• The Leading Expert
    in Eyelid & Cosmetic
    Surgery

Glossary

Glossary

Cosmetic surgery is a highly specialized field of medicine and surgery with its own growing list of specialized terms, procedures, and technologies. This list is not exhaustive. Rather, it was compiled by Dr. Steinsapir to help you understand important concepts and terms that are often poorly defined or simply used without a proper definition. Dr. Steinsapir invites you to submit additional terms that you may encounter for inclusion into this glossary by emailing the term using our contact us page.

Click on a glossary term to learn it’s meaning

Anchor Blepharosty

Anchor blepharoplasty refers to a specific upper eyelid surgery procedure that tightens the upper eyelid platform skin, that is the skin between the upper eyelid lashes and the upper eyelid crease. This procedure specifically addresses the crepey skin that develops on the upper eyelid platform and also deals with lash ptosis, a common situation where the upper eyelid eyelashes droop down. This procedure supports the upper eyelid lashes. An anchor blepharoplasty should be part of every upper eyelid blepharoplasty. However, it is not commonly offered because very few surgeons possess the technical skill needed to execute this extremely important, but often neglected, component of upper blepharoplasty.

Anterior levator resection ptosis surgery

When the upper eyelid droops, it is important to distinguish between excessive skin in the upper eyelid with a heavy fold and an actual fall in the eyelid margin. Upper eyelid ptosis has a number of causes. There are two principle surgeries that are used to correct the position of the upper eyelid: Anterior levator resection ptosis surgery and Mueller’s muscle resection. Anterior levator resection ptosis surgery strengthens the effect of the levator muscle, which elevates the upper eyelid. The surgery shortens the tendon of this muscle called the levator aponeurosis and effectively elevates the eyelid making the eye look bigger.

Arcus Marginalis

Eyelids have several layers. The middle layer is a sheet of connective tissue called the orbital septum. The orbital septum extends the rim of the boney orbit, the space in the facial skeleton that holds the eye. There are two boney orbits, one for each eye. The septum thickens as it inserts on the orbital rim and this thickening is referred to as the arcus marginalis.

Arcus Marginalis Release

Refers to a specific surgical procedure for the lower eyelid where the orbital septum is cut as it inserts onto the lower orbital rim. This cut is made from behind the lower eyelid. This allows the lower eyelid fat responsible for the pillow of fullness that is commonly seen in the lower eyelid to be reduced. The fat representing this fullness is repositioned and used to fill in the hollow circle commonly present below the lower eyelid at the top of the cheek.

Artefill

An FDA approved permanent filler composed of small plastic beads in a carrier of bovine collagen. Past formulations of this product were prone to lumps, which is thought to be less of an issue with the current formulation. Although the manufacture of this product claims that the results are essentially permanent, it also clearly stated on its website that the effects of Artefill have not been studied beyond one year.

Asian Blepharoplasty

Describes a range of cosmetic eyelid surgery procedures performed on the Asian eyelid to create the appearance of a double upper eyelid fold. There is an unfortunate and all too common misconception that the goal of these procedures is to “Westernize” the Asian eyelid. This is an absolute misconception that gets perpetuated in the lay media. Unfortunately, many well-meaning surgeons seem to also share this misconception. Making the two eyelids as symmetric as possible is often an important ancillary goal of surgery. In some cases, there may be a well-defined double fold on one side but not on the other. Double fold surgery is a very specific exercise in anchor blepharoplasty.

Autogenous

Graft material harvested from one’s own body. Fat, dermis, skin, hard palate and bone are all examples of autogenous materials that may be harvested from the body and used to reconstruct the orbit and eyelids.

Baker Gordon Peel

The deepest of all chemical peels, a combination of croton oil and phenol acid. The agent can penetrate a full millimeter into the skin, three times deeper than a CO2 laser. This effect can be enhanced by taping the skin. A peel this deep is seldom necessary and the undesirable effects are numerous. Generally, this peel produces profound depigmentation of the skin. When performed on the full face, the effect was referred to as the porcelain white complexion. On the plus side, the tightening effect is amazing and lasts forever. Generally, these positive aspects don’t outweigh the undesirable side effects and it is best to use this peel very sparingly.

Beverly Hills Haircut

Slang for the old style open coronal forehead lift where the scalp is surgically cut from one ear to another. The forehead was elevated and extra scalp was removed. The scalp removed is generally hair barring accounting for the expression.

Beverly Hills Melt Down Syndrome

Too much over done surgery. Picture an overdone forehead lift with over aggressive eyelid surgery, oversized cheek implants, an over tightened face lift, and over-resected nose job. Only the surgeon who did this surgery would think it looks “marvelous.” It is important to understand that we only have finite resources to both look natural and our best. The key is to understand the limits of what cosmetic surgery can accomplish. Too much is not better. It is generally best to have a conservative result that looks natural.

Blepharoplasty

Plastic surgery on the eyelids. Blepharoplasty may be done to correct ptosis (sagging eyelids), remove fatty bulges around the eyes, and eliminate hanging skin from the eyelids.

BOTOX®

The Allergan brand of Botulinum toxin A. This is currently the only FDA approved botulinum toxin A on the US market. BOTOX® comes in a small 100 unit vial. The vial contains approximately 500 nanograms of purified protein. The product is dry in the vial and is reconstituted in the doctor’s office with saline. How much saline is used determines how many units of BOTOX® are in the 1 cc syringe. Typical dilutions vary between 2 to 4 ml. A 2 ml dilution produces a 1 cc syringe that contains 50 units of BOTOX®. A 4 ml dilution produces a 1 cc syringe that contains 25 units of BOTOX®. Be aware that some office dilute their BOTOX® with as much as 20 ml of saline producing a syringe that contains just 5 units of BOTOX®. There are two other Botulinum toxin A products that are pending FDA approval including Reloxin® and Puretox®.

BOTOX® Day

BOTOX® has a short shelf life once it is reconstituted. Offices that do a small number of BOTOX® treatments look to cluster treatments on a given day to avoid spoilage of the reconstituted BOTOX®. Offices that do enough treatments don’t need to designate a special BOTOX® day because they do so many treatments that they are always using BOTOX® and spoilage is not an issue.

BOTOX® Party

Think of a Tupperware party with alcohol and needles. BOTOX® treatments are performed in an informal party setting. Generally, these events are unethical and in many cases illegal. Medical organizations are concerned that the informal environment creates a setting where potential patients can be taken advantage of. Medical boards are concerned that the treating individual in these settings is not always properly licensed, that there is no good faith examination by a treating doctor, and no appropriate follow up care. Fortunately, this has become a less common phenomenon.

Botulinum Toxin A

Generic term for BOTOX®.

Botulinum Toxin B

There is seven immunologically distinguishable forms of the Botolinum toxin (called a serotype). Botulinum toxin A and B are the strongest of the serotypes in terms of blocking muscle contractions. Myobloc® is an FDA approved Botulinum toxin B preparation. This product is primarily used for treating medical conditions rather than for cosmetic reasons. Cosmetically, the product was not found to be as useful as Botulinum toxin A because it wears off faster and there appears to be a noticeable incident of unwanted systemic side effects not seen with Botulinum toxin A.

BTX

A general term for representing all of the serotype of Botulinum toxins: A, B, C, D, E, F, and G. Clinically, only serotypes A and B have been found to be clinically useful.

Brow Ptosis

Laxity in the forehead allows the eyebrows to fall. With this the skin below the eyebrow also falls into the upper eyelid space making the upper eyelid fold heavy. This encroachment of tissue onto the upper eyelid platform stimulates the brain to send a signal to the frontalis muscle of the forehead to lift accounting for the forehead lines associated with eyebrow ptosis. Treatments like BOTOX® can be used to relax the muscles that pull the eyebrows down and create a forehead lift effect. Alternatively, an actual forehead lift surgery can be performed to reposition the forehead tissues higher. When eyelid surgery is performed in this setting without controlling the position of the eyebrow, typically, skin is removed in the upper eyelid. This reduces the amount of encroachment of the upper eyelid fold onto the eyelid platform. The result is that there is less stimulation of the frontalis muscle to lift the eyebrows and they tend to relax after eyelid surgery. This affect needs to be anticipated before surgery so that relaxation of the eyebrow ptosis does not lead to post-operative disappointment.

Canthoplasty

Surgical procedure to tighten the lower eyelid. This procedure is commonly used as part of other procedures when the lateral canthal angle is surgically taken apart to create access for procedures performed behind the eyelid including midface procedures. The surgeon controls the degree of tightening and also the position of the lateral canthal angle. Ideally, the canthoplasty is done under light sedation making it possible to sit the patient up during the procedure and judge the position of the canthal angle. Small differences in the height of the lateral canthal angles relative to each other are readily discerned after surgery. It is the surgeon’s goal to make the procedure as symmetric as possible. This is a work-horse procedure for eye plastic surgeons and conversely, a procedure which other plastic surgeons are often quite uncomfortable in performing.

Canthopexy

A lateral canthal tendon tightening procedure used to reinforce the position of the lower eyelid at the time of other lower eyelid procedures. A nonabsorbable suture is used to reinforce the lateral canthal tendon. Placement of this stitch is critical to avoid unwanted distortion of the lateral canthal angle.

Canthus

Refers to the corners of the eyes. There is a medial or inner canthus, also called a canthal angle and an outer canthus or lateral canthal angle or lateral canthus.

Cheek Implant

A solid implant positioned over the prominence of the cheek bone to enhance the projection of this facial area. Solid silicone implants are the most common material used, however, implants are also less commonly available in other materials including porous polyethylene and ePTFE. The implants are available in a variety of sizes and shapes depending on the facial contour deficits that need to be addressed. The implant can be placed through an incision through the mouth, or behind the eyelid. With the availability of good long-term fillers such as Perlane® much of the volume needs that might prompt one to consider a cheek implant can be met with an an office based filler service with almost no downtime and no surgery.

Chemical Peel

Skin rejuvenation stimulated with the use of irritating acids of various strengths. Peels can be mild to very strong (see Gordon Baker peel). The mild peels can vary from the light glycolic acid peels performed by aestheticians to peels that can produce profound facial tightening. Generally, there is no free lunch with chemical peels. The more work that must be done with a chemical peel, the more down time is needed to heal the face. Moderate to medium depth peels produce results that are comparable to the best results seen with multiple passes of Fraxel® (fractional CO2 laser treatment) or erbium laser treatment. Lighter peels with trichloroacetic acid 10 to 20% improve skin tone and color, and firm the face with almost no downtime. These treatments can be easily combined with other office based services to produce easy to obtain yet profound results. As peels increase in strength, the need for anesthesia in the form of oral sedation, and local numbing of the face to make the procedure comfortable increases. Also the post-procedure skin care increases in complexity and length to ensure that the face heals quickly and with the best possible result. Generally, the deeper facial peels produce results that rival what can be accomplished with surgery and recovery to the point where make-up can hide facial redness occurs in 7-10 days. Men usually heal one or two days faster than women because they have a higher density of skin adnexal (hair follicles, sweat glands, etc.) structures from which the face heals from.

Chemodenervation

Use of a neuoparalytic agent like Botulinum toxin to weaken unwanted muscle contraction. This can have both cosmetic and function applications such as improving the lines between the eyebrows or stopping unwanted facial spasm seen in certain medical conditions.

Chemosis

A specific type of swelling that may occur following surgery effecting the conjunctiva, the lining behind the eyelids (palbepral conjunctiva) and on the surface of the white of the eye (bulbar conjunctiva).

Chin Implant

A solid implant positioned over the prominence of the chin to increase the projection of the chin. Solid silicone implants are the most common material used, however, implants are also less commonly available in other materials including porous polyethylene and ePTFE. The implants are available in a variety of sizes and shapes depending on the facial contour deficits that need to be addressed. The implant is usually placed through an incision under the chin. With the availability of good long term fillers such as Perlane® much of the volume needs that might prompt one to consider a chin implant can be met with an office based filler service with almost no downtime and no surgery.

Chinese BOTOX®

There is a Botulinum toxin A product produced in China. It is not BOTOX® and it is not FDA approved for human use in the United States. Why do doctors smuggle this product into the country and use it on their patients? Profit motive. Yes, BOTOX® is an expensive product but it is also a very safe product with a 20 year track record. Don’t compromise your safety for a few dollars, get treatment from reputable doctors using legitimate products.

Closed rhinoplasty

Cosmetic nasal surgery performed via incisions that are made inside the nose so that the scars are not visible. Generally this approach is less useful when repairs need to be made to the nose in revising a prior rhinoplasty.

Collagen

Collagen is the primary building block that holds our tissues together. It is also the name of the original filler material. It came in three forms: Zyderm I, Zyderm II, and Zyplast. For a very long time, this was the only viable filler on the market. The effects of Zyderms were very short lived. The Zyplast seemed to last only a couple of months. Essentially only the wealthy could afford this service. These products have now been replaced with Restylane®, Perlane®, and to a lesser extent, Jevederm®. The Zyplast was fantastic for treating the edge of the lips, but the longevity of the product limited its usefulness.

Congenital Eyelid Ptosis

Drooping of one or both of the upper eyelids from birth. There are several possible causes of this condition, but in many cases, the muscle that elevates the upper eyelid, the levator muscle, did not form normally and is not capable of generating all the force needed to elevate the upper eyelid.

Conjunctiva

The mucosal lining behind the eyelids (palbepral conjunctiva) and on the surface of the whites of the eye (bulbar conjunctiva). This is the tissue that becomes red and irritated with pink eye.

Cool Laser

An oxymoron. A cool laser is a marketing concept not an actual device. In many cases, the instrument in question is an ablative laser like a CO2 or erbium laser with the energy setting so low that the treatment can be tolerated with minimal drugs or topical anesthetic. It’s the marketing people who come up with the cool name to make you think it’s a magic wand. Like chemical peels, laser resurfacing treatments are no free lunch, the less treatment applied, the less effect is seen in the final result. In many cases, there is a minor degree of improvement but nothing comparable to what can be accomplished with an actual appropriate energy setting or an appropriately chosen chemical peel. The results of these treatments are often disappointing given their costs.

Coronal Canthoplasty

Tightening of the lateral canthal angle performed through an upper eyelid blepharoplasty incision. This seemingly helpful procedure has produced some of the most bizarre and complicated canthal angle post-surgical injuries. The answer seems to be that the idea is attractive but like most things in life, you really need to know what you are doing.

Cosmetic Eyelid Surgery

Eyelid surgery performed to improve ones appearance. This can include forehead surgery, upper and lower eyelid surgery as well as midface surgery.

Craniofacial Surgery

Reconstructive plastic surgery that moves the bones of the facial skeleton to improve the facial appearance. This tends to be major facial surgeries that are performed to correct developmental issues or skull asymmetries. Occasionally, these techniques are employed to address facial skeletal abnormalies after trauma. Less commonly, these techniques have been employed to address cosmetic issues.

Dacryocystorhinostomy

Tear duct surgery to restore the drainage from the eye into the nose.

Dark circles

The discoloration that develops under the eyes. These are sometimes referred to as allergic shiners. Pigmentation can contribute to the dark circles. However, generally the dark circles are the result of several optical phenomena. First, there is shadowing from the brow rims. Secondly, the lower eyelid possess almost no subcutaneous fat. Fat is yellow and acts like a reflector for light that penetrates through the skin. In the cheek adjacent to the lower eyelid this reflected light from the cheek fat makes the skin of the cheek look lighter relative to the lower eyelid skin. In the lower eyelid with no subcutaneous fat, light passes through the skin and is absorbed by the dark red under lying orbicularis oculi muscle. The light is not available to be reflected back into the skin and therefore this skin looks darker compared to adjacent cheek tissue. Filling in the dark circle with Restylane® fills out this area and reduces the appearance of the dark circle.

Deepfill™ Restylane®

The placement of Restylane® under the eye at the level of the orbital rim. This location is deep enough to reduce the incidence of surface irregularities even though the under eye hollow area has very little fat to hide this material. Also the bony orbital rim provides a very safe landmark for placing this material. Dr. Steinsapir invented this widely acclaimed method of treating the under eye hollow area.

Deep Plane Face Lift

Face lifts involve tightening the face in two layers: the skin and the deeper muscle and fascia layer. The deep plane layer is the muscle and fascia layer. In the deep plane face lift, this plane is lifted from the side of the face and then tightened and sutured. The skin is then trimmed and closed. This procedure is associated with a very small percentage of facial nerve injuries resulting in temporary or in some cases permanent nerve damage. However, studies comparing this method of performing face lifts with more conventional plication and imbrication methods of tightening the deeper layer which are not associated with nerve injury, there is no cosmetic benefit to the deep plane face lift. It may be macho to dance around the facial nerves, but at the end of the day, the risk is not worth it.

Depressor Anguli Oris Muscle

This muscle is present on both sides of the mouth and is responsible for pulling the corners of the mouth down. A small amount of BOTOX® in this muscle can effectively improve a mouth that appears to have a perpetual frown. Fat is commonly lost around this muscle creating a volume deficit. This muscle on each side of the chin accounts for much of the appearance we associate with jowls. This can be very effectively addressed by placing a filler like Perlane® into the depressor anguli oris depression-a great treatment option.

Depressor Supercilli Muscle

On of the muscles on the side of the nose that help pull down the central eyebrow. BOTOX® can be effectively used to counter act the pull of these muscles.

Double Fold Surgery

Upper eyelid surgery performed in the Asian eyelid to create a distinct break in the upper eyelid.

Ectropion

An abnormality usually of the lower eyelid where the edge of the lid rotates away from the eye. Laxity of tissue is usually the cause of this but occasionally deficiency of lower eyelid skin contributes to the problem. Accurate assessment of the problem is critical in developing an appropriate surgical plan to address the issues.

Endoscopic Forehead Lift

A forehead lift surgery performed using a rigid fiber optic telescope that allows visualization of the surgery through small incisions in the scalp. The immediate benefit of this approach is a much smaller incision compared to the old style open coronal forehead lift. The smaller the incision, the quicker the recovery. While the endoscopic forehead lift has become the standard approach for forehead elevation, there is significant variation in how these procedures are done, how tissues are released, and how the tissues are fixated.

Endoscopic Face Lift

Whereas the endoscopic forehead lift is a standardized procedure, the endoscopic face lift is more of a marketing concept. Generally this refers to degloving the soft tissue of the midface via an intraoral incision. The mobilized tissues are then elevated through a temple incision. There are a couple of things to keep in mind. First an endoscope is not actually necessary to perform this type of surgery, as it is possible to directly visualize the work being done through the typical incisions. Also what makes a face lift is the trimming of excessive skin. As this is not done, the procedure is effective only for people who don’t have excessive skin and they probably don’t need a face lift surgery in the first place.

Entropion

An abnormality usually of the lower eyelid where the edge of the lid rotates away from the eye. Laxity of tissue is usually the cause of this but occasionally deficiency of lower eyelid skin contributes to the problem. Accurate assessment of the problem is critical in developing an appropriate surgical plan to address the issues.

Epicanthal Fold

A small web of skin along the side of the nose that stretches from the upper eyelid to the inner corner of the lower eyelid. The epicanthal fold is characteristic of Asian eyelids. Inside upper eyelid folds tuck under the epicanthal fold.

Eye Tack

Lay term for cosmetic eyelid surgery.

Eyelid Fold

The fold of skin in the upper eyelid where the skin below the eyebrow breaks to attach to the upper eyelid crease.

Eyelid Platform

Portion of the upper eyelid between the eyelashes and the upper eyelid crease. Generally, much of the eyelid platform is covered by the upper eyelid fold.

Eyelid Surgery

General expression for any surgical procedure involving the eyelid. This term covers both cosmetic and reconstructive procedures.

Face Lift

A range of surgical procedures to tighten the lower face. A face lift may or may not address the neck as well. Some surgeons separate these two areas or omit the neck procedure altogether. However, the additional work needed to address the neck cord and skin laxity at the time of lower face lift compared to what is required to tighten the neck after a lower face lift is not so great. Therefore, it is highly worthwhile to have the neck done at the time of the lower face. Conversely, if the neck does not need to be tightened, then it is improbable that the lower face lift is really necessary.

Fat Transfer

Fat is harvested from one place in the body and injected into another location. Typically fat transfers are used to place large volumes into the face to restore volume. Transferred fat is an example of an autologous implant from one’s own body. Approximately 60-70% of the transferred fat is retained and produces long term volume restoration. These procedures can be done in the office under local anesthesia.

Festoons

Cheek bags. These are the waves of fullness at the top of the cheek but below the eyelid. They are caused by slippage of tissue at various layers of the midface. Options to address these bags include filling around them, tightening the overlying skin with surgery or chemical peeling.

Forehead Lines

Wrinkles present on the forehead. These lines represent activation of the frontalis muscle that lifts the eyebrows. This is always the result of heaviness of the upper eyelid fold on the eyelid platform although considerable variation is seen in the degree of sensitivity to this stimulation.

Fotofacial®

Intense pulsed light (IPL) based facial treatment that addresses a broad array of facial concerns including red spots, small blood vessels, flushing, brown spots, large pores, acne scars, and fine lines. Four to 6 sessions done at 3-week intervals are needed to maximize the treatment. Each session takes about 15 minutes and is comfortable with numbing cream. IPL has an advantage over laser in that the intense pulsed light is composed of many wavelengths of light allowing many skin issues to be treated simultaneously.

Fraxel®

Fractional CO2 laser resurfacing. A new variation on the CO2 laser. What the engineers have done is modify the output of a CO2 laser so that each treatment spot size is pinpoint. Imagine a grid of skin where about 30% of the skin is randomly subjected to this type of treatment. The result is rapid recovery from treatment with improvement of skin issues with healing. Typically several sessions are needed to treat 100% of the face. No question these treatments improve the complexion and the technology is impressive. However, improvement is modest and the level of improvement appears to be equivalent to a relatively light chemical peel which can be comfortably preformed in the office with only slightly more downtime than a Fraxel® treatment. This raises the question if the big price tag that comes with these treatments is really worth the expense.

Glabella

The part of the forehead at the top of the nose and between the eyebrows.

Glabellar Rhytids

Also known as brow furrows. Typically two vertical lines made by the muscles of facial expression between the eyebrows. This issue is often very effectively addressed with an FDA approved treatment using BOTOX®. Allergan, Inc., the maker of BOTOX®, calls these lines the “11 lines” in marketing materials.

Herring’s Law

The scientific observation that certain movements about the eyes are paired (i.e. look left and both eyes look left, look up and both eyes look up). These paired muscle muscle movements occur because of the nerve signals from the brain stem to the muscles are the same. Herring’s law dictates that a heavy eyelid on one side will stimulate an over correction on the opposite eyelid. Commonly, patients will present with one ptotic or heavy eyelid and the other side will be in a normal position. Herring’s law means that both sides are getting the same amount of innervation. This means that if surgery is only performed on the side with obvious heaviness, after surgery, the otherside that did not get a surgical correction will end up being too low. An experienced eyelid surgeon will be on the look out for this well described phenomena and generally recommend that both eyelids have surgery to prevent this issue.

Hyaluronic Acid

This is a carbohydrate polymer or sugar gel that is found throughout the body and is a main component of the fluid in our joints. In the early 1970’s this material found use in intraocular surgery as a viscoelastic material used to cushion the inside of the cornea during intraocular surgery. This material is what made all of the recent advances in anterior segment and cataract surgery possible. This material only lasts a few hours in the body. By crosslinking the hyaluronic acid, it was possible to have a gel that persisted in the body much longer before being broken down. This became the basis for a treatment of osteoarthritis. Restylane®, Perlane®, and Juvederm® are all hyaluronic acid fillers that persist in the body for a year or more and have proven to be one of the most popular office based services for facial filling, replacing other fillers. In some cases, these services have proven to be a viable alternative to facial and eyelid surgery.

Inside Fold

An upper eyelid crease that tucks under the epicanthal fold.

Klingon Forehead

Abnormal horizontal wrinkle lines that appear above the lateral aspect or tail of the eyebrows on the forehead. These lines tend to heap and can extend from the eyebrow itself all the way to the hairline. They are the result of abnormal muscle recruitment following aggressive BOTOX®; treatment to the forehead. In these cases, the BOTOX® has been placed in the glabella and central forehead. This paralyzes the central portion of the forhead creating central descent of the forehead and eyebrows. The brain automatically compensates for this by activating the forehead elevators. Unfortunately, the only muscle in the forehead not affected by the BOTOX® is at the sides of the central forehead. These muscles are forced to work extra hard to compensate for the fall in the eyebrow. The result is the heaping lines on the side of the central forehead referred to as a “Klingon” forehead.

Laser Resurfacing

The use of an ablative (burning) laser to create a partial injury of the skin thereby stimulating facial healing. The CO2 and erbium lasers are the lasers typically used for this purpose. The CO2 is associated with much more thermal effects and creates more facial tightening but also longer healing times, more pigmentary issues, and unwanted textural changes. The erbium laser penetrates less deeply than the CO2 laser and produces less thermal injury but also less facial tightening. Both lasers leave the skin raw meaning approximately one to two weeks of healing before the skin is intact and about that much downtime before the face will hold makeup.

Lash Ptosis

Downward rotation of the upper eyelashes. In youth the upper eyelashes are perky. Overtime, the eyelid platform skin, which helps hold the upper eyelid lashes up, becomes lax and the eyelashes rotate down. When severe, the lashes can actually interfere with vision. Lash ptosis is one of those subtle things that make the eyes and the face look haggard. Lashes ptosis is corrected using an anchor blepharoplasty.

Liquid Face Lift

Refers to office based filler and BOTOX® treatments performed in the office with results that rival facial surgery. In some cases, the results are better than what can be achieved with surgery. The down time from these procedures is minimal compared to the results achieved. In Dr. Steinsapir’s office a typical treatment might include a Microdroplet™ BOTOX® forehead lift and placement of BOTOX® in the chin to reduce chin pitting and in the neck to reduce neck cords. Filler services might include 1 syringe of Restylane® under each eye to address the under eye hollow, a syringe of Restylane® in the lips, and 2-3 syringes of Perlane® in the pre-jowl sulcus along the jaw line, in the nasolabial fold, and in the cheeks to volumize these areas. Small skin bruises are common but deeper and more significant bruising, which can occur, is less common. One or two post procedure visits may be needed if there are any visible skin irregularities of concern, which are always adjustable when the hyaluronic acid fillers are used. When there is no bruising, swelling from the procedure might last 30 or 40 hours but is usually minimal. Makeup may be applied to the face after a few hours. Treatment results from the fillers can easily last over a year.

Lateral Canthus

The outer corner where the upper and lower eyelids meet.

Levator Palberae Superioris Muscle

The muscle that raises the upper eyelid. When the upper eyelid droops the action of this muscle is strengthened by shortening the tendon of this muscle, the levator aponeurosis.

Levator Aponeurosis

Tendon of the levator palbebrae superioris muscle that inserts broadly on the upper eyelid tarsus and sends fibers into the eyelid platform skin. The highest such attachment forms the upper eyelid crease. It is this tendon that connects the levator muscle to the upper eyelid so that the upper eyelid retracts upward when the levator muscle contracts.

Lidlift

Lay term for cosmetic eyelid surgery.

Lifestyle Facelift®

Heavily promoted, proprietary S-lift variant. The doctors who perform the procedure are essentially franchisees who pay for the privilege of obtaining referrals. The surgeons are board certified plastic surgeons or fellowship trained facial plastic surgeons. There is nothing wrong with the basic premise of the Lifestyle facelift®. What is troubling is seeing the amount of negative feedback about the surgery on the web. Dr. Steinsapir does not offer the Lifestyle facelift®, but he has consulted with patients who have been very satisfied and very unsatisfied with their Lifestyle facelift®. Cookie cutter approaches do not work well. It is up to the individual surgeon to adapt the Lifestyle facelift® to their patient. Be aware that many surgeons now offer non-propriety limited incision face lifts that share many of the benefits of the Lifestyle facelift®, which for the right patient can be performed under local anesthesia. The key is a careful assessment of the patient and a flexible surgical plan that addresses the anatomic needs of the individual. Tailoring is one of the most important and time-consuming aspects of any face lift. It is what can make or break a procedure. For many individuals needing a face lift, a lower neck liposuction alone will not address the neck issues unless resuspension of the neck cords is also performed. If this is an issue for you, be certain that your surgeon will surgically address the neck cords.

Lower Eyelid Crease


The first line or crease under eye lower eyelid. The fullness of the cheek should extend to the lower eyelid crease but seldom does.

Lunch-Time Face Lift

More of a marketing concept than an actual procedure. The implication is that you can return to the rest of your daily routine right after your lunch-time face lift (i.e. back to work after lunch). That time frame is usually a little optimistic and you might very well have a different idea of how much down time you need after your “lunch-time” prcedure(s). The concept is having an aesthetically meaningful treatment with very little down time. A BOTOX®, Filler service, and a light chemical peel dovetail well with this concept. However, actual surgery procedures including things like Feather lift, contour threads, meloplication, mini-facelifts, and lower face and neck liposuction are procedures that most reasonable people feel they need 2-5 days of recovery for before they feel ready to face the world. The take home message is that these types of services can be great, just make sure that what you think of as needing down time and what your doctor’s office thinks requires down time mesh so you don’t find yourself sitting self-consciously in front of your client wondering if they are acting a little bizarre because you are more than a little bruised and swollen.

Malar Fat Pad

Also known as the cheek fat pad. It accounts for the cheek fullness. This pad tends to fall from the top of the cheek over time contributing to the lower eyelid hollow and the relative fullness of the nasolabial fold and the jowl.

Maxillary Hypoplasia

The cheek bone under the eye should project as far forward as the brow. This is important because a prominent orbital rim helps to support the lower eyelid and the cheek. When the bone is not so projected, there is reduced support for the cheek soft tissue. This is a contributing factor in midface ptosis.

Midface Ptosis

Literally downward sagging of the malar fat pad. The malar fat pad is held in place by the orbitomalar ligament. Over time these ligaments loose their grip on the malar fat pad which begins a gradual descent down the cheek. This is the cause of midface ptosis. There are a variety of midface lifts, the goal of which are to correct this fall in the malar tissue. The big problem with many of these surgeries is that the theory behind many of these surgeries is wrong. The malar fat pad falls down vertically. Many midface surgeries don’t lift vertically because there is nothing great to sew to at the inferior orbital rim. Dr. Steinsapir gets around this problem by attaching a piece of ePFTE felt to the orbital rim with titanium microscrews. This creates a place to sew the vertically lifted cheek soft tissue. However, most midface lifts actually involve a superior lateral lift because there is very good fascial tissue to sew to in the temple region. The surgeries work in the sense that the tissue stays up-that’s the good news. The bad news is that the malar fat pad looks real funny when it gets dragged up over the cheek bone. The look is generally described as dysmorphic (doctor talk for not quite right).

Melolabial Fold

Also known as the nasolabial fold. It is the heavy fold of tissue that develops at the junction between the mouth and the cheek and extends to the base of the nose.

Meloplication

Minimally invasive method of threading sutures to attempt to lift the nasolabial fold and the malar fat pad toward the temple. The original method uses non absorbable sutures with ePTFE pledgets to hold the cheek fat in position. The procedure can also be attempted with barbed suture like the contour threads or the feather lift threads. These procedures have been uniformly disappointing. Initally the cheek is lifted but then typically over a period of months, the cheek volume falls back to its original position.

Midface Lift

Lifting surgery to raise the malar fat pad. There are a variety of approaches. The key is that the surgery in question addresses the issues present and does not create a dysmorphic or unnatural appearance. Also, since non surgical methods are so good now with volumizing the under eye hollow with Restylane® using the Deepfill™ method and Perlane® to volumize the cheeks, the risks and downsides of having surgery must be weighed against what can be accomplished with with these new, fantastic methods.

Midcheek Fold

A depression that develops under the lower eyelid area between the egde of the nose and the prominence of the cheek bone. The underlying bone has a deep groove in this area and as fat disappears from the cheek there is a natural tendency for a hollow to develop in this area. This issue responds beautifully to volumizing with Perlane®.

Mohs’ Cancer Surgery

Specialized technique of completely excising skin cancers while preserving as much of the surrounding normal tissue. This method was developed by Frederic Mohs, a general surgeon at the University of Wisconsin. The key principle of the technique is the microscopic examination of the excised tissue by the surgeon. Mohs cancer surgery is primarily practiced by fellowship trained dermatologists. The technique is associated with a very high cure rate and substantial preservation of normal tissue adjacent to the skin cancer compared to other excision methods. In many areas of the face, the closure is completed by the Mohs cancer surgery. When the lesion involves the eyelids, closure is coordinated with an eye plastic surgeon. Mohs surgery has been a significant advancement for the preservation of eyelid structure. However, many of the reconstructions challenge the eye plastic surgeon because a more general approach is needed to tailor the repair for the defect. Dr. Steinsapir often secondarily repairs the eyelids following the original closure performed at the time of the Mohs surgery. This is not a reflection on the original reconstructive surgeon. Rather once the tissues have had an opportunity to heal for a period of time, the body tends to repair the microcirculation in the vicinity of the original repair. This creates the opportunity to address deficiencies from the original repair and in particular, secondary repair creates the opportunity to restore the aesthetic appearance and improve the function of the eyelids.

Muellerectomy

Muller’s muscle-conjunctival resection ptosis surgery is a reliable means of elevating a mildly heavy eyelid 1-2 millimeters. A surprisingly common situation. The Muller’s muscle is the fight or flight muscle that lives inside the upper eyelid. In fight or flight situations, the sympathetic nervous system dilates the pupils and causes the eyelid to elevate. A simple test with neosynepherine determines if this predictable surgery is right for the individual. This is part of the oculoplastic consultation.

Myobloc®

Brand name for the only FDA approved Botulinum toxin B. This agent is essentially only used for functional muscle overaction. Its effect is seen more rapidly than BOTOX® and the agent diffuses more than BOTOX®. Overall, the effects wear off much faster than BOTOX®. One of the major concerns with Myobloc® is a high incidence of systemic side effects such as voice weakness which is attributed to diffusion of the agent once it is injected. This type of effect is only seen with very high doses of BOTOX® used in treating muscle spasm in larger muscles. The doses used for cosmetic treatment are not associated with distant effects.

Nasolabial Fold

See also the melolabial fold. It is the heavy fold of tissue that develops at the junction between the mouth and the cheek and extends to the base of the nose.

New-Fill®

Now marketed as Sculptra. New-Fill® is a facial filler made from polylactic acid (PLA) hydrogel. This is actually the material that a type of dissolvable suture material is made from. The lay literature implies that this filler stimulates collagen and causes long term benefits. However, there is very little published data to suggest that the improvements last more than 2 years.

No Scar Eyelid Surgery

An oxymoron. No “surgery” can be done without creating a scar. The key is hiding the scar. Lower eyelid surgery can be done behind the eyelid. The scar is not visible and some clever marketing people tout this as scarless surgery. Upper eyelid surgery hides the scar in the fold so when the eyes are open, the scar is hidden.

Open Forehead Lift

Forehead lift performed using a long incision that extends over the top of the head from one ear to the other. This procedure is also called the coronal forehead lift. The procedure is fast for the operating surgeon and effective. The endoscopic forehead lift by comparison takes longer to perform and is associated with a significant learning curve and requires specialized equipment. Consequently, a number of older surgeons never made the transition to the endoscopic forehead lift. The open forehead lift has a number of issues. First, the description of the surgery causes a certain degree of anxiety (“you’re going to cut me from where to where?”), there is permanent numbness on the top of the head following surgery. Hair loss along the edge of the coronal incision is common. The recovery time is also significant due to the length of the incision and the amount of blood loss associated with the surgery. In contrast, the endoscopic forehead lift has none of these problems and for this reason has become the preferred method of elevating the forehead.

Open Rhinoplasty

Cosmetic nasal surgery performed by making conspicuous incisions at the base of the nose. This permits wide exposure to the internal nasal cartilages. This approach is often helpful when extensive methods are needed to improve the nasal contour.

Outside Fold

An upper eyelid crease that does not disappear under the epicanthal fold. This configuration is associated with a Caucasian eyelid. In contrast, the inside fold, where the upper eyelid crease tucks under the epicanthal fold, is commonly seen in Asian eyelid configurations.

Perlane®

Stablized hylauronic acid gel filler with a larger molecular structure than Restylane®. Perlane® is also distributed by Medicis, Inc. the same company responsible for Restylane®. Perlane® is intended for volumizing the face in the deep dermis and superficial subcutaneous fat. Early consumer dissatisfaction with this product appears to relate to its use as an alternative to Restylane®. Perlane® and Restylane® are not equivalent products. It is essential that Perlane® is placed deeper than Restylane®. When this is done, the product is an excellent alternative to volumizing products like Scluptra® and Radiesse®. Like Resylane®, Perlane® can be modified or even erased with hyaluronidase products like Vitrase® making these treatments highly flexible. Treatment effects appear to last well over a year.

Phenol Peel

Phenol, also known as carbolic acid, is a medium depth chemical peeling agent. Properly used it is highly effective in reducing under eye wrinkles and can be used as an alternative or adjunct to lower eyelid surgery. Peels need to be tailored to the individual patient needs. Phenol is often used in conjunction with other peeling agents to achieve a balanced effect. Full-face chemical peels can produce results that rival facial surgery. The treatment is performed very comfortably under local anesthesia. Peels that use phenol and the higher concentrations of trichloracetic acid should not be confused with lighter chemical peels that heal with no or minimal downtime. The deeper peels provide considerable facial tightening. Depending on the degree of peeling, typically it takes about 8 to 10 days to heal the face following these peels. Usually follow up is very closely monitored until healing has taken place. Once the skin is intact, the skin will stay red for several weeks to several months depending on the depth of the chemical peel. Results of these peels last many years.

Prejowl Sulcus

This is the hollow that tends to develop on the side of the chin. This groove accentuates the appearance of the jowl along the jaw line. The jowl develops from descent of the malar fat pad, skin tethering from the masseter-cutaneous ligments, and the depression of the prejowl sulcus. This sulcus is also referred to as the depressor anguli oris depression. A variety of solutions are often proposed to address this issue including face lifts and chin implants. However, filling the sulcus with Perlane® can cause a profound improvement in the appearance of the prejowl sulcus.

Pretrichal Incision

Trichal means hair and the pretrichal incision is a cut made along of the hairline above the forehead to perform a forehead lift. The approach is often proposed as a means of “shortening” a long forehead. The incision can be beveled which allows hairs to grow through the edge of the incision to help hide the scar. Generally this approach is not as acceptable as performing the forehead lift endoscopically.

Radiesse®

FDA approved filler composed of calcium hydroxylapatite (CaHA) microspheres. The filler is thought to last approximately a year or more in the face. The material is slowly broken down by the body. The material does induce a tissue response that is touted as collagen stimulation, but as with other fillers, there is no evidence that this new collagen persists once the body has removed the Radiesse®. Due to the tissue response, it is essential that this material not be placed too close to the skin surface which can create visible irregularities. This filler is being displaced in the market by Perlane® which seems to last just as long, can easily be adjusted and is less prone to surface irregularities.

Red Lip

The vermillion portion of the lip. The lower lip can be double the size of the upper lip.

Restylane®

Hylauronic acid filler distributed by Medicis, Inc. Restylane® is a cross linked sugar gel that is used to correct wrinkles, volumize the nasolabial fold and lips. This is the basis for filling in the hollow under the eyes and improving dark circles using the Deepfill™ method. Restylane® appears to last about a year. Treatments can be adjusted, if needed, at anytime using hyaluronidase, making the treatment highly flexible. Bovine Collagen was the gold standard of fillers for many years but has now been displaced by Restylane® which is now the filler to which all others are compared.

Rhinoplasty

The art and science of nasal reshaping. This procedure can have a profound effect on the face. Because the surgery continues to change for several years after the procedure, a great deal of know how is needed to get the most from this procedure. Current trends in rhinoplasty emphasize the conservation of tissue and structure. Over resection of the nasal cartilages, and over rotation of the nasal tip is now avoided whenever possible. Discussing your overall goals is important because some who think they need a rhinoplasty are actually bothered by flatness in the cheek, which makes the nose seem out of proportion. This can be addressed with a filler service without the necessity of a rhinoplasty or other surgical procedure.

Retro-Orbicularis Oculi Fat Pad

Sub eyebrow fat. It was the surgical fashion for a while to sculpt or resect the sub eyebrow fat. This had the unfortunate effect of taking away the natural fullness of the upper eyelid fold. We now understand this and now actually take steps to add volume to this area when needed.

Sculptra®

Poly L lactic acid based filler that is hydrated prior to treatment. The product is FDA approved for volumizing in HIV related facial lipoatrophy. The treatment is relatively expensive and the claimed collagen stimulation does not seem to last longer than 24 months. The treatment can produce lumps and irregularities. There are several methods of reducing the incidence of these.

Silicone Oil

This product is only FDA approved for use in repairing complex retinal detachments. This does not seem to prevent both physicians and non-physicians from injecting silicone oil into the face and other parts of the body. The history of silicone injections is long and sordid. It is true that physicians can use FDA approved drugs for non-approved uses. However, the damage caused by silicone oil has been so heinous that the FDA has aggressively gone after physicians who persist in injecting these products into patients. Be aware that not all silicone oils are suitable for injection into the human body. Many of these products are actually industrial lubricants never intended of use in humans. However, lay injectors are out there traveling to hair salons and other unsupervised setting to perform these treatments. These bogus treatments are certainly much cheaper than being treated with FDA approved fillers. Pumping parties where lay injectors treat with silicone oil are reported to be on the rise. A woman died in Florida after being injected with a large volume of silicone oil into the buttocks. Other deaths related to silicone oil injections have been reported. Even small facial treatments into the lip and nasolabial fold over time can result in permanent and irrepairable facial disfigurement. Friends don’t let friends do silicone oil.

S-lift

A short flap face lift that features two large plication sutures that help tighten the face. The procedure is relatively easy to learn and quick for the surgeon to perform. Like anything, in the right hands and for the right person these rapidly healing face lifts can be a good choice. However, operator experience is an absolutely critical issue. Poorly done, these face lifts can produce almost no result. Even worse, inexperienced operators lack the finesse needed to minimize the scars associated with the procedure. Facial nerve injury has also been reported from the deep plication sutures. Generally, most individuals are better served by a customized limited incision face lift with a midline platysmaplasty. Tailoring of the skin around the ears is also of critical importance to obtain the most from any face lift. Recovery from face lifts is 10 to 14 days for most individuals. Your individual time frame for recovery should be part of the discussion during your consultation.

Smartlipo™

Liposuction using a small cannula assisted with a 1064 nm Nd:YAG laser. The laser liposuction machine used for the procedure is made by Cynosure, a publicly traded company. The aspect of the surgery that seems to please most patients is that their liposuction was performed under local anesthesia with a mild oral sedative. Down time is minimal like tumescent liposuction under local anesthesia. The results are comparable to what can be accomplished with other methods of performing liposuction under local anesthesia. To understand the hype it is important to understand this technique is being marketed to sell a very expensive machine to doctors. The good new is that these doctors are being forced to adopt what is essentially tumenscent liposuction. It is not at all clear that the laser makes any difference at all. Traditionally, general plastic surgeons performed liposuction under general anesthesia with very little wetting of the tissue. Large cannuals (over 4 mm but usually 6-8 mm in diameter) were used. There was considerable trauma associated with these procedures with patients often needing blood transfusions following surgery. Recovery required months with 6 to 8 weeks in compression garments. Ninety-nine percent of all liposuction malpractice lawsuits are associate with this type of liposuction. In contrast, dermatologist and non-general plastic surgery cosmetic surgeons tend to practice tumescent liposuction developed and taught by Jeffery Klein, M.D., a dermatologist. Dermatologists like to perform procedures under local anesthesia. Dr. Klein developed a very safe method of performing liposuction under dilute local anesthesia and tiny cannulas (1-2 mm in diameter) not much larger the needles used to inject the anesthetic. By numbing the fat to be removed and using tiny aspiration cannulas, fat is removed very gently with almost no blood loss. Since the patient is awake it is easy to move the patient around encouraging more accurate and complete fat sculpting. Enter ultrasonic liposuction. This technology supposedly caused more through removal of fat. However, the ultrasound burns the skin and fat if the tissue is not fully saturate with wetting solution. Dilute local anesthetic was used for this purpose. The dilute anesthetic solution which contains epinephrine reduced the amount of blood loss. Also the cannula that is attached to the ultrasound machines have diameters that are much less than 4 mm reducing the trauma associated with liposuction performed by most general plastic surgeons under general anesthesia and using much larger cannulas. Unfortunately, the combination of general anesthesia and large quantities of local anesthetic caused a rash of deaths until surgeons figured out they needed to limit the amount of surgery done at a given time. Enter Smartlipo®. To use the technology, small cannulas (1-2 mm diameter) are used under local anesthesia. So it forces the surgeon to practice tumescent liposuction, which is good, and likely the laser is superfluous. Like tumescent liposuction, the technique is slow, which discourages more complete fat reduction. Recovery is rapid just like tumescent liposuction. This is good for patients. However, Smartlipo® tends to be much more expensive than tumescent liposuction because of the increased costs associated with the laser and disposables. Smartlipo® is it smart? The Wall Street Journal does not think so. They interviewed a number of leading liposuction surgeons who found no advantage over tumescent liposuction. This is just another example where it is hard to separate hype from reality.

SMAS Plication Face lift

A standard type of face lift where the deeper tissue layer is tightened by stitches that fold the SMAS. Compared to composite or deep plane face lift, this procedure has virtually no incidence of facial nerve injury. Additionally, long term results of these types of face lifts are indistinguishable from the long term results of the higher risk procedures suggesting the risk of injuring the facial nerve is not worthwhile. This tightening maneuver can be used in mini (incision limited to in front of the ear), limited (incision stops behind the ear), or standard larger incision (incision extends into the hair behind the ear) face lifts.

Softform®

Alloplastic hollow tube made from ePTFE that is threaded into the lip or under the nasolabial fold. This material had some undesirable characteristics including infection, extrusion, and shrinkage. The contour of the material sometimes heals with too much lip edge volume suggesting that the lip was stuffed like a sausage. This type of complication has nothing to do inherently with the implant but rather the surgeon’s choice in placing too large a diameter tube in the lip edge. This implant has lost a lot of popularity and Restylane® lip augmentation is currently unrivaled for lip augmentation.

Submalar Implant

A common midface implant that is placed below the malar eminence to increase the fullness of the cheek. Like anything in cosmetic surgery, this implant has its place in the right individual. However, because it is a stock silicone implant, it is often placed even by very experienced surgeons after an incorrect analysis of the patient’s facial volume needs. Under this circumstance, it creates fullness very low in the midface. Some have argued that this creates an “apple cheek”-think of Cher’s cheeks. Dr. Steinsapir would argue that the full low hanging malar fat pad that this implant can accentuate is not a youthful and desirable look unless you are seventy in which case looking like a 45 year old with a tired sagging cheek might be a very good thing. For most 35-50 year olds, this extra volume in precisely in the wrong place. In youth the bulk of the malar fat pad sits high on the cheek right up into the lower eyelid. This is what creates a heart shaped face. Surgery and facial volumizing needs to be directed at restoring this feature not accentuating a change that is the result of aging!

Sub-Orbicularis Oculi Fat (S.O.O.F.)

Here is an anatomic description that has really confused many surgeons, and that confusion probably accounts for more than a few adverse outcomes from midface procedures. This is really the case of the three blind men describing an elephant based on the part they touched. The so-called SOOF fat is encountered in transconjunctival lower eyelid surgery. A layer of fat very adherent to the cheek bones is encountered when surgical dissection is extended to the bony orbital rim. Because this layer is deep to the orbicularis oculi muscle, it got the name sub-orbicularis oculi fat pad. The real problem came when several often quoted papers suggested that this structure was a distinct layer of fat. Actually, it is the deepest extension of the malar fat pad, which early in life starts firmly held by the orbitomalar ligament high onto the cheek. As that ligament stretches over time, the malar fat pad falls creating midface ptosis and various hollows under the eyes. How was it that some pretty well respected surgeons got the anatomy wrong? The answer is theory. A pretty smart surgeon once said that in surgery your theory has to be right because you operate on that theory. In the case of the facial anatomy, most of the superficial fat of the face is divide by a thin fibrous plane of connective tissues called the superficial muscular aponeurotic system or SMAS. It is stated in numerous papers that the SMAS extends through out the face. Based on this, some authors assumed that SMAS also extended into the triangle of the face under the eye in which case, the malar fat pad and the SOOF would be anatomically distinct structures. Thanks to some very well carried out microanatomy studies of this area of the face, we now know that the SOOF disappears in this area and in fact the SOOF is just the deep extension of the malar fat pad.

Tear Trough

Another name for the under-eye hollow. There is in fact a silicone implant called the tear trought implant specifically for this area. Alternatively Dr. Steinsapir prefers to custom hand carve an implant for this area using ePTFE sheet material. The ePTFE is very strong and can hold sutures and microscrews in a way that solid silicone can’t. This creates the opportunity to lift the cheek’s soft tissue vertically and sew it to the ePTFE implant for long-term support.

Temple Lift

A surgical lift of the temple area through an incision made above the ear. Generally a small amount of hair bearing scalp is also removed to permanently elevate the temple. This maneuver should always be part of a forehead lift either open or endoscopic as this supports the outer corner of the eyebrow.

Thermage

Radio frequency skin tightening. This was another of those incredibly promising technologies. A contact probe, which is essentially a fancy antenna, sits on the surface of the skin. An intense radio signal is sent from one part of the probe to another. The energy of the signal passes through the tissue at a depth where the skin should not be injured (i.e. burned) but the dermis and the subcutaneous fat under the skin is heated stimulating collagen and healing. This is the basis for the skin tightening. The first generation probes were uncomfortable and cases of skin irregularities from damage to subcutaneous fat were reported. The new generation of probes are much more comfortable and because the energy settings are more gentle, fewer side effects are now reported. The treatment should produce very little changes on the skin and most people return to their routine the next day. Unfortunately, for all the hype and expense, the amount of improvement seen is modest and a significant percentage of those having the treatment feel that there was no benefit or the benefits were so minor it was not worth the money.

Thyroid Eye Disease

An autoimmune condition that stimulates a specific type of inflammation in the thyroid gland and in the orbit. Thyroid eye disease is usually associated with Grave’s disease, autoimmune over active thyroid but it can be also be associated with Hashimoto’s thyroiditis, which causes an underactive thyroid. The eye changes include eyelid retraction, bulging of the eyes (proptosis), chronic irritation and redness, double vision, and less commonly loss of vision. The changes typically run a time course over one to two years. At first the symptoms increase, stabilize, and then gradually there is a degree of improvement. Treatment is initially supportive with education and dry eye treatments. If the inflammatory changes are judged to be vision threatening, treatment with oral steroids, or orbital radiation may be considered, and early surgery to reduce damage to the optic nerve may be proposed. Once the disease has run its course, rehabilitation of the eyes is staged and tailored to the needs of the patient. This can included orbit surgery to decompress the orbits and help reduce prominence of the eyes, muscle surgery if there is persistent double vision, and eyelid surgery to address residual eyelid malposition. The overaction of the thyroid is generally managed separately but there does appear to be a worsening of the eye changes when the thyroid gland is treated with radioactive iodine. Consequently, some advocate the use of steroids to cover this period of increase eye disease activity.

Transconjunctival Blepharoplasty

Lower eyelid surgery to contour the herniated orbital fat that creates fullness under the eyes where the fat is approached by an incision made behind the lower eyelid. This approach avoids an incision on the surface of the eyelid and also minimizes the risk of altering the contour of the eyelid margin after surgery. In many cases, the eyelid fat can be preserved and rotated into the hollow under eyes. This is referred to as arcus marglinalis release (see above) and this can also be performed through the same incision.

Transcutaneous Blepharoplasty

Lower eyelid surgery to contour the herniated orbital fat. In this case surgery is performed through an incision made just below the lower eyelid lashes. This surgery can damage the function of the orbicularis oculi muscle and affect the lower eyelid contour. However, this approach permits the removal of excess skin from the lower eyelid. In some cases, it is appropriate to remove the lower eyelid fullness from behind the lower eyelid but remove excess skin from the front using a skin pinch technique or an incision just below the eyelashes (infracillary incision).

Trichal Incision

An incision made along a hairline. See also pretrichal incision.

Trichloroacetic (TCA) Acid

Light to medium depth peeling agent depending on the concentration of the agent. The lower, clinically useful concentrations are 10 and 15% TCA. These provide a freshening and firming of the face. At this strength there is generally improvement in superficial sun related brown spots. These peels don’t tighten the skin sufficiently to improve fine lines. These peels are considerable more effective than the glycolic peels administered by estheticians. Although not considered to need downtime, the skin may mildly discolor and the face will flake and peel for about a week revealing the fresh new complexion. It will look like you are recovering from a sun burn. These types of peels are effective for two or three months. Stepping up to 20 and 25% TCA increases the firming of the skin and the skin looks pretty beat up for about a week but is never raw. Overall, these strength of peels remove more sun spots and provide some mild overall facial tightening. TCA 35% is considered to be a medium depth peel in that it will create facial tightening and improve fine lines. The treatment is sufficiently irritating that local anesthesia is needed in the form of topical numbing cream, injected local anesthetic, and post-procedure icing. Generally the old skin stays on like a bandage and peels off in about 5-7 days. Care involves icing the face for the first two days, frequent showers beginning 2 days after the peel and close monitoring by the surgeon. By day 7 the old skin is usually off revealing the fresh, intact skin. At first the skin is too dry to hold make up but by the tenth day, make up can be used to hide the mild redness that persists 3 to 6 weeks. Stronger concentrations of TCA are generally to be avoided due to the risk of scaring. However, 95% TCA is used for ice pick type acne scars.

Tumescent Liposuction

This is liposuction performed with the patient awake under local anesthesia and using small cannulas. Liposuction is effective for sculpting areas of body fat that are resistant to diet and exercise. Typically for women this is the abdomen and flanks, inner thighs, outer thighs, and the arms. For men the typical areas are the abdomen, flanks, and breasts. Liposuction is a sculpting method and not appropriate for weight reduction. Provided the weight is relatively stable, the contour improvement will be permanent. It is important to be realistic about what can be accomplished with liposuction. Generally, people are quite pleased with their improved body contour. Liposuction is not able fix cellulite, the dimples that develop in the skin of the thighs. Tumescent liposuction under local anesthesia with small cannulas is incredibly safe compared to other liposuction methods. Recent studies of large numbers of patients undergoing tumescent liposuction have revealed no deaths with this method. Also because large volumes of dilute local anesthesia is used, the area undergoing liposuction stays numb for about 18 hours making the procedure remarkably comfortable. Narcotics are almost unnecessary. Generally, down time is minimal with most individuals returning to work in 2 days. Compression garments are usually worn for just 5 days.

Ultrasonic Liposuction

Liposuction performed using an ultrasonic cannula. The high frequency vibration of the cannula disrupts fat and advocates of the technique feel this speeds up the aspiration of the fat. However, there are some concerns with the method. First to prevent skin burns, a guide sleeve must be place in the incision made to introduce the cannula. This means that a relatively large scar is created wherever the cannula is introduced. The vibration of the cannula can cause tissue burns if the fat is not infiltrated with dilute local anesthetic. This led plastic surgeons using the technique to combine large volumes of local anesthetic with general anesthesia. The combination can be toxic. Surgeons got the message and cut back on the number of procedures attempted at one time. Finally, the instrument can efficiently remove fat and over resection of fat is common. Fat is golden. The goal of the procedure is sculpting fat not removing all the fat.

Undereye Restylane®

Filler treatment with Restylane® gel under the eyes to fill in the undereye hollows. This has proven to be a very important treatment. The Deepfill™ method of placing Restylane® under the eyes can accomplish as an office services what can’t even be accomplished with surgery. The method is versatile. Hollows under the eye can be filled. This tends to also improve dark circles. Filling can also be performed in individuals with herniated orbital fat. The groove between the top of the malar fat and the lower eyelid fat can be filled in to create the impression of continuity between the lower eyelid and the cheek.

Upper Eyelid Crease

The skin crease under the upper eyelid fold and at the top of the eyelid platform. The upper eyelid crease is formed by the first attachments between the skin and fibers from the levator aponeurosis.

White Roll

The skin of the upper lip that meets the vermillion lip. This skin can be observed to be less pigmented than adjacent skin.

W-Plasty

A reconstructive tissue rearrangement method. Commonly, a W-plasty is used to revise an old scar. The excision of the old scar tissue is outlined with multiple W-plasties. These are lined up and sutured closed. The zigzag produced with closure of the excision helps hide the new scar, making the reconstruction less conspicuous than the original scar.

Z-Plasty

A reconstructive tissue rearragement method. The Z-plasty is used to help expand a tissue area or bring in more tissue in a given location.

LidLift