Online Health Chat with Raymond Isakov, MD
October 2, 2013
From fillers to face lifts, plastic surgeons can help patients decide if and what type of facial cosmetic procedures may be right for them. The reasons for electing to have cosmetic surgery are varied, and can include aging, dissatisfaction with an aspect of your appearance, congenital defects and trauma. Cosmetic surgery can refresh your appearance and provide you with confidence.
Cosmetic surgery of the face usually produces pleasing results, and procedures are varied. Some techniques are minimally invasive, and are accomplished through non-surgical facial rejuvenation (such as Botox® [botulinum toxin] or other injectable fillers). However, some of these techniques do not produce long-lasting results compared to other procedures. Cosmetic procedures include eyebrow and forehead lifts, eyelid surgery, cosmetic nose surgery, cosmetic ear surgery, face or lip lifts, facial implants and chin surgery—to name a few. Various surgical techniques can be used to accomplish a goal, such as a face and neck lift, and depend on a surgeon’s preference and patient’s goal. (These can include short-scar facelifts and other minimally invasive facelift techniques.) Patients need to understand what kind of results to expect, and the risks and benefits of surgery.
Cosmetic facial procedures can help restore your youthful appearance and re-awaken your natural beauty.
About the Speaker
Raymond Isakov, MD is a plastic surgeon in Cleveland Clinic’s Dermatology & Plastic Surgery Institute, Cosmetic and Plastic Surgery Center. He is board certified in general surgery and plastic surgery, and specializes in plastic and reconstructive surgery. Dr. Isakov’s specialty interests are facial cosmetic surgery, including facelifts (rhytidectomy), eyebrow and neck lifts, cosmetic ear surgery (otoplasty), cosmetic nose reshaping (rhinoplasty) and non-surgical facial rejuvenation. Other cosmetic interests include lipoplasty, primary and reoperative aesthetic breast surgery, and body contouring procedures. He also specializes in the surgical treatment of melanoma and non-melanoma skin cancers. Additionally, he performs breast reconstruction following mastectomy and partial mastectomy.
Dr. Isakov completed a fellowship in aesthetic facial plastic surgery at Zeeba Clinic, in Lyndhurst. He completed his plastic surgery fellowship, general surgery residency and internship at Cleveland Clinic. He graduated from medical school from Chicago Medical School.
Dr. Isakov sees patients at Cleveland Clinic main campus and Twinsburg Family Health & Surgery Center.
Let’s Chat About ‘Love Your Face – Chat Cosmetic Facial Options with a Plastic Surgeon’
Moderator: Welcome to our chat "Love Your Face - Cosmetic Plastic Surgery" with Raymond Isakov, MD, Cleveland Clinic plastic surgeon. Dr. Isakov will answer your questions about cosmetic plastic surgery such as which procedures will give you lasting effects, what kind of results one can expect, and what are the risks of surgery.
Botox® and Injectables
iggie: I have heard that starting younger with Botox® (botulinum toxin) injections can produce a more natural result later on, and may prevent the need for a full facelift in the future. But aren't there side effects from using Botox® for too long—like several years?
Raymond_Isakov,_MD: This is an interesting question. I am seeing more younger patients coming in for Botox®. It works just as well, if not better, on a younger person who does not have very dense wrinkles. There is a theoretic benefit of not developing wrinkles in the future or needing a facelift as soon as a normal-aging person without Botox® treatment may, but there is no clinical evidence that that's the case. I have investigated the long-term use of Botox®, and there seems to only be evidence of difficulties in rare situations. Most of the time, once Botox® wears off, the muscles come back to normal and perform as if nothing has happened.
schaefer: At what age should women think about doing injectables, and at what age should they think about rhytidectomy?
Raymond_Isakov,_MD: Honestly, there is no set age. Most of this is due to the patient's individual desires and degree of facial aging. As stated before, we are seeing younger and younger patients coming in for Botox® and fillers. There is some evidence as well, that doing a facelift younger may last longer because you get better tissue quality at a younger age and at the time of the operation. In our demographic, doing facelifts on very young patients is rare. In other geographic areas, is not uncommon to do facelifts on 40-year-old patients. I do not believe that most patients who are in their 40s need a facelift. The ones who have significant issues which I feel can be treated appropriately I will address. It is a very personal decision as to whether or not a patient is ready for this fairly significant commitment. Again, everybody is so different that addressing their individual facial aging, anatomy, physiology and goals is very important.
san_drab: When do Botox® and fillers stop working and a facelift becomes necessary?
Raymond_Isakov,_MD: This is another good question. Sometimes, fillers never work in a patient who has significant depth of their wrinkles with poor elasticity of the skin. Sometimes though fillers are all you need. Botox® can be used even as the patient gets older with generally good effects. The fillers do have limitations. First of all, they do get reabsorbed completely in time. Usually filler’s effects last nine to 12 months in the nasolabial folds (deep wrinkles that lead from the sides of the nostrils to the mouth) and even less time around the mouth and lips. When the skin quality is poor enough that using multiple syringes is not enough to prop up the skin, I do not use fillers—as I feel this would be a waste of the patient's resources. Other than that, once patients stop getting the results they want, want something more permanent, are willing to and ready to undergo a facelift, and can afford, this is the time most patients go for facelift.
uglyshoes: Can having shingles (of the face) and prior psoriasis (not of the face) prevent someone from having either Botox®, injectables or a facelift?
Raymond_Isakov,_MD: Having shingles of the face can lead to significant pain issues. The history alone may not prevent one from getting a facelift, but certainly that virus could be reactivated. Patients who have cold sores, for example, are all treated with antivirals any time we do peels. Botox® most likely would not affect the shingles. It is unpredictable as to whether or not a facelift would reactivate the virus. Psoriasis, in and of itself, most likely is not a contraindication to facelift and certainly not Botox®.
Treatment for Acne Scarring
pavda: What is the best procedure to reduce acne scarring?
Raymond_Isakov,_MD: Acne scarring can be quite difficult. Patients who have had cystic acne that leave deep pockmarks certainly are a challenge. These can be quite distressing to the patients. Many techniques have attempted to address pockmark scars, but very few are tremendously successful. Treatments range from a deep peel, such as that achieved through dermabrasion or chemical or laser peel, all the way to facelift surgery. There are certain individual acne scars they can be treated with fillers. However, diffuse acne scarring is most likely treated the best combination of facelift and peeling. Unfortunately, sometimes it is trial-and-error to see what will work best.
Alternatives to Facelifts
JoyD: I had a neck lift seven years ago. I was happy with the immediate tightening of my jaw line. However, the past couple of years I have noticed the deepening folds around my mouth and nose that have continued to progress as I age. Also, I had Radiesse® injected into my chin last year, but the results were not as pronounced as I expected, so I haven't kept it up. What can I do short of a face lift?
Raymond_Isakov,_MD: A common question is how long will a facelift last. In truth, you will continue to age as soon as the facelift is complete, and your biology and your desires will dictate future treatment. Fillers are a good bridge to further treatment, but certainly have the limitations based on skin quality and how much wrinkling you have. The gold standard is certainly to redo the facelift. Short of this, peels may tighten the skin—more especially around the lips and mouth. Ulthera is a relatively new, noninvasive mechanism to tighten the skin. It is certainly not the gold standard and results can be variable, but recovery is minimal. For these noninvasive therapies, realistic expectations, just like any other cosmetic procedure are very important. Ulthera may be an option to tighten what was already done and even may be used to delay a facelift.
Cosmetic Surgery with Coexisting Medical Conditions
xJanL: Before cosmetic surgery is performed, does a patient need to be in any specific physical condition? Specifically, are there factors such as weight, diabetes (controlled) or hypertension considered before proceeding?
Raymond_Isakov,_MD: There is no question that every patient who undergoes any sort of cosmetic surgery should be physiologically fit enough to undergo that operation. Diabetes is not considered a reason to withhold medical treatment by itself, but may increase the complication rate due to health problems often associated with diabetes. Well-controlled diabetes is very important. High blood pressure needs to be well treated. This would be a risk factor for the anesthetic as well as postoperative bleeding. We certainly do have our patients evaluated by medical doctors and treated by our board-certified anesthesiologists. If the patient's weight is too high, not only may this increase the complication rate, it may also decrease the overall aesthetic improvement. This also has to be evaluated individually.
Jeremy40: I have epilepsy and am on medication. Is a face lift safe for me? Also, I have had filler injections many times, but the effects never lasted more than a month. I also had Sculptra® Aesthetic, which was like throwing money in the trash—it did not work at all. Is there any filler that has longer lasting results?
Raymond_Isakov,_MD: The question is most likely more complicated than could be addressed in this scenario. Ultimately, however, we do evaluate the patients very carefully for their coexisting medical conditions to make these operations as safe as possible. Epilepsy—in and of itself—is likely not a contraindication, so long as neurology and anesthesia teams are on board. Certain medications do need to be held off around the time of surgery and this may play a role. As for your fillers, it is possible that there are specific issues not anatomically appropriate for the fillers. If they're only lasting for a month, it is most likely that you had temporary swelling augmenting the filler and the filler itself was not enough. Similarly, I am not sure why Sculptra® did not work. A good physical examination, and review of her medications and comorbidities would be mandatory.
GRAMMYRUTH: What would the procedure be for removing bags from under the eyes? It tends to run in my family and is very unbecoming.
Raymond_Isakov,_MD: This is a common complaint. Baggy lower eyelids can be a complicated issue. Much of this is due to how much laxity the eyelids have. If the skin quality and eyelid tone is very good, sometimes just removing the fat from an incision inside the eyelid does a wonderful job. For patients whose eyelids are very slow to come back when pulled down, these patients need more work done with suspension of the lower lid. Often times I have found lower lid surgery is beneficial.
bouthie: I have drooping eyelids and forehead creasing in the area above my nose and on top of my eyebrows. My eye doctor tells me I should address this situation in the very near future. I am a 70-year-old man who is not vain, but I feel that the drooping is affecting my vision. I have seen celebrities that look rather— shall I say, unbecoming—following cosmetic surgery. Can you explain the advantages and disadvantages of a forehead and eyelid lift?
Raymond_Isakov,_MD: Your concerns are relatively common—especially in patients of your age. As we get older, the eyebrows definitely droop. This, in turn, pushes on the eyelids, which have also developed extra skin. The situation certainly can block the upper visual fields. Generally speaking, this is not necessarily treated as a cosmetic situation and may be covered by insurance, if we have very good documentation of your blocked out visual fields. A brow lift may be necessary to help the eyelid lift so it is not an unreasonable issue. How to perform that brow lift is more complicated due to various scar issues. Many of the celebrities that you refer to have had poor outcomes due to overaggressive and/or multiple operations. It is not likely that you would have such an issue especially from a functional operation.
Mini Facelifts and Lifestyle Lift
mariaelena: What can you tell me about ‘Lifestyle Lift’? What is done during the procedure? How long does it last? Is it similar to other facelifts? The patients that I see on television ads don't look as bad as some that have had standard facelifts.
Raymond_Isakov,_MD: Lifestyle Lift is a mass-marketed mini-type facelift. It is one of the more common facelifts performed in the United States, but it certainly has limitations. The problem with this technique is basically applying it to everybody. This is not something that most patients I see would benefit from. There are many ways to do a facelift, and a mini-facelift—like Lifestyle Lift—is beneficial to somebody with mild facial aging. Lifestyle Lift also addresses the neck in different manners. The results that are shown on television are most likely more than just a facelift, had multiple procedures, and are most often done by some of their better surgeons. The issue is more about applying the appropriate operation to the appropriate patient. In certain instances, less is not more.
hilo323: Is Lifestyle Lift a surgical procedure? You mean, it is not a face cream? The television commercial does not describe the procedure. They ask you to call a phone number.
Raymond_Isakov,_MD: My understanding of the Lifestyle Lift is that it is a type of mini facelift which has been taught to the participating doctors. It is a corporation. It is an invasive operation, and not a cream or topical treatment. As this corporation does not exactly detail their procedure, I cannot give you details.
graciousme: Are results from facelifts more natural than they used to be, i.e., lumpy skin and pulled back features?
Raymond_Isakov,_MD: I would like to say that in our practice, the answer to that question is yes. There are many different techniques of doing a facelift. Not all facelifts are equal. The traditional facelift done many years ago was to pull the skin very hard. With that accomplished was mostly very visible scars and a pulled down ear, but an improvement of the contour of the face. However, that did not last as long as it does now. We try to, in the modern facelift, suspend the deep tissues of the face and not rely on the skin to hold the lift. These techniques tends to give a much more natural appearance that seems to last longer, but doesn't give telltale signs of having a facelift.
val22: What is the recovery time for a full facelift? Can you get multiple facelifts in your life, and how many until it starts to look ‘unnatural’?
Raymond_Isakov,_MD: Again, the recovery time for a facelift is usually not as bad as patient's think. It is somewhat uncomfortable for a day or so. Patients usually do not feel like going out and about for approximately seven to 10 days, but can whenever they feel comfortable. Honestly, there is no set limitation on the number of facelifts that one can have in a lifetime. That being said, the patient that undergoes multiple procedures tends to look more unnatural. It is difficult to put a number on how many that is. Very few patients end up having a significant number of facelifts.
BEACHBABIES: What do you recommend for sagging jowls? How extensive is the surgery, what is recovery time like, and while recovering will people ‘know’? I have the same question for eyelids.
Raymond_Isakov,_MD: Sagging jowls are one of the biggest complaints that we see. This, however, is usually only a portion of the generalized facial aging. Some non-surgical rejuvenation can help in milder cases. Ulthera (more information can be found at www.ultherapy.com), peels and fillers may temporarily help the situation, but the jowls respond very well to facelift surgery. Recovery for a facelift is usually not as bad as most patients think. It matters on how many procedures we do, such as the brow and the eyelids. Usually eyelid surgery itself does not present a significant recovery, and usually does not add that much to facelift recovery. The brow, however, does increase swelling and bruising. Generally, the face is swollen and bruised for upwards of seven to 10 days. Patients can usually go out whenever they feel comfortable. We slowly increase activity. Postoperative discomfort is usually limited to a few days, which is mostly tightness or a burning feeling. As for if people will ‘know,’ if they see you within a few days of surgery the answer is most likely yes. That being said, most patients don't look too bad, but the vast majority stay away from social events for approximately seven to 10 days.
mhsraleigh: I am a 52-year-old male with a ‘turkey neck.’ Much of this is due to being overweight. I am five foot and seven inches tall and weigh 200 lbs. However, some of the cause seems clearly genetic based on my mother's side of the family. What options do I have for getting rid of this wattle? What are the costs, side effects and recovery time. If money falls from the sky, should I have it now or wait until a later date?
Raymond_Isakov,_MD: An unattractive neck is frustrating to many patients. The treatment is based on the problem. A neck that has severe problems needs much more work than for somebody who has a mild issue with his neck. Since you are only 52 years old, you may have good quality skin and an anterior type approach alone is possible. Mild necks with good skin may be treated with liposuction alone. Based on the skin quality and the deformity, surgery making an incision under the chin alone may help. A facelift is the best treatment as this affects not only the neck, but also the jowls. Some men do not care so much about the jowls and the upper face, but really hate the neck. For an older man, a direct excision of the ‘turkey neck’ is possible, which will leave a scar that is somewhat visible, but usually not terrible. For a younger person, I would not advise that. Generally speaking, a neck lift or full facelift that includes a neck lift would be the best treatment. However, I recommend you consult a plastic surgeon to advise you as to what the best course of treatment for you would be. You can learn more about these procedures, and see before and after pictures from our patients on our website.
Moderator: The hour has gone fast. I'm sorry to say that we are at the end of our chat. Thank you, Dr. Isakov, for taking the time to discuss facial cosmetic surgery with us. The questions were excellent and your responses were detailed and personal.
Raymond_Isakov,_MD: Thank you for your questions and time today.
To make an appointment with Dr. Isakov or any of the other Cleveland Clinic cosmetic plastic surgery specialists, please call 216.444.6900 or call toll-free at 800.223.2273, ext. 46900. You can also visit us online at clevelandclinic.org/renewyou.
For More Information
On Plastic Surgery
For more information about all cosmetic procedures, to schedule a consultation with one of our specialists and more, visit Cleveland Clinic Cosmetic & Plastic Surgery Center online at www.clevelandclinic.org/renewyou. A full listing of Cleveland Clinic specialists, locations and before and after images can also be viewed on the site.
If you're interested in a consultation but not ready to come into the office, we offer an online consultation option. You can submit pictures of the body part you have questions about, and our expert plastic surgeons will review and provide their consult through our secure online system.
Interested in fixes for droopy, baggy eyes, crow’s feet or wrinkles? Read ‘Tips For Younger Looking Eyes’ from Dr. Isakov on our Health Essentials blog.
On Cleveland Clinic
Cleveland Clinic’s Department of Plastic Surgery Cosmetic and Plastic Surgery Center provides expertise for both surgical and non-surgical cosmetic procedures ranging from body contouring to breast procedures to Botox® injections. The Center offers patients access to a range of cosmetic specialists including plastic surgeons, dermatologists, oculoplastic surgeons, head and neck surgeons, and aestheticians. Additionally, our surgeons are dedicated to improving patient outcomes through innovative cosmetic surgery advances including minimally invasive facelift techniques, alternatives to face and necklift surgery, short-scar facelifts, and Smartlipo technology™.
On Your Health
MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: firstname.lastname@example.org.
A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.
If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!
Some participants have asked about upcoming web chat topics. If you would like to suggest topics, please use our contact link clevelandclinic.org/webcontact.Reviewed: 10/13
This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2013. The Cleveland Clinic Foundation. All rights reserved.