There can be a number of reasons for why the lower eyelid sags after surgery.  In some cases swelling can push the lower eyelid away from the eye.  This can occur in conjunction with a process called chemosis.  Chemosis is the medical term for swelling of the white of the eye or the conjunctiva.  Just as the eyelid will swell after surgery, the conjunctiva can swell.  When it is swollen, the conjunctiva has been described to look like “jelly.”  The best treatment for this is ocular lubrication and time.  This often resolves with tincture of time.

Another cause of lower eyelid sagging is preexisting laxity of the lower eyelid.  Swelling after surgery causes the laxity to be exaggerated resulting in the unsatisfactory position of the eyelid.  In many cases again time is the best treatment.

When the surgeon cuts the skin of the lower eyelid to remove “extra lower eyelid skin,” malposition of the lower eyelid can be more serious.  Under these circumstances the lower eyelid can be short of skin or the muscle that helps hold the lower eyelid against the eye can actually be damaged by the surgery.  Rather than allowing this to heal, surgeons often feel the need to provide an early fix.  That early fix can help resolve the issue or make it worse.

Generally, due to mechanical issues, some of the simple treatments can actually be helpful.  These include steroid injection, mechanical finger winking, and when appropriate a pull up suture placed to support the eyelid corner for a few weeks.   When these measures fail, it is best to let the eyelid heal before attempting revisional surgery.  So often Dr. Steinsapir is called in to fix an eyelid where the original surgeon has made several well meaning attempts to “tuck up” the eyelid early after the original surgery with each procedure making the situation worse.

What will your eyelid need?  It often depends on precisely what factors are contributing to the circumstance.  If your surgeon was not a fellowship trained oculoplastic surgeon, it is often helpful to see someone who is.  The additional training and experience may be precisely what is needed to address the situation.

About Dr. Steinsapir

Dr. Steinsapir is a board certified eye surgeon and fellowship-trained in oculoplastic surgery and cosmetic surgery in Los Angeles where he specializes in balanced facial cosmetic surgery for natural results, with an emphasis on minimally invasive techniques, fast recovery time, and leadership in medical technology. Dr. Steinsapir has a private practice and also serves as an Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, at the David Geffen School of Medicine at UCLA. Contact us today to learn how Dr. Steinsapir’s experience and training make him an expert in cosmetic surgery, which can be a vital part of your evidence-based treatment plan.

Services described may be “off-label” and lack FDA approval. This article is informational and does not constitute an advertisement for off-label treatment. No services should be provided without a good faith examination by a licensed physician and an informed consent with a discussion of risks, benefits, alternatives, and the likelihood of treatment success. Only you and your treating physician or surgeon can determine if a 

Dear Editor:

I read Robert Johnson’s article “A Nip and a Tuck” about cosmetic surgery for the 65-plus crowd that appeared in the October 31, 2011 WSJ.  The article only mentions a single specialty that offers cosmetic surgery: general plastic surgeons certified by the American Board of Plastic Surgery.  Either general plastic surgeons are very good at public relations (they are), or the author was unmotivated to provide readers with a balanced perspective.  General plastic surgeons are not the only board certified surgeons who offer safe, high quality cosmetic surgery.

For years general plastic surgeons failed to train their residents for cosmetic surgery. General plastic surgery residency instead focused on broad training in reconstructive general plastic surgery.  Despite claims to the contrary, treating a burn is not the same as performing liposuction, a facelift, or an eyelid surgery.  This lack of leadership has resulted in a less than ideal standard of care for these elective cosmetic surgeries.

Over the past 40 years, otolaryngologists, ophthalmologists and dermatologists have built excellent fellowship training programs in facial plastic surgery, oculofacial plastic surgery, and dermatologic surgery that provide in-depth training in cosmetic surgery to allow these surgeons to offer cosmetic surgery to the American public that is arguably safer and of better quality than that offered by general plastic surgeons.   The American Board of Cosmetic Surgery, a non-ACGME board, accredits high quality cosmetic surgery fellowships that are open to a number of surgical specialties including general surgeons, gynecologists, oral maxillofacial surgeons, as well as general plastic surgeons. These highly trained specialists provide a quality alternative to board certified general plastic surgeons who lack formal training in cosmetic surgery.  It is now well accepted that fellowship trained dermatologists practicing liposuction are much less likely to be sued for liposuction malpractice than general plastic surgeons to cite just one example.

It is not controversial to state that general plastic surgery residencies do not provide adequate training in cosmetic surgery.   Fortunately the field of general plastic surgery has recognized this and now offers a growing number of fellowships in aesthetic surgery for board eligible general plastic surgeons.  However, compared to fellowship trained specialists in facial plastic surgery, oculoplastic surgery, dermatologic surgery, and cosmetic surgery; general plastic surgeons still have a ways to go before the public trust in this specialty is truly deserved. Unfortunately readers of Mr. Johnson’s article were left unenlightened about these issues.

Sincerely,

Kenneth D. Steinsapir, M.D., Los Angeles, Ca.

Associate Clinical Professor

Division of Orbital and Ophthalmic Plastic Surgery

Jules Stein Eye Institute

David Geffen School of Medicine at UCLA

Treating Syringomas

Syringomas are difficult to permanently remove because they originate from the deep dermis level of the skin.  The most common forms of removal include shaving, chemical peel, electrocautery, and lasers.  All of these methods are intended to superficially flatten the bumps caused by syringomas.  These treatments often have to be repeated regularly.  Smaller growths are easier to remove using these methods.  Although this is not a long-term solution, it carries less risk of scarring, permanent tissue damage, and slow-healing.

Deep Dermis Treatment

In order to completely remove syringomas, the treatment needs to penetrate the deep dermis under and around your eyes.  There are many different opinions among physicians about which method is the most effective.  Some physicians use CO2 lasers, while others prefer the deeper laser resurfacing of a Fractional CO2 laser.   Likewise, deep electrocautery may also effectively remove the lumps, however, all of these methods carry a risk of scarring.  Even after the syringomas are removed from the deep dermis level they can still return.  The overgrowth of eccrine sweat glands is not related to any external causes, but is a genetic trait that can’t be treated with skin creams.

Factors for Successful Removal

Smaller syringomas are easier to remove so the earlier you address the problem the better results your doctor can achieve.  Although the bumps can always be removed using chemical peels or shaving, there is a substantial risk of scarring.  Electrocautery and CO2 lasers can damage the delicate tissue around your eye and the deeper the penetration, the more damage can be done.  Removing syringomas requires a skilled hand and experience with lower eyelids.  Dr. Steinsapir utilizes his advanced understands the structure of the lower lid and skin healing to minimize skin damage that can be associated with the treatment of the syringoma.  Generally he will recommend removing one or two syringomas to learn how your skin responds before performing a larger scale treatment.

About Dr. Steinsapir

Dr. Steinsapir is a board certified eye surgeon and fellowship-trained in oculoplastic surgery and cosmetic surgery in Los Angeles where he specializes in balanced facial cosmetic surgery for natural results, with an emphasis on minimally invasive techniques, fast recovery time, and leadership in medical technology.  Dr. Steinsapir has a private practice and also serves as an Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, at the David Geffen School of Medicine at UCLA.  Contact us today to learn how Dr. Steinsapir’s experience and training make him an expert in cosmetic surgery, which can be a vital part of your evidence-based treatment plan.

Services described may be “off-label” and lack FDA approval. This article is informational and does not constitute an advertisement for off-label treatment. No services should be provided without a good faith examination by a licensed physician and an informed consent with a discussion of risks, benefits, alternatives, and the likelihood of treatment success. Only you and your treating physician or surgeon can determine if a treatment is right for you.

Removing old implants

Since the 1990s, implants have evolved to a more anatomic shape.  Most implant-related issues are the result of oversized implants or implants that have settled in less than ideal fashion.  Ill-fitting implants may require surgical removal, replacement, or both.  Implant placement can be associated with motor nerve damage to the muscles of facial expression or can compromise the appearance of the lower eyelid.  Sometimes post-surgical changes associated eyelid surgery may need to be revised at the same time the cheek implant is removed.  As many of these situations have unique characteristics, Dr. Steinsapir prefers hand-carving a custom ePTFE implant to replace the old implant.

Revising the Submalar Implant

A submalar implant, which sits low on the cheek is a newer type of cheek implant.  While this submalar volume positioned at a low level may have appeared complementary at the time of the surgery, some find that this implant begins to look objectionable as the face ages.  Occasionally this problem is made worse because the original surgeon chose the wrong size of implant, or because the implant may not have settled correctly after surgery.  In these circumstances, the best approach is to remove the original implant, and then replace the volume deficiency with a hand-carved custom orbital rim implant in conjunction with a vertical midface lift.

Other methods have also been described to address midface deficits. Cheek implants represent a classic approach to midface deficiencies. The implant is notched to accommodate the inferior orbital neurovascular bundle. More recently, a porous polyethylene implant has been introduced on the market to accomplish the same augmentation.  However, these techniques provided only a modest improvement in the nasojugal groove and importantly it removes volume from the lower eyelid.

Choosing a physician

Because your current surgeon is not addressing your discontent to your satisfaction, it may be best for you to find a new surgeon to perform the adjustments to your cheek implants.  When looking for a physician, make sure to choose someone who listens to your concerns and someone who is willing to work with you to find a solution that works with your face, your situation, and helps you to find a satisfactory conclusion.

About Dr. Steinsapir

Dr. Steinsapir is a much sought after oculofacial cosmetic surgeon.  He is an innovator in minimally invasive cosmetic procedures and has invented new methods for treating with BOTOX, Fillers and cutting edge facial surgery.  He specializes in high precision eyelid surgery and is a leader in correcting prior facial and eyelid surgery.  He attended medical school at the UCLA and completed ophthalmology residency at The University of Chicago.  He is multiple fellowship trained including three years of fellowship training in oculofacial plastic surgery at UCLA, and a two year cosmetic surgery fellowship in Rancho Mirage.  He is widely published and lectures to other surgeons nationally and internationally.  He is an associate clinical professor of Ophthalmic Plastic and Reconstructive Surgery at the Jules Stein Eye Institute at UCLA.  His private practice is located in West Los Angeles, immediately serving the Los Angeles and Beverly Hills communities.  Additionally, individuals from all over the country and the world regularly come to Los Angeles for this expert care  Please contact us today to learn more about how Dr. Steinsapir can help you attain your aesthetic goals.

The perils of liquid silicone

Receiving silicone oil injections in Mexico ( or in the United States at “pumping parties” or from unscrupulous injectors) is a dangerous decision for several reasons.  Non-medical injectors are known to use liquid silicone illegally on the black market.  Although medical professionals using liquid silicone in an off-label fashion use medical grade material, on the black market the silicone is often not medical grade but rather industrial silicone oil, which was never intended for the human body.  There have been deaths from these types of illegal treatments.

Technically, since physicians may use FDA-approved products for non-approved uses, you can legally receive silicone oil treatments as a facial filler; but that doesn’t make it a good idea.  Injecting silicone oil into the face and other parts of the body like the buttocks is not a case of careful and thoughtful use.  It violates the very oath that every doctor takes to do no harm.  Unfortunately a few non-physicians and even physicians continue to use silicone oils this way.

Deaths related to silicone oil injections have been reported. Even small facial treatments into the lip and nasolabial fold over time can result permanent and irreparable facial disfigurement.

Don’t be fooled by the price

When it comes to financing cosmetic procedures, here is the bottom line: if you can’t afford safe, quality treatment from an actual physician (not an assistant, technician, traveling person with unspecified qualifications, the black market, or your own hand), then you are better off without any treatment.  Silicone oil injections have too many associated complications, including migration and permanent disfigurement

Instead of automatically assuming you cannot afford legitimate, trustworthy, FDA-approved fillers, consult a bona-fide, fellowship trained cosmetic surgeon to learn about the cost and payment options for a safe, dependable filler.  Silicone oil injections are cheap for a reason.  Anyone who tells you they are a good cosmetic option is misleading you and omitting the facts.

Fixing facial fillers

Unfortunately, silicone oil is a poor alternative to real hyaluronic acid fillers like Restylane® or Perlane® because it cannot easily be modified after the treatment.  The first step in addressing and removing unwanted silicone is to identify the exact source of the injected silicone.

• Was it medical grade or industrial silicone oil?
• What is the lot number and expiration date?
• Where was it manufactured?
• Did the injector take precautions and use sterile technique?

Removing silicone is difficult, which is why Dr. Steinsapir believes that it should not be used as a filler material.  Once you have identified the above information, the next step is to decide if surgery or some other approach is needed.  Silicone oil is permanent and can’t be dissolved so removing it may require invasive surgery.  The type and extent of your surgery will depend heavily on the location of the original injections, the type of silicone used, and the amount.  The benefit of removing the material must be weighed against the potential complications that might be caused by surgery.

It is important to choose an experienced and knowledgeable surgeon to perform your surgery.  Find someone you can trust and who will work with you to find a treatment plan that works for you and your individual situation.  Unfortunately, a decision to receive silicone oil in Mexico, or any other black market injector often results in a greater expense in order to have the foreseeable complications addressed.   In too many cases, there are no good options.  Dr. Steinsapir strongly encourages anyone considering a black market cosmetic treatment of any kind to take into account the fact that while the initial treatment may be less expensive than a proper visit to a cosmetic surgeon and paying full price for your procedure, the long-term costs of a decision like this far out-weigh the short-term savings.

About Dr. Steinsapir

Dr. Steinsapir is a much sought after oculofacial surgeon.  He is an innovator in minimally invasive cosmetic and reconstructive procedures and has invented new methods for treating with BOTOX, Fillers and cutting edge reconstructive eyelid and midface surgery.  He specializes in high precision eyelid surgery and is a leader in correcting prior facial and eyelid surgery, including multiple revised cosmetic eyelid reconstructions.  He attended medical school at the UCLA and completed ophthalmology residency at The University of Chicago.  He is multiple fellowship trained including three years of fellowship training in oculofacial plastic surgery at UCLA, and a two-year cosmetic surgery fellowship in Rancho Mirage.  He is widely published and lectures to other surgeons nationally and internationally.  He is an associate clinical professor of Ophthalmic Plastic and Reconstructive Surgery at the Jules Stein Eye Institute at UCLA.  His private practice is located in West Los Angeles, immediately serving the Los Angeles and Bevery Hills communities.  Additionally, individuals from all over the country and the world regularly come to Los Angeles for his expert care.

To learn more about Dr. Steinsapir’s specialized Restylane treatments, please contact us today.

Services described may be “off-label” and lack FDA approval. This article is informational and does not constitute an advertisement for off-label treatment. No services should be provided without a good faith examination by a licensed physician and an informed consent with a discussion of risks, benefits, alternatives, and the likelihood of treatment success. Only you and your treating physician or surgeon can determine if a treatment is right for you.

Lips

Your lips are one of the first parts of your face to appear aged.  With a loss of volume and an increase of lines around the the mouth makeup has a tendency to exacerbate the problem by feathering.  Full soft lips are not just a sign of beauty, but also a sign of youth.  Fortunately, your lips are one of the simplest fixes without the need for surgery.  Fillers can provide a very natural solution to lips that are thin or losing volume.

With so many fillers available on the market today – Restylane®, Radiesse, Perlane, Juvederm, Artefill, Sculptra, Matridex, and even silicone oil – it can be easy to feel overwhelmed by the options.  However, not all of these fillers should be used as lip fillers under normal circumstances.  Hyaluronic acid fillers like Restylane, Juvederm, and Perlane are much more suitable for lip augmentation than permanent and semi-permanent fillers.  This is because they are much more forgiving, do not tend to lump, and can be simply and easily adjusted with the enzyme hyaluronidase.

Dr. Steinsapir prefers the use of Restylane as the best filler for lip volume deficiencies.  This is because the lips are very sensitive and irregularities can arise.  Fortunately, Restylane doesn’t tend to form bumps, and an experienced physician specialist can skillfully place Restylane for natural looks and long-term benefits.

Under Eye Fill

Dark circles under your eyes, or even a hollowness above your cheekbones is easily improved using a similar method as with the lips.  Dr. Steinsapir also prefers Restylane to reduce the appearance of dark circles because it can be easily adjusted.  Despite what the old wives tales say about dark circles and getting enough rest, persistent dark circles are actually the result of your lower eyelid muscle showing through the delicate and thin skin of your lower lid area.  When there is no subcutaneous fat between the skin and the muscle, the area appears dark and sunken.

The treatment requires a skillful hand but once placed and adjusted, the treatment is completely natural and can’t be detected by others. No wonder this has become the most popular eye dark circles treatment.

It is critical that the injecting physician assess how you do after the treatment because a certain percentage of treatments require an adjustment.  Dr. Steinsapir explains that everyone holds a slightly different amount of water in the tissues and small areas of fullness can spoil an otherwise great result.  For this reason, he encourages his patients to follow up about a week after treatment to assess how the service has settled.

Microdroplet BOTOX® and Dysport®

Of course, forehead wrinkles and brow lines are considered unfeminine, even among the older generations of stars like Diane Keaton, Susan Sarandon, and Jane Fonda.  Despite all of these women being over 60, all their photographs show them with smooth foreheads and full cheeks despite their features showing other signs of aging.  Maintaining a youthful appearance is a large part of looking feminine because it’s these features in women that are signs of femininity.

Unlike standard treatment methods, Microdroplet™ BOTOX® and Dysport create brow lift without forehead paralysis.  Microdroplet™ BOTOX® works with greater precision with your facial muscles.  The care and interest Dr. Steinsapir has shown in inventing this treatment demonstrates his dedication to achieving a beautiful, more youthful appearance without impeding the ability to express emotion.

Standard injection methods tend to freeze the forehead.  The forehead can’t move and the eyebrows drop like stones.  What looks good is a gently lifted eyebrow, no crows feet lines or brow pinch, and a forehead with reduced lines that is still able to move.  Imagine a BOTOX® or Dysport® treatment that allows you to have natural expressions!

Chemical Peel

Flawless skin has always been the ideal for beauty and as we all age, men and women alike, our skin develops flaws and spots that may not have been there when we were young.  But cosmetic products are not marketed to men so there is even more pressure on women to maintain clear, beautiful skin.

There are many types of chemical peels available and they treat many types of concerns, so it can be difficult to figure out which chemical peel is right for you.  But the chemical peel is truly an art form with versatile abilities depending on your needs, so it’s vital to understand that for a successful face peel with profound results, you’ll need an expert in performing facial peels who has extensive treatment experience and understands how to combine science and aesthetic planning for the best results possible.

Chemical peels can effectively treat facial concerns like aging skin, fine wrinkles, dark spots, acne, creases, loss of elasticity in the skin, and other concerns.  This frequently makes the chemical peel an excellent alternative to surgery that removes excess skin for the lower eyelid.  A chemical peel in the eyelid region is a minimally invasive procedure that preserves your natural features while rejuvenating your appearance.

Pigmentation is always an important consideration to any chemical peel.  The range in skin colors and complexions is complex, so this is something to consider with your doctor on an individual basis.  Fortunately there are many people who can and do benefit from chemical peels.  Your doctor can tell you more about skin-types as classified by the Fitzpatrick scale, and let you know what that means for you and your candidacy for a chemical peel.  A chemical peel can also help improve concerns with irregular pigmentation.

About Dr. Steinsapir

Dr. Steinsapir is a board certified eye surgeon and fellowship-trained in oculoplastic surgery and cosmetic surgery in Los Angeles where he specializes in balanced facial cosmetic surgery for natural results, with an emphasis on minimally invasive techniques, fast recovery time, and leadership in medical technology. Dr. Steinsapir has a private practice and also serves as an Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, at the David Geffen School of Medicine at UCLA. Contact us today to learn how Dr. Steinsapir’s experience and training make him an expert in cosmetic surgery, which can be a vital part of your evidence-based treatment plan.

Services described may be “off-label” and lack FDA approval. This article is informational and does not constitute an advertisement for off-label treatment. No services should be provided without a good faith examination by a licensed physician and an informed consent with a discussion of risks, benefits, alternatives, and the likelihood of treatment success. Only you and your treating physician or surgeon can determine if a treatment is right for you.

Many people travel from across the United States as well as internationally to have surgery with Dr. Steinsapir.  He is world-renowned for his leadership in facial cosmetic surgery.  If you are considering traveling to have reconstructive surgery or other cosmetic treatment with Dr. Steinsapir, here are some important considerations that will help you have the best experience possible.

Consult First

Many people who travel for cosmetic treatment feel they should be able to have surgery at the time of their initial consultation.  They want to take care of everything in just one trip, so they may fly or make a long drive to Los Angeles, have their consultation, and have surgery all during the same trip.  This idea may seem appealing because you only have to book a flight and pack your suitcase once, and you may even save a little money—but please reconsider this approach.  Dr. Steinsapir doesn’t believe in performing an initial consultation and surgery at the same time.  Even if you save a few dollars in airfare, in the end this amounts to hasty and high-pressure decisions.  Your choice to move forward in having surgery with the right doctor is important, and it’s not a good idea to cut corners here.

Reconstructive surgery should be something you and your surgeon approach calmly, thoughtfully, and with confidence.  Instead of too much pressure, Dr. Steinsapir strongly advises and encourages you to take the time to make sure you have found the right doctor and right treatment approach.  He wants you to have time to think about the options and be completely comfortable with the proposed surgical plan.

Take Time to Reflect

Consulting now and having surgery later is a sound approach for anyone seeking the right cosmetic treatment with any doctor.  Although admittedly not convenient, slowing down, thinking about your choices and being fully comfortable ensures that you can make a fully informed choice without the pressure of time.  When you consult with Dr. Steinsapir, he won’t pressure you into committing to surgery.  It is better for everyone if you have the opportunity to meet with the surgeon, then have time to think about the issues discussed well before undergoing reconstructive surgery.

Make Thoughtful Decisions

Even if you’re traveling from very far, Dr. Steinsapir will not perform surgery at the time of your initial consultation.  The best surgery is always performed with the utmost of care, consideration, research, and planning.  You should go into surgery comfortable and confident that you have made the right decision.

About Dr. Steinsapir

Dr. Steinsapir is on active staff at the UCLA Hospital and Medical Center at the David Geffen School of Medicine as an associate clinical professor of Ophthalmology in the Division of Orbital and Ophthalmic Plastic Surgery. UCLA is consistently rated the best hospital in the West and ranked third among all medical centers in the United States. Many surgeries are performed on an outpatient basis at the Surgery Center at the UCLA Medical Center. Larger procedures may also be performed on an inpatient basis at the Jules Stein Eye Institute. Dr. Steinsapir addresses a broad array of oculofacial reconstructive concerns.  Contact us today to schedule a consultation, followed by a brief consideration of the more common reconstructive issues that bring people to see Dr. Steinsapir.

It seems that television programming be it a local news shows or programs like The Doctors have no capacity to independently assess the validity of the science upon which these devices are often promoted.  This is unfortunate because it seems Television and Cable shows are just as uncritically attracted to big, expensive, shiny aesthetic procedure devices as the surgeons are.  It is not well understood that the Federal Drug Administration does not apply the same level of scrutiny to the clearance of medical devices as they do to the approval of a new drug.  There are different levels of device clearance and they are often subject to subsequent review based on clinical experience once the device is released.

This means that for medical devices released to the market, it can be a bit of buyer-beware (Caveat Emptor).  The Zerona laser (Erchonia Corporation, McKinney, TX) is an excellent example of this marketing phenomenon.  A promotional mailer sent by the company, which is intended for physicians to encourage them to buy the device, makes a number of scientific-sounding claims.  Let’s look through the claims that are made in this advertising brochure.  On the cover of this 4 page piece is the claim: “The first FDA-approved non-invasive body contouring procedure to effectively remove excess fat.”  Inside the brochure in large bold print is the claim: “Zerona, the most researched medical procedure on the market.”  What follows is a series of claims regarding the validity of the science behind the procedure.  For ease in keeping track of these claims, I will number these:

1. Studies prove that Zerona’s low level laser energy promotes the release of stored lipids and fatty material through the creation of a transitory pore within adipocyte membranes.
2. After low level laser treatment, stored lipids and fatty material enter the interstitial space where the lymphatic system is readily capable of removing the fatty debris.
3. Histological evidence shows that the clinical outcome of the Zerona laser is achieved without inducing adipocyte death.
4. The adipocyte is an important endocrine organ that is responsible for the synthesis of bioactive peptides which participate in autocrine, paracrine, and endocrine pathways.
5.  The FDA granted market clearance following the completion of  a Level 1 clinical investigation evaluating sixty-seven participants.  The results obtained from this double blind, randomized, multi-site and placebo-controlled study was absent of diet restrictions, exercise component, or any other adjunctive components in order to properly illustrate the clinical efficacy of the Zerona laser and set the precedent on other aesthetic devices should be evaluated.
6. The results proved Zerona is a safe and effective way to remove fat from the hips waist and thighs.  Test patients lost an average of 3.64 inches of fat combined from their waist, hips and thighs, whereas placebo patients only lost an average of half of an inch.  Statistical Significance of p<0.0001.

To assess the validity of these claims, we will look to the medical literature and assess the underlying papers that support or refute these claims.

The first claim is that the Zerona laser is the “The first FDA approved non-invasive body contouring procedure to effectively remove excess fat.”  Keep this claim in mind and after you have read this review, asks yourself if you think this claim is valid.  The issue is whether the company that manufactures the Zerona laser has in fact shown that its device effectively removes excess fat.

The next claim is that “Zerona, the most researched medical procedure on the market.”  Really, the most researched medical procedure on the market?  As they say, this one does not pass the sniff test.  The National Library of Medicine maintains the most extensive online library of peer reviewed medical papers. A search on the medical procedure coronary artery bypass graft performed to restore the blood circulation to the heart reveals 51,213 published papers.  A search on laparoscopic cholecystectomy or laproscopic gallbladder surgery finds 11,173.  A search on the procedure tonsillectomy finds 8,459 published research papers.  Looking at elective surgery, a search on the procedure facial laser resurfacing reveals 4,695 paper, facelift 2,340 papers, liposuction 3,146, Lasik 4,191,  BOTOX 1,136 papers, Restylane 183 papers.  However, this database contains zero papers on the Zerona laser.  The statement: “Zerona, the most researched medical procedure on the market” is not remotely factual.

The company in its promotional literature cites 4 published studies on the Zerona laser.  We will consider each of these studies:

1.  Jackson RF, Dedo DD, Roche GC, Turok DI , Maloney RJ.  Low-Level Laser Therapy as a Non-Invasive Approach for Body Contouring: A Randomized, Controlled Study

Lasers in Surgery and Medicine 41:799–809 (2009)

These authors investigated the use of low-level laser irradiation directed at the skin as a means of performing non-invasive body contouring of the waist, hips, and thighs.  The authors state that their study was structured as a double-blind, randomized, placebo-controlled trial.  The study included 67 volunteers.  Subjects were randomized to low-level laser treatments three times per week for two weeks or a matching sham treatment.  Measurements of the waist, hip and thighs was used as the treatment end point by comparing these measurements prior to treatment with those made at the end of the two week treatment period.  The authors claimed that compared to controls, treatment patients showed a combined reduction of 3.51 inches, which was statistically significant compared to the control patients.  The authors conclude that low-level laser was effective as a method of non-invasively contouring the body.  The big problem with this study is it is not a double blind study.  Double blind studies are studies where neither the subject nor the investigator know who is actually receiving treatment.  This prevents the introduction of bias.  However, this is not how this study was designed.  The investigators who performed the treatments knew which device was actually a low-level laser and which device was the sham device.  This means that investigators in some subtle way could have communicated their knowledge of which treatment the subject received.  It is not hard to imagine that this could easily introduce study bias.  Patients who have received encouragement of the likely success of their treatment might be more compliant with their usual diet and exercise during the course of treatment.  In contrast, patients who consistently receive negative reinforcement from the investigator during the course of their treatment might not be as consistent with their usual diet and exercise program.  This study flaw most likely accounts for any actual difference between the two groups.

Another issue with the study is the possibility of post-hoc data analysis.  This generally means looking at the data after the study and finding the best way to present the data.  The authors indicate that the overall success criterion determined by the FDA was a treatment difference of 35%.  This equated to a combined circumference measurement reduction of 3.0 inches.  It is interesting that this study exactly met this criterion.  It is worth noting that the investigators knew which subjects were treated with the actual or the sham devices and these were the same investigators who also took the measurements.  It is of concern that of 67 subjects, 8 subjects did not have circumference measurements recorded at the 2-week post-procedure measurements.  Precisely half of these individuals had sham treatment and half had actual treatment.  To handle this, the authors made up (fabricated) the data using the Last Observation Carried Forward method.  This method is used to handle statistical analysis when patients drop out of a study.  However, the absence of the data on these 8 patients is not the result of patient drop out, but, rather, investigator omission.  Why might the investigator omit recoding this data even though this is the primary study endpoint?  This is the effect of bias.  There might be other explanations, however, it is likely that these investigators, knowing who was and was not treated by the actual device, recognized that the circumference measured on the final visit was inconsistent with the conclusions they anticipated.  Failure to record this data may have been intentional or unintentional.  In either case, this omission is highly damaging to the integrity of the study.

Under these circumstances, Last Observer Carried Forward method is not appropriate.  At a minimum, the authors should have presented the analysis omitting these subjects.  It would be essential to know that the statistical conclusions of these authors are supported by the data when these subjects are excluded.  Even then the study is questionable because of the possibility of data manipulation.  Because these authors failed to inform the readers of the effects of such an analysis, it can be concluded that excluding the subjects with omitted data substantially weakens the conclusions of the study.  At the very least, the authors have subjected their data to post-hoc analysis, which is considered data manipulation that undermines study integrity.  Given this weakness, and the fact that the study was not properly designed with double blind controls, the conclusions of this study should be considered unsubstantiated and unreliable.  This study should not have been used as a basis for granting FDA clearance for the device.

2.  Neira R, Jackson R, Dedo D, Ortiz CL, Arroyave JA. Low-level laser-assisted lipoplasty appearance of fat demonstrated by MRI on abdominal tissue.  American J Cosmetic Surgery. 2001:18:133-140.

This is a study of 3 patients who had serial MRI before any treatment, after infiltration with tumescent anesthetic solution, and then after exposure to 4 and 6 minutes of Low-Level Laser (Electric diode 635nm laser).   Following this the patients underwent liposuction.     The study implies that each patient was subject to liposuction.  The authors then analyzed the T1 weighted and T2 weight MRI images to conclude that low level laser energy applied to the outside of the body “liquefies fat by causing it to escape from inside the cell to outside (interstitial space).”  Unfortunately authors make no effort to substantiate the changes in the MRI they claim exists.  Looking at the images in the study, exposure of the abdomen to low-level laser treatment does not appear to make any differences the MRI images presented despite the author’s statements to the contrary.  The authors fail to present any quantitative data to support their conclusions.  The paper contains three scanning electron micrographs that the authors claim represent the tissue effects of the low level laser on adipose tissue.  However, the authors do not explain how these images relate to their study.  In fact no mention is made of subjecting the harvested fat to scanning electron microscopy and the material and methods section do not explain how these specimens were obtained.  For this reason there is no logical connection between the presented scanning electron micrographs that illustrate this study and the study itself.  These images appear to be very similar to images from the Neira, et. al. 2002 study.

3.  Reduction in cholesterol and triglyceride serum levels following low-level laser irradiation: A noncontrolled, nonrandomized pilot study.  American J Cosmetic Surgery. 2010; 27: 177-184.

The authors hypothesize that low-level laser irradiation (shining the laser on the skin) may suppress serum cholesterol and triglycerides by altering gene expression and inducing cellular adipocyte modifications.  The authors claim that laser-induced alteration of cholesterol biosynthesis may play a vital role in the suppression of cholesterologenesis, the name for synthesis of cholesterol in the body.  The authors make the claim this treatment could be used to lower serum cholesterol.  The study included 19 patients between the age of 18 and 65 who were seen by the authors for liposuction.  Prior to laser treatment, blood work was obtained to assess serum lipids.  The subjects were treated with the Zerona laser for a total of 6 treatments over a 2 consecutive weeks (3 procedures per week each 2 days apart).  The serum lipid levels were then rechecked after the course of treatment.  The authors concluded that 84% of the study participants had a reduction of their serum cholesterol and this reduction was statistically significant.  Unfortunately, as the authors indicate in the title of this paper, this is a uncontrolled and nonrandomized study.  The series is not even a consecutive series.  This means that we have no idea how these individuals came to be included in the study.  For all we know, the individuals could have been included because their cholesterol was lower after the study.  The authors attribute the decline in cholesterol to the low-level laser treatment.

Assuming that the authors did not cherry pick their data and this decline in cholesterol is real, is there any more likely explanation other than low-level laser?  The answer is placebo effect.  The placebo effect is the result the belief in a sham treatment.  The patient’s in this study presented to the authors for liposuction.  While the authors do not tell us what they told these individuals, presumable they were advised that the low level laser was an alternative to the liposuction procedure there were seeking.  Believing in the effectiveness of the treatments might very well prompt these individuals to eat less and exercise more during the course of the treatment.  The effect of this could more likely account for the noted change in cholesterol.  It is interesting that these authors included very little information about the study participants such as their weights before and after the course of treatment.   It is well known that even short-term weight reduction is associated with decreases in total cholesterol and serum light density lipid. These weaknesses make it difficult to place much stock in the conclusions drawn by these authors.

4.  Neira R, Arroyave J, Ramirez H, Ortiz CL, Solarte E, Sequeda F, and Gutierrex MI. Fat Liquefaction: Effect of Low-Level Laser Energy on Adipose Tissue. Plast. Reconstr. Surg. 110:912-922, 2002

These investigators examined the effect of low-level laser energy in 12 patients who were exposed to 635-nm, 10-mW diode laser radiation for 0, 2, 4, and 6 minutes with and without tumescent liposuction.  The authors claim that the adipose tissue was externally irradiated through the skin.  Following this, superficial and deep fat samples were taken from the infraumbilical area.  The authors then report in their methods section that fat samples extracted with out tumescent technique were also taken and irradiated after being harvested.  The fat was then examined by scanning and transmission electron microscopy.  The authors then describe the appearance of the adipose tissue according the the time of exposure.  They observe that the specimens subject to tumescent solution and zero minutes of low level laser appear intact.  After 4 minutes of exposure, the authors report partial adipocyte break down.  After 6 minutes of exposure, “fat was completely removed from the cells and remained in the interstitial space.  Comparing the fat that received tumescent anesthesia with fat that did not have this treatment, the authors conclude that the tumescent solution enhances the effect of low-level laser treatment.  Analyzing the transmission electron micrographs, the authors conclude that laser exposure for 6 minutes: “ the (adipocyte) membrane is temporarily disrupted, creating a transitory pore that allows the liquefied fat to come out of the cell and be released into the interstitial space.”  The authors did not report the difference between the superficial and deep fat specimens.  Also the authors state that the low-level laser creates a transitory pore through which fat leaks out of the cell.  However they do not in fact present evidence of this mechanism, which must be considered an unsubstantiated conjecture.

One of the measures of the validity of a scientific work is reproducibility.  Not all scientific work has been taken up by other laboratories to validate a given set of experiments.  This is not the case here.  Investigators Brown, Rohrich, Kenkel, and Young, et. al. (Brown SA, Rohrich RJ, Kenkel J, Young L, Hoopman J, and Coimbra M. Effect of Low-Level Laser Therapy on Abdominal Adipocytes before Lipoplasty Procedures. Plast. Reconstr Surg. 2004; 113:1796-1804.) examined the validity of  the study performed by Neira and colleagues, described above.  Brown and co-workers took several approaches to investigate these claims.  They used a low-level 635-nm laser to directly treatment cultured human preadipocytes for 60 minutes, a far longer and more intense exposure than that used by Neira and co-workers.  Yet scanning electron microscopy did not detect a change in appearance between these irradiated cells and the non-treated control cell.  The authors also studied a porcine model to compare lipoaspriates after exposure to low-level laser for 30 minutes with traditional liposuction, and ultrasound-assisted liposuction.  Again, the tissue specimens were examined with light microscopy and scanning electron microscopy.  Porcine skin exposure times to low-level laser prior to liposuction were 0, 15, 30, and 60 minutes with and without liposuction wetting solution.  There were no differences in the appearance of the fat cells seen between the low-level laser specimens and standard liposuction with no exposure to low-level laser.  Finally the authors studies three humans undergoing liposuction.  Two patients had areas that were being aspirated as part of a planned liposuction exposed to low level laser prior to aspiration.  No structural differences were detected in the human fat when comparing the areas irradiated with low-level laser and those areas that were not irradiated.  These authors concluded exposure to low-level laser had no effect on the adipocytes.  These authors found no support for the study of Neira and could not reproduce their work.

In Part 2, we will look at how this faulty data undermines the claims by the manufacture regarding the Zerona laser.

Consider the impact of surgery

While television programs are full of stories about how plastic surgery transformed the lives of the patients, these grand results are much less common than the TV might lead you to believe. An improved upper eyelid won’t suddenly transform your life by helping you to get a better job, end conflict with your spouse, or make you an instant celebrity.  A realistic goal is that you will be pleased with the improvement and happy that you had surgery.  However, it is unrealistic to expect the surgery will help you land that promotion and help you pay off the cost of surgery. Don’t opt for surgery if it is a choice between basic necessities and having surgery.  Paying rent and health insurance is more important than elective cosmetic surgery.  These are personal choices, but cosmetic surgery is a luxury and not a necessity.  Make sure you aren’t over committing yourself financially in deciding to have surgery.

Consider your motivations

Before deciding to undergo cosmetic surgery, ask yourself “why.”  The first step to understanding if you are ready for surgery is to understand your motivations.  Do you want surgery to please yourself, or to please someone else?  There is no right answer, but if you want surgery to please someone else, ask yourself if the surgical outcomes are something you also want.  Do you find yourself preoccupied with thoughts of a particular surgery?  Do you avoid social situations because you are concerned that people are staring or whispering about you?  Do you spend hours every day repeatedly thinking about an issue that your friends have trouble seeing?  These may be signs of a condition called body dysmorphic disorder.  Body dysmorphic disorder is an obsessive thought pattern characterized by focusing on a slight or nonexistant flaw. Unfortunately, it is difficult to fix subtle or nonexistent issues surgically.  Occasionally this leads to a flat out misunderstanding between surgeon and patient, and even more trouble after surgery.  Dr. Steinsapir find that it is best to air these issues openly and if necessary involve a psychotherapist to help the individual better understand their motivation to have surgery.

Consider your support system

One last series of questions you should ask yourself is about support from family and friends.  Are others around you supportive of you having cosmetic surgery?  Keep in mind that a negative environment can be harmful to your healing process following surgery.  It is so important to make sure those you love are supportive of your decision before you undergo cosmetic surgery.  Don’t try to hide the fact that you are undergoing cosmetic surgery; be open about your plans and find support from those around you.

About Dr. Steinsapir

Dr. Steinsapir is a board certified ophthalmologist and fellowship-trained in oculoplastic surgery and cosmetic surgery in Los Angeles where he specializes in balanced facial cosmetic surgery for natural results, with an emphasis on minimally invasive techniques, fast recovery time, and leadership in medical technology.  Dr. Steinsapir has a private practice and also serves as an Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, at the David Geffen School of Medicine at UCLA.  Contact us today to learn how Dr. Steinsapir’s experience and training make him an expert provider of cosmetic surgery.

Reality vs. Reality Television

When it comes to cosmetic surgery reality shows, the term “reality” becomes a very loose term.  These programs have ridden (some would say helped to stimulate) the wave of interest in cosmetic surgery, yet they provide only a very distorted view of the practice of cosmetic surgery. The consultation becomes a sound bite and in the process minimizes the risks and appropriate concerns that must be addressed.  So many procedures are performed on some of these shows at one time that the surgery becomes unnecessarily life threatening.  No one should be placed in a position of choosing between their beauty and their health.  Of course there are risks with any surgery and anesthesia.  However, these risks can be managed and reduced by using the most appropriate anesthesia, operating in the proper setting, and limiting the amount of surgery performed at a given time.

Choosing the right doctor

By playing on your desire for a “quick fix,” advertisers are reinforcing the misconception that cosmetic surgery is just another quick trip to the doctor’s office; like receiving a flu shot.  But just as a flu shot comes with risks, so too does cosmetic surgery.  Although there are risks with any surgeon and procedure, an expert surgeon will guide you through these risks helping you to make an informed decision.  Offices that gloss over these concerns are trying to take advantage of your lack of expert knowledge.  It is the job of the surgeon and their staff to educate you and help you make the right decision, not hustle you into having surgery.  At the end of the day it is essential that you trust your doctor.  It goes without saying that your doctor should make sense, listen to you, and treat you with respect and dignity.  The office staff should also listen to your concerns and treat you with respect. Don’t be intimidated by the doctor’s reputation.  That reputation is meaningless if the doctor doesn’t treat you like a human being.  Before and after pictures are also extremely important. This is generally a doctor’s best work. If you don’t like what you are seeing, it is a mistake to think your results with that particular doctor will be better than what you are being shown.

Consultation is key

Whether you decide to seek help from a clinic advertised on TV, or to take the recommendations of a friend or family member, it’s important to first attend a consultation with your chosen physician.  That consultation should also include meaningful time with the surgeon who will be doing your surgery.  If the surgeon is not detailed during your consultation, is it reasonable to assume they will be detailed in performing your surgery?  To get the most from a consultation, do your homework. Have a good idea of what you are trying to accomplish. Be open to an approach that is different from what you thought you needed.  Choose your surgeon based on his or her expertise, not based on media hype or discounts.  If you don’t like what you are being told, don’t try to convince the surgeon to do something they have just advised you to avoid.  Instead, consider seeking a second opinion to ensure your surgeon is giving you the options that he or she is most comfortable with and the safest possible plan-of-action.  The good news is that in most cities, there are lots of options for cosmetic surgery care. No one person has all the answers.  If all the other doctors you have seen recommend against a particular course, think long and hard about allowing that surgeon to perform your surgery.

About Dr. Steinsapir

Dr. Steinsapir is a board certified ophthalmologist and fellowship trained in oculoplastic surgery and cosmetic surgery in Los Angeles where he specializes in balanced facial cosmetic surgery for natural results, with an emphasis on minimally invasive techniques, fast recovery time, and leadership in medical technology.  Dr. Steinsapir has a private practice and also serves as an Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, at the David Geffen School of Medicine at UCLA.  Contact us today to learn how Dr. Steinsapir’s experience and training make him an expert provider of BOTOX, DYSPORT, Restylane and Perlane, and advanced eyelid and facial surgery, which can be a vital part of your evidence-based treatment plan.