– Good afternoon my name is Greg Evans and we are here to answer some questions about plastic surgery. – And I’m Dr. Raj Vyas. – We’re both board-certified plastic surgeons in the Department of Plastic Surgery here at UC Irvine Health. And our goal today is to try to demystify some of the questions and some of the procedures that occur in plastic surgery. -So let’s get started. Please feel free to type in any of the questions you may have in the comment box below. Let’s take a look. Dr. Evans and I always get this question, the two of us always get this question. The first one is is Botox permanent? -So Botox is not permanent it is a neurotoxin and there are a variety of neurotoxins. One of the trade names is Botox and depending on how much you’ve had, how many injections have had previously, neurotoxins usually last about three months. It also depends a little bit on the location of where the neurotoxin is injected. -Alright another question here, how long do fillers last? -So fillers uh can are usually a hierarchic acid component and there are different sizes. So some of the fillers have smaller size beads, other fillers have larger sized beads. Again, it depends a little bit on where it’s injected. Areas that get lots of motion may last a little bit less time, probably around 10 to 12 months. Areas to get probably a little bit less motion in the face, let’s say the cheek area, may last a little bit longer, between 12 and 16 months. So it depends a little bit on the size of the filler, depends on where it’s injected, and subsequently then it depends on motion of the face and how long the filler is going to last. -Excellent ok we have another Botox question here. Is it true that Botox can be used for migraines? -It can be used for migraines, and i’m actually going to have Dr. Vyas answer this because that’s part of his area of specialty. -It’s certainly true that nowadays our understanding of migraines has fundamentally changed. We know that there are certain trigger nerves, most specifically if I point to them, I’m sure maybe you will also realize this. There is the super orbital and super trochlear nerves, there’s a branch of a nerve here called the zygomaticotemporal branch of the trigeminal nerve and then there’s occipital nerves back here and each of these nerves can be triggers for migraines. And the way that that happens is the nerve is compressed in some way it can be either because of bone, muscle, the thick layer above muscle called faccia, or blood vessels that wrap around the nerves that caused some compression on these nerves and when that happens the nerves become ischemic or they get low blood flow and they send signals of pain back to the brain and that’s how migraines start and spread. So Botox can relieve a component of that by relaxing the muscles around these nerves and if Botox works on on these specific trigger nerves, then we also know that these same patients are candidates for what we call migraine surgery, which is to do surgery that does essentially what the Botox does but last indefinitely and so I think using Botox in migraine is an excellent wait to treat migraine but it’s actually even a better way to diagnose good candidates for migraine surgery. -Let me ask dr. Vyas a question, what percentage of the population would respond to Botox for migraine headaches? -Right, so people, but it’s used for patients with chronic migraine headache so that’s defined as having had 14 or more headaches of which at least nine are migraine in a month. For those patients, a majority, over 80%, respond to Botox and the same percentage of people respond to surgery so our best studies, which are level 1 evidence, which means double-blinded placebo-controlled, randomized trial shows that at five years, there’s about an eighty-two percent success rate in decreasing the frequency, severity, and duration of migraines by at least fifty percent at five years and eighty-two percent of patients can expect that kind of an accomplishment. Really the key is patient selection and using Botox as a diagnostic tool is the main sort of tool we have to select good patients. We also do a thorough headache journal and history and physical, that kind of pinpoint exactly which nerves would be good targets for this. Here’s another good one, what are the benefits of silicon vs saline implants? -The two basic types of breast implants are saline vs silicone. Saline tends to be a little bit more firm compared to silicon, Silicon is a little more natural in feel and appearance. The silicon tends to sometimes implants can actually ripple and if you look down here you can see that the implant itself can ripple a little bit and silicon tends to ripple less sometimes than the saline implants. The advantage of having a saline implants is its full of water, salt water, so that if it ruptures it’s usually absorbed by the body. Silicon, if it does rupture, can be contained within the scar tissue around the implant but would not be absorbed and sometimes a little bit more difficult to detect there’s a rupture or not. With the MRI scans and ultrasounds now however we’ve been good at detecting any implant complications so these frequently are utilized in patients coming in that have had implants in for a longer period of time. All implants are a mechanical device, they do not last permanently. We normally tell patients that implants last about seven to ten years and would have to be replaced after that. -This is an excellent question for you Dr. Evans, what type of chemical peel should i get? -So there are a variety of chemical peels and it really depends on the depth, so lighter – what we call glycolic acid peels – are obviously a little bit, deal with just mainly the upper layers of the skin, deeper peels that utilize a variety of other stronger chemicals like phenol or TCA are both deeper peels that obviously develop better results in some respect but have more downtime, more pealing, more redness to the face, more time perhaps away from your work, so skin type and color and texture is important with all this. Ensuring that somebody is on certain type of products prior to peeling to make sure that their skin is specifically ready for peeling, specifically retin-A, are all part of the evaluation and consultation process and then sitting down with your physician and determining what type of peel is most appropriate would also be part of that evaluation process. Some of the lighter peels you might be able to come over at lunchtime have the light peel done then go back to work, maybe have a little redness to your face sort of like a sunburn going out in the Sun for about an hour, but certainly some of the deeper peels may require some more sedation and or anesthetic to have the peels performed. -You can see Dr. Evans get his… -You can see my chemical peel on video -On our YouTube, we’ll put that down in our comment section below .Another question here about implants, we got two in a row so I’ll just ask them both. Will I still be able to breastfeed after getting implants and do you have to replace your breast implants and if so when? -So the breastfeeding depends a little bit on location of the implant and it depends a little bit on how the implant was inserted. So if implants were placed for what we call cosmetic purposes or augmentation purposes, sometimes an incision that’s placed around the areola, the nipple-areolar complex can or may perhaps interfere with some of the glands that produce milk for breastfeeding. If the incision is placed along the lower inframammary fold of the breasts, then there is less of a chance of interfering with breastfeeding. So the reality is that most women are able to breastfeed following the implant placement, depends a little again if it’s above or below the muscle and how much dissection occurs around the glands and placing the implant. So all implants are like I said not permanent. At some point in your life the implant will probably rupture and when it does rupture we do recommend that the implant be replaced. -Okay, I have a question here, Kimberly Jones asked what is the darkest and lightest peels? -So I guess I’m not quite understanding the question a little bit, it’s really not about dark or light peels, maybe you’re talking about depth. So traditionally a phenol peel is usually the deepest, it’s a chemical that is used, and frequently sedation and other mechanisms need to be done. And obtaining that peel, more of the what we call fruity acid or glycolic acid peels are a lot more superficial and perhaps what you mean by that is that they are lighter, that they don’t produce as much of a result, but there’s less downtime as well so that may be what you’re saying by lighter and/or darker. -Yeah probably. Kim ask us a follow-up if you’d like. We have another question here about laser hair removal. Does laser hair removal cause hyper-pigmentation. -Usually not, but I think again it depends a little bit on tissue quality and your pigment. so they’re different categories of your pigment. But the darker the skin that you have, the more chance that you may get some hyperpigmentation, but really the laser focuses on the hair and the hair follicles. Darker hair does much better, the laser focuses and is able to remove the darker hair more than let’s say blonde and or white hair. And certainly if we do laser hair removal we would ask you to come in with some hair growth so that we can identify where those hair follicles are and use the laser. It may require repeat laser treatments in order to decrease the amount of hair growth. -Here’s sort of a tricky question: what fillers do you recommend for eye troughs? -So again i think a little bit of that is a personal physician selection what you want in an eye trough area is a filler that is smaller in side and perhaps may not produce as much volume. And I think in the eye trough area, less is better or injecting the very small amount we measured, in what we call ccs – very small amount – in order to try to smooth that area between where the trough is and the cheek zone but at the same time not put too much in to make it so that it’s protruding. So again some of that’s a little bit of physician selection but you would want a filler that doesn’t have a huge amount of large volume so that it doesn’t – it’s going to show very easily, so we don’t want fillers in there with a very large volume. -Another person is asking what is the best time of life to get a tummy tuck, would it be after having children? -So the ideal answer is yes if you are planning to have children it’s better to have the procedure done after having kids and the reason why is that your body is going to go back to having expansion obviously because of the kids the kids are going to grow in your belly and all of the muscles that we tighten up are going to loosen again because it’s your body’s normal tendency to get ready for delivery. So certainly if we tighten things up with sutures, all of those most likely will become loose and the tightening that we do will sort of be for not in that it will proceed to loosen despite having us put sutures in along the along the muscle layer. -Brenda asks, are there any signs of implant rupture from breast implants? -There can be clinical signs and ultimately pain maybe one of them. Another clinical sign is the shape of the breast may change so that it may be tight in one area. We call also the capsules that form around the implants those are classified for us what we call a baker classification so one is a not very firm, four is very firm and painful. So many times we can tell if an implant ruptures by altering or looking at the breasts and saying there’s an altered shape in regards to the breast itself or that capsule, the firmness of the capsule that forms around the implant them. -But sometimes you may not know and especially for silicon implants so that’s why it’s not recommended that you get an MRI every two to three years to check. Another question here is there a non-invasive treatment for scars. -Why don’t I let you answer that one? -Scars are the result of trauma or surgery to your skin and that’s the way your skin heals. So when we think about how to treat them, you know people often ask can i get rid of this scar, usually you can’t get rid of a scar completely, you can do one of two things: you can either replace the scar, so you can cut out the scar and hopefully make it nicer than – nicer means it’s thinner, maybe without any track marks, a little bit less raised, all those things are things that can be surgically controlled and it’s worthwhile if you’re interested in that seeing a plastic surgeon to see whether or not it’s a scar can really be made nice because sometimes you can’t. It depends on the location and the quality and the age of the scar. The second thing that can happen to scars instead of just replacing them is trying to refine them and so things like fractionated lasers, chemical peels, dermabrasion are all things that are designed to really refine a scar. And the way they work is by actually causing scarring, but on a micro-level so instead of causing like a big scar they damage the outer layer of the skin and a little bit of the dermis – the sort of inner layer of the skin – in a way that causes the skin to regenerate on its own. The process of doing that can take what looks like kind of an ugly scar and break it up in a way that, because of all the fresh growth of collagen and substances within skin, make it look a little bit nicer. And again these are sort of individual things that need to be discussed with patients based on the location, size, the age, and other factors of the scar, -The only other thing I would add to that is that scars are always changing throughout one’s lifetime, so they tend to build up more scar tissue and teardown more scar tissue. If more scar tissue builds up, a lot of times then the scar can go beyond its boundaries and we call those a keloid. Sometimes during injections can help with those large scars and just regular scars a lot of times either there are a variety of products out there that can be used on scars, its sort of the massaging action or pressure or silicone sheets have been demonstrated that may help thin and flatten the scar as well. -And with that sort of basic scar teaching for any scar after surgery all that would be recommended by us. Esther asks what is the recovery time after laser resurfacing? -So again it depends a little bit on the death of the laser, so just like we talked about depths of peels, there are different depths of lasers. A CO2 laser is a little bit deeper as opposed to let’s say an erbium laser which is a little bit more superficial. Erbium laser: more redness, probably for two to three days co2 laser: a lot more pealing, a lot more redness. So I would normally say maybe a co2 laser – probably two weeks, more or less, one to two weeks. And erbium laser: maybe about three to seven days -Okay, so we’re almost at the end of our session, let’s take some final questions. This one – who should I see for plastic surgery? -So in our opinion, you need to see a board-certified plastic surgeon. There are 28 boards that are certified by the American Board of Medical Examinations and one of those boards is plastic surgery. It’s a rigorous program for training we have to not only be certified by both the written and oral examination, but we have to be recertified every 10 years, so we’re continuing in a process called maintenance of certification, just like your airline pilots have to go back to the simulator every six months. We have to demonstrate our ability to continue to practice at a very high level of care. So for us ensuring that patients understand what board certification is and seeing a board-certified plastic surgeon is critical and making sure that you’re going to be safe with any type of invasive of non-invasive procedure that you have performed. -Okay, Jenny asks what can i do to reduce the size of my pores on my face? We have a variety of skin products that we utilize in this practice and we can certainly get you – we also have an aesthetician, we can get you on a variety of products that can help with not only pore size but also with the quality of the skin and it depends whether you have some dark areas, depends on what you’re kind of looking for, but there are a variety of products that we utilize in the practice that can help with that. Here’s our final question: what can I take to prevent aging? -Unfortunately, aging is a very genetic thing. I think that from our standpoint certainly there are things that you can do to help with trying to decrease the aging process. One obviously is getting on good skincare, one is obviously utilizing a sunblock on a daily basis because we know that the Sun can create a lot of advanced aging components, smoking also affects skin significantly so stopping and quitting smoking will also help that process. So i think again eating right, taking good care of yourself, making sure that you know you get adequate sleep and have appropriate skin care, I think is very helpful in decreasing the aging process. Unfortunately it’s going to happen all of us and it all happens to us at various times in our lives and there is a great deal of genetic predisposition to that. -And I lied, we have one more final question here. Nicole is asking, after repeated Botox injections, will facial muscles ever lose the ability to frown? -So it’s interesting that you ask that question so the answer is no but the but the effectiveness of the Botox may actually decrease with the frequency of injections. So you may get, if you’re working on your 10th or 12th or 15th injection, it may not last as long and it may not work as well as during the first injection but there are other neurotoxins out there then that you can use that affect different nerve and plates that may be more effective in those patients that have had quite a bit of Botox. -Alright, that seems to be all of the time we have for your questions today. Thank you so much please visit our web page, it’s listed down here in the comments box below. If you have any additional questions or you’d like to make an appointment. Also please be sure to check out our YouTube videos on Botox and chemical peels, you’ll get to see Dr. Evans taking it like a champ. -You’re going to watch me peel. -And thanks again for participating on our Facebook live chat session today. Hope you have a good day. -Good day.