and the suitability of this procedure for a given individual can be determined only at the time of consultation. All procedures have some degree of risk. Minor complications that do not affect the outcome occur occasionally. Major complications are rare.
Almost everyone has heard that they should look for "board certification" when seeking a qualified plastic surgeon (or any other physician for that matter). Most people don't really understand exactly what this means and what is involved in becoming "board certified."
Even fewer people know about certification of operating facilities, who certifies them and what protection such certification offers. We believe patients need this information to make informed choices in their search for the right surgeon, surgery facility and anesthesia provider.
At our office, we have gone to great effort and expense to ensure the highest standard of safety for our patients. As you consider plastic surgery, we hope the following information will help you to evaluate the choices available to you.
The American Board of Medical Specialists (ABMS) is the agency which oversees sub-specialty boards. More than 100 "boards" have been submitted to the ABMS for formal approval, but only 24 have met their strict educational and examination criteria. They are as follows:
| Allergy and Immunology |
Orthopaedic Surgery |
| Anesthesiology |
Otolaryngology (ear, nose and throat) |
| Colon and Rectal Surgery |
Pathology |
| Dermatology |
Pediatrics |
| Emergency Medicine |
Physical Medicine and Rehabilitation |
| Family Practice |
Plastic Surgery* |
| Internal Medicine |
Preventive Medicine |
| Medical Genetics |
Psychiatry and Neurology |
| Neurological Surgery |
Radiology |
| Nuclear Medicine |
Surgery |
| Obstetrics and Gynecology |
Thoracic Surgery |
| Ophthalmology |
Urology |
* The American Board of Plastic Surgery is the only ABMS board that has traditionally overseen the training and certification of cosmetic and reconstructive surgeons.
You may call the ABMS at 1-866-275-2267 to see if your surgeon is certified by the American Board of Plastic Surgery. Give them the name of your surgeon and they will tell you if and when he or she was certified. Certification by other boards does not give you the same protection. Other boards have less strict criteria for certification and some require only a fee. A few of the boards which have not been approved by the ABMS are as follows:
| Aesthetic Plastic Surgery |
Plastic Esthetic Surgery |
| Cosmetic Plastic Surgery |
Dermatologic Surgery |
| Facial Cosmetic Surgery |
Ophthalmic Plastic Surgery |
You may also want to call the local hospital and ask the Medical Staff Office secretary whether your surgeon has privileges to perform the proposed procedures in the hospital.
Whenever you are heavily sedated or have general anesthesia, you put your life in someone else's hands. Much of that responsibility falls to the person administering the medications and monitoring your vital signs. You need to know the qualifications of the person assuming that responsibility. Their training can range from specialization after earning a medical degree (anesthesiologists) to specialization after nursing training (nurse anesthetists) to nursing training only.
We have chosen to use board-certified anesthesiologists for all of our general anesthesia and for monitored anesthesia care. Some of our anesthesiologists are board certified in at least one other specialty as well. We choose physicians who are in active practice at a hospital because we believe their skills will be at the highest level in the event of an emergency.
CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA): A CRNA is an RN who has completed an additional two years of specialized training in anesthesiology. Their certification is also overseen by each state's Board of Nursing. In contrast to an RN, a CRNA is able to administer general anesthesia.
YOUR SURGEON: In some centers your surgeon may actually be the person administering the medications to make you drowsy during your surgery. Almost never does he or she personally monitor your vital signs. This is usually done by a member of his staff, most often a nurse.
REGISTERED NURSE (RN): Each state has its own Board of Nursing, but there is a great deal of common requirements between states. He or she is licensed to administer intravenous drugs at the direction of the surgeon and monitor your vital signs.
CERTIFIED PLASTIC SURGICAL NURSE (CPSN): These nurses have worked full time for a minimum of two years in the field of plastic surgery before they are eligible to take a national certifying exam.
At the present time there are few local, state or federal laws requiring office-based operating rooms to be certified. Any physician may perform any procedure in an office as long as basic fire and safety codes are met. No level of sanitation, patient care, monitoring or peer review is required. Unfortunately, tragic consequences have occurred because of faulty equipment, lack of trained personnel and inadequate emergency equipment. As a result, there will most likely be requirements imposed in the future, but for now certification is purely voluntary.
MEDICARE:
An agency of the Federal Government with very strict requirements as to personnel, procedures and equipment.
AMERICAN ASSOCIATION FOR THE ACCREDITATION OF AMBULATORY SURGERY FACILITIES.
This accreditation certifies that the surgery facility meets nationally recognized standards through an accreditation program operated by the experts who set and evaluate the standards.
ACCREDITATION ASSOCIATION FOR AMBULATORY HEALTH CARE:
An alternative national accrediting body that most insurance companies recognize.
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Computer Imaging
