An Integrative Approach to Facial Cosmetic Surgery and Rejuvenation Medicine – RejuvLIFT
Brazilian Academy of Anti-Aging and Regenerative Medicine
May 2012
Leonard A. Rubinstein, M.D., F.A.A.C.S., F.A.A.Oto-HNS/F
Medical Director – Gulf Coast Cosmetic Surgery Center, Sarasota, Florida, USA
Medical Director – Center for Integration in Cosmetic Surgery and Rejuvenation Medicine,
ENT, Allergy and Skin Wellness, Sarasota and
Bay Harbor island (Miami), Florida, USA
Medical Director- Allergy Clinic of Sarasota, Florida, USA
Visiting Professor – Dept. of Plastic and Cosmetic Surgery,
Zunyi College of Medicine, Zunyi, Guizhou Province, P. R. of China
Clinical Faculty – Lake Erie College of Osteopathic Medicine
Visiting Faculty- East/West College of Natural Medicine
An Integrative Approach to Facial Cosmetic Surgery & Rejuvenation
Our concept of an Integrative Approach to Facial Cosmetic Surgery and Body Contour Image
Enhancement would combine Eastern (Oriental-Chinese) Medicine principles and Western
(Allopathic, Homeopathic and Osteopathic) Medicine principles in an Integrative manner for the
maximum enhancement and longevity of the patient results.
Integrative Medicine: Combining Allopathy, Homeopathy, Oriental Medicine
Provides for a holistic approach to patient treatment.
May include aspects of aromatherapy, acupuncture, nutrition, massage, energetics, informational
medicine, herbal medicine, osteopathy, reflexology, etc.
Provides a more complete and more realistic approach to the problem at hand rather than relying
on merely conventional Immunotherapeutic “messaging” to the Immune system.
Proposed Team Approach
A more complete paradigm for assessing and treating the patient should include a team:
Cosmetic Surgeon, Nurse, Oriental/Homeopathic Medicine, Age Management, Dietary and
Exercise Counseling.
Our Approach to the Cosmetic Patient
“Cosmetic” = “Self-Image Enhancement”
An Integrated approach including Allopathic, Homeopathic and Oriental/Chinese Medicine
components.
Utilization of a team approach: Doctor of Medicine (Cosmetic Surgeon), Doctor of Oriental
Medicine, Age Management physician, Nurse, Esthetician, Massage, Dietary and Exercise
Counseling.
The goal is to achieve a maximal natural-appearing result with self-esteem enhancement and
WELLNESS with the least recovery time.
Components:
Nursing Assessment: General Health Assessment and Expectations Assessment. Is the patient
realistic?
Cosmetic Surgeon: General Health Assessment, review expectations with patient, assess other
issues that may affect the subjective nature of the results, design a therapeutic approach and
determine possible additional evaluations, i.e. in-vitro allergy tests, hormonal assessments,
associated therapies, i.e. mesotherapy or detox.
Conventional Medicine
Various fields of specialization that comprise conventional medicine, each one of which focuses
exclusively upon its particular branch of medicine and the organ system it treats, usually without
regard for how the human organism and life itself are interwoven.
Alternative Medicine
Complementary Medicine
Integrative Medicine
Holistic Medicine
Does not discount Conventional Medicine!
Philosophy of Alternative Medicine
5000 BCE - “physician-sages” formulating the healing traditions of both traditional Chinese
Medicine (TCM) and Ayurvedic Medicine (from India) recognized that human beings were
comprised of body, mind and spirit, and that health represented a harmonious balance within all
three of these aspects of existence, as well as a free flow of invisible vital energy (known in
China as qi and in India as prana) throughout the various organ systems.
Alternative Medicine
What is Alternative Medicine?
Denotes approaches to health and healing that do not rely on drugs, surgery and/or other
conventional medical procedures for treating illness.
How does it work? How does its underlying philosophy differ from that of conventional
medicine?
Homeopathy
German physician and chemist, Samuel Hahnemann (1755-1843), recognized the inherent
limitations of such a symptom-based approach to medicine, as well as its potential to cause harm
(side effects) to patients.
He coined the term Allopathy (meaning “other suffering”) to describe what, in his view, was a
misguided and inadequate method of disease care and prevention….Allopathic Medicine is
modern Conventional Medicine.
Definition of Homeopathy
A system of medicine utilizing medications manufactured according to homeopathic
principles/standards
Remedies stimulate the body’s own regulation and defense systems
HOMEOPATHY = similar suffering
Holistic Medicine
C. Norman Shealy, M.D., Ph.D., neurosurgeon, in 1978, founded the American Holistic Medical
Association with a goal to provide a common community for physicians committed to treating
the whole person according to the philosophy of holistic medicine.
Based on a belief that conventional medicine relies on pharmaceutical drugs and surgery in
treating life-threatening illness but fails in terms of handling chronic conditions.
We adopted an Integrative Holistic Approach…..
Most effective form of health care treats the patient’s entire being- body, mind and spirit and
empowers patients by educating them to take personal responsibility for their health!
An Integrative (East-West) Approach to Skin Care, Rejuvenation Medicine and
Cosmetic Surgery
Evaluation:
Patient Expectations and Family Expectations (realistic?)
Readiness: Schedule, Work, etc., Social History
Habits: Drugs, Smoking, Chewing Tobacco, Alcohol, etc.
Past Medical and Surgical History
Education and Culture
Medications/Treatments in Progress/Nutriceuticals/Dietary Habits/Exercise Regimen
Allergies and Endocrine Factors
Financial Capacity
Levels of Hormones can markedly affect Facial Cosmetic Surgery results!
We spend a great deal of time deciding amongst various surgical techniques of re-arranging the
position and texture of facial tissues but ignore all of the other factors that are affecting those
same tissues!
We compare surgical techniques to determine which are best for maximal longevity of results but
fail greatly in involving ourselves in the very fundamental factors that regulate tissues!
In essence, we are simply focusing on the wrong things!
We are just moving old unhealthy and aging tissues into new positions…the result is old tissues
in new positions!
We need to be more concerned about the factors that will affect the patient’s perception of the
surgical results we provide and about the functional state of the tissues on which we are
operating!
Hormones interact to regulate all functions of the body!
Hormone levels change throughout the life of the patient. Most, if not all, of the patients we are
operating on for Facial Rejuvenation are Hormonally Un-Balanced!
The body can most often heal itself if supplied with the proper building blocks of vitamins,
minerals, fats, and especially bio-identical hormones.
It is our responsibility as “Self-Esteem Enhancing Surgeons and Physicians” to serve as
educators and mentors in all aspects of rejuvenation!
If we don’t take responsibility for this who will?
•
The family practice doctor?
•
The endocrinologist?
•
The health food clerk?
•
The pharmacist?
Aging is about the development of chronic age-related inflammatory disease.
Bio-Identical Hormone supplementation will positively affect moods, sleep, hair health, GI
health, the immune system, skin tone, muscle tone, tissue elasticity, nerve function and repair,
tissue edema, color, pigmentation, perfusion, bone health, vascular health, memory, thinking…..
Nutritional Supplements
Recommended Daily Allowances (RDA) are arbitrary, set too low in many cases, and do not
begin to address unique nutritional needs.
Robert A. Anderson, M.D., and Robert S. Ivker, M.D., founding President and President-Elect of
the American Board of Holistic Medicine, provided a suggested dosage range for the most
common anti-oxidant vitamins and minerals:
New Ranges:
Vitamin C (polyascorbate): 1000-2000 mg TID
Beta carotene: 25,000 IU 1-2X/day
Vitamin E: 400 IU 1-2X/day
B-Complex Vitamins: 50-100 mg of each/day
Folic Acid: 400-800 mcg/ day
Seleniium: 100-200 mcg/day
Zinc picolinate: 20-40 mg/day
Calcium citrate or apatite: 1,000 mg/day
Magnesium citrate or aspartate: 500 mg/day
Chromium polynicotinate: 200 mcg/day
Manganese: 10-15 mg/day
Copper: 2 mg/day
Iron: 10-18 mg/day
Alteration of Lab tests by Herbal Supplements
Elevated Liver Enzymes and Bilirubin: Kava Kava, Comfrey, Chaparral, Mistletoe, Germander,
Skullcap
Unexpected Low Glucose: Garlic, Ginseng, Ginger, Chromium, Nettle
Abnormal Thyroid Profile: Kelp
Hypokalemia: Licorice
Abnormal Bleeding: Garlic, Ginger, Gingko Biloba, Gong Qui, DanShen, Motherworth, Red
Clover, Fenugreek
The Concept of Beauty
What is the patient’s concept?
This is the most critical assessment that you as a Cosmetic Surgeon must make…..
If you don’t know where you need to arrive, you’ll never understand which “road(s)” to take
and you’ll rarely get there!
What obstacles are in your way?
The patient is often unaware of the issues……they are being highly influenced by family,
significant others, self-esteem and mood issues, and by the media.
The culture of the patient…..you must understand the influences of those around the patient
because it is to that culture that the patient will return after you have begun your involvement in
their care!
Dietary and Exercise Counseling
Is the patient willing to make lifestyle changes and maintain what you accomplished?
Nutrition
Complete Physical Exam including Dental (Take care of gingival issues first!)
Emotional Status: attitude towards “self” and patient’s willingness to cooperate with plan and to
be held accountable
Skin and Hair Quality
Stance/Orthopaedic and Neurologic Issues
ENT/Respiratory Issues
Allergy/Endocrine Issues
Age Management Assessment
Hormone levels: requiring supplementation?
Nutritional deficiencies requiring supplementation?
Habits and supplements that may affect results.
Dietary issues that may affect results.
Exercise regimen that may affect results.
Detoxification protocols?
Assessment from Oriental/Chinese Medicine Perspective
Acupuncture?
Herbal supplements?
Massage?
Qi Balance?
Injection Acupuncture/Homeopathic Therapies?
Assessment from Osteopathic Medicine Perspective
Structural concerns that may influence results?
Musculo-skeletal issues?
Neuro-muscular issues?
Cranio-sacral issues?
Esthetician/Skin Care Issues
Are there adjunct skin-enhancing procedures that could be performed to maximize the results?
Are there nutraceuticals/topical regimens/homeopathics/ayurvedics that could maximize results?
Make-up, Cosmetics, Image Enhancement attire?
Skin and Hair Issues
Skin Appearance Enhancement?
Surgical Approach Component?
Facial Surgery: Brows, Eyelids, Nose, Mid-Face, Neck, Otoplasties, Skin Resurfacing, SoftTissue Augmentation and Filling, Hair Replacement Procedures.
Hair Restoration
Facial Rejuvenation?
Subtle Facial Rejuvenation?
Nasal and Chin Reshaping?
Facial/Neck Contouring
More Extensive Nasal Reshaping, Eyelid Rejuvenation, Liposuction of Neck and Facelift
Total Facial Rejuvenation
One must be highly familiar with all of the available resources, tools and procedures (Western,
Oriental, Homeopathic, Ayurvedic) so that the patient can receive the benefit of a well-planned
program which takes into account all of the necessary aspects.
It is not fair to the patient to provide a single regimen, tool or treatment when there are so many
options and considerations that should be taken into account.
A sculptor uses many different tools to achieve the end result….
Available tools…..
Herbals, Nutraceuticals
Essential oils: inhaled, oral ingestion, topical
Dietary Regimens based on needs: may require allergen-specific IgE and IgG antibody testing
with subsequent diet and/or immunotherapy (injection or Sublingual)
Exercise Counseling
Energetics Assessment (i.e. ETAscan™, kinesiology, etc.)
Lymphatic Drainage with Massage, Endermatherapy or Light Beam Generator Therapy
Acupuncture
Peels, Tissue Fillers, Botox, Implantable Threads, etc.
ANTI-AGING MEDICINE….AGE MANAGEMENT
Anti-Aging Medicine
Bio-Identical Hormones are replaced if found to be abnormal – test saliva, blood, 24 hr. urine
Testosterone, Estrogen, Progesterone
Human Growth Hormone/Sermorelin
Thyroid
DHEA, Vit D3, Cortizone
What good is surgical and skin rejuvenation without endocrine regulation/rejuvenation?
Our approach is “Beauty Inside and Out!”
Achieve Beauty and Wellness together!
What’s New In
Cosmetic Surgery?
The buzz words are:
*No down time*
*Lunch Time Procedures*
*Minimally Invasive*
*Quick Recovery*
The Use of Vibratory Percussive Massage in Liposculpture
Dynamed Capsule
Allergy
Food allergies are more common in children than adults. 7 out of 100 kids have them, and only
2 out of 100 adults do. Food allergies can be delayed (IgG) or immediate (IgE). Children often
outgrow their food allergies. But if you have a food allergy as an adult you will most likely
have allergies to certain foods for life.
Allergy and the Skin
Eczema
Dermatitis
Skin Prick Testing
Problems inherent with Skin Testing
Too subjective!
Not standardized: non-standardized testing extracts, techniques, interpretation scales,
prognosticating standards.
Dangerous and painful.
Skin may be too sensitive an organ leading to false positives.
Skin may not be where the reactions can be seen.
Tough to identify delayed reactions.
Allergen-specific IgE and IgG testing
We are searching for the specific allergy antibodies present in the serum that are associated with
potential binding to the environmental allergen.
When the binding occurs, the complex migrates to cells that release substances (i.e. histamine)
that cause allergy reactions in multiple end-organs. De-sensitization (immunotherapy) is directed
at blocking these reactions by blocking the binding of specific antibody to antigen.
Pharmaceutical therapy is aimed to block or limit the reactions prior to the end-organ or at the
end-organ itself.
Allergy Testing by a Simple Blood Test: Our Preferred Technique
T.R.U.E. Test (thin-layered, rapid use, epi-cutaneous test)
T.R.U.E. Test
T.R.U.E. Test
Can be useful for chemical contacts.
i.e., Latex-related eczema, delayed Type IV rubber-additive allergy.
Persistent eczema which does not remit with topical corticosteroids- may indicate allergy to
steroids, moisturizers, or personal care products.
Flare-ups in an otherwise stable eczema.
Sublingual Immuno-Therapy
(S.L.I.T.)
How do allergy drops work?
Allergy drop treatment (S.L.I.T.) works similar to shots by delivering a slowly increasing dose of
physician-prescribed antigen that, over time, builds the body’s tolerance.
The drops are placed under the tongue and affect the immune system through very specialized
cells found under the tongue. Research shows these cells are a safer and more effective route for
long-term desensitization, making it an ideal option for patients who aren’t candidates for shots.
Most patients take allergy drops each day for three to five years.
S.L.I.T.
Can be administered for airborne allergens and for food allergens.
Can be combined with injection immunotherapy.
Can be combined with Rotation Diet
Progress must be monitored periodically and adjustments made.
Provides a great alternative!
Kinesiology
Homotoxicology presents a simplified, logical and technically-based method of using
homeopathic principles in daily practice
Homeopathic Formulas
“Regulation Therapy”
Based on the use of therapeutic techniques that maintain or restore dynamic:
 physiochemical,
 energetic and/or
 information flow within and throughout the “Matrix” system
A harmonious and uniform functioning “Matrix” is necessary for optimum health. We employ
Oriental Medicine and Informational Medicine to accomplish this.
The Skin
The skin is constantly renewing and repairing itself.
It helps to keep water in and out.
It protects from extremes in temperature through sweating and invasion of microorganisms by
secreting antimicrobial substances.
The skin is an organ of respiration this is usually overlooked.
Eastern healing philosophies often refer to the skin as the third lung.
Regular full body massage.
Essential oils.
Aromatherapy in conjunction with diet actually enhances the efficacy of homeopathic treatments.
Reducing stress enhances healing…..meditation and yoga, healthy relationships,
intimacy…companionship.
Lymphatic Stagnation (Lymphastasis) and Metabolic Stagnation
PHOTON LIGHT BEAM GENERATOR (LBG)
►The LBG uses extremely low current cold gas light photons to transfer energy frequency
patterns to the area of the cell providing an environment, which allows the cell to correct its
electromagnetic charge.
►This results in the cell balancing its field charge and disassociating itself from the binding
agent responsible for the collection of water and pooling of protein within the affected area.
Because the tissue is in a state of free flow, this is the ideal condition to effectively treat swollen
tissue.
► With application of minimal or no massage drainage techniques, rapid movement of waste
material occurs, enhancing delivery of waste material to organs and nodes responsible for waste
elimination.
Surgical Approaches for the Aging Face
Browlift (coronal, trichophytic, endoscopic)
Blepharoplasty (eyelid surgery involving removal of excess skin, sometimes fat, and may
involve lower eyelid repositioning)
Facelift-Rhytidectomy (multiple techniques involving “deep plane” lift, midface lift, Slift)….RejuvLIFT™
Liposuction, Liposculpture, implants ie. Cheek, chin, jaw.
Surgical Procedures
Must be familiar and proficient in multiple variations in techniques, each with their intrinsic
benefits and limitations. “If you only have a hammer, you’ll start seeing everything as a nail…”
There are many years of accumulated experience that others are willing to share with all of
us….be willing to learn from their wisdom.
Learn the subtle benefits and rationale behind each technique.
Autologous Fat Transplantation
100 years old
Techniques are quite varied
Existing research lags behind the field regarding treatment and results
Not a standardized procedure
Misconception regarding the aging face – therefore, the aging process has long been
misdiagnosed
Lifts don’t correct the problems of aging and they address only 2 vectors: superior and posterior.
To correct the anterior vector you must add some filler to augment the soft tissues…..FAT is the
most natural option!
Focus of Lipo-Augmentation
The nasal-labial crease- usually caused by a loss of volume so you need to lift out the entire
cheek with fat and not just inject fat into the crease.
Temporal hollows
Nasal reshaping
Sub-columellar (anterior maxilla)
Lips
Cheeks
Sub-malar regions
“Lacrimal groove”
Chin
Orbital rim
REST OF BODY!
Advantages of Fat as a Graft
Replacing Like with Like…puts back what is missing. Axiom of Sir Harold Gillis.
Living tissue! Fat survives in part because of the transfer of pre-adipocytes (fat stem cells) which
then differentiate into fat, muscle or bone depending on where they are placed.
More natural result than other dermal fillers
Less invasive procedure
Readily available
Can be combined with other lifting procedures
Fat sculpturing
Tissues injected with tumescent technique
Fat harvested through suction of 12 cc syringe
Fat (syringe) placed in centrifuge for 2 minutes
Blood drained off, oil wicked off with neuro-patty
Fat transferred to 1cc syringes
Removing the Tumescent Aspirate
Fat sculpturing/grafting
Questions to be answered….
Tumescent or no tumescent prior to obtaining graft? Epi or no epi?
Optimum harvesting tool(s)?
Optimum injection tool(s)?
Wash or no washing of graft?
To centrifuge or not to centrifuge?
To freeze or not to freeze? If yes, how to freeze and how to thaw?
Additives to graft? i.e. insulin, albumin?
Will ultrasonic-assisted product take as a graft? Literature starting to point to “yes”.
VECTORS OF GRAVITATIONAL DESCENT
SKIN INCISIONS
Skin Incisions- preauricular crease and/or post tragal
Be considerate of temporal tuft
Post auricular into hair line (importance of matching up with closure), S-lift, RejuvLIFT™
Closely evaluate male patients (beard will move with face lift)
Surgical Approaches for the Aging Face
Browlift (coronal, trichophytic, endoscopic)
Blepharoplasty (eyelid surgery involving removal of excess skin, sometimes fat, and may
involve lower eyelid repositioning)
Facelift-Rhytidectomy (multiple techniques involving “deep plane” lift, midface lift, Slift)….RejuvLIFT™
Liposuction, Liposculpture, implants ie. Cheek, chin, jaw.
RHYTIDECTOMY TECHNIQUES
Skin only
RejuvLIFT™
SMAS (superficial musculo-aponeurotic system)
Extended SMAS
Subperiosteal-Midface
Triplanar lift
Deep plane/Composite lift
Fat sculpturing- “the third dimension” in treatment of the aging face
SKIN INCISIONS
Submental incision added for neck liposuction and platysmal plication
A small medial strip of platysma may be resected and then the platysma closed with interrupted
Prolene sutures
Malar descent with SOOF
SOOF Lifting w/ resuspension of orbicularis
Brow-lifting Techniques
Midface suspension via temporal and sub-labial approaches
Mid-face Suspension
Release of tissues around lateral orbit and cheek
Suspension of two areas: origin of zygomaticus major muscle and Bechet’s fat pad
Suspension to deep temporal fascia with nylon sutures
Conclusions
Multiple ways to treat the “aging face”
There are many surgical options for treating the aging face. Each patient must be treated
individually, their needs taken into consideration, and ultimately the surgical plan completed.
Eyelid Rejuvenation, Botox™ Treatments and Restylane™ Injections
Juvederm™, Restylane™, Radiesse™, etc.
Multiple tissue fillers have been developed for augmenting soft tissues in addition to Silikon
1000™ (off-label use of FDA approved product vs. Face-Fill™ (Biopolymer- Silicone) which is
not allowed in the United States at the present time. We use Silikon 1000 as an off-bael use of an
FDA-approved product.
Tissue Fillers - Sculptra
Blepharoplasties
Blepharoplasties, Radiesse™, Restylane™
Blepharoplasties, Radiesse™, Restylane™
Fat transplants, Blepharoplasties, Chin, Lipo neck
Subcutaneous Threads (Featherlift™ and RejuvLIFT™ using Barbed Threads)
Bleparoplasties, RejuvLIFT™ using Barbed Threads
Mid-Face & Brow
Before
After
Mid-Face & Brow
Before
After
Mid-Face & Brow
Before
After
Mid-Face & Brow
Before
After
Blepharoplasties, RejuvLIFT™
Blepharolasties, RejuvLIFT™ Browlift
RejuvLIFT™ in older female:
RejuvLIFT™ in older female:
RejuvLIFT™ Mini-Neck Lift
Ultrasonic-assisted Lipo neck and RejuvLIFT™ using RejuvLIFT™ Threads
Other Modalities for Facial Appearance Enhancement
Skin Care
Microdermabrasion
Radiofrequency
Broad Band Light
Laser Therapies: Ablative and Non-Ablative
Fractional and Pro-Fractional
Chemical Peels
L.E.D. , etc.
Obagi™, Microdermabrasion and Revitalight™ (L.E.D. therapy), Chemical Peel
Mesotherapy: Pharmaceutical vs. Homeopathic vs. Injection Acupuncture
Cosmetic Surgery is Surgery on Self-Esteem!
An Integrative Approach to Cosmetic Surgery & Rejuvenation
Our concept of an Integrative Approach to Facial Cosmetic Surgery and Body Contour Image
Enhancement would combine Eastern (Oriental-Chinese) Medicine principles and Western
(Allopathic, Homeopathic and Osteopathic) Medicine principles in an Integrative manner for the
maximum enhancement and longevity of the patient results.
Our Approach to the Cosmetic Patient
“Cosmetic” = “Self-Image Enhancement”
An Integrated approach including Allopathic, Homeopathic and Oriental/Chinese Medicine
components.
Utilization of a team approach: Doctor of Medicine (Cosmetic Surgeon), Doctor of Oriental
Medicine, Age Management physician, Nurse, Esthetician, Massage, Dietary and Exercise
Counseling.
The goal is to achieve a maximal natural-appearing result with self-esteem enhancement and
WELLNESS with the least recovery time.
Consider a New Definition of Beauty….
Our approach = “Beauty Inside and Out!”
Our goal: To Achieve Beauty, Patient Self-Esteem and Wellness together!
Some topics to be explored together!
What is the role of Acupuncture?
What is the role of Herbal/Supplement Medicine?
What is the role of Energetics Medicine?
What is the role of Mesotherapy?
How to incorporate principles of LONGEVITY?
What is the role of Nutrition?
What is the role of Exercise- i.e. Passive-Active mechanisms (i.e. V.E.R.T.)
Can we combine East and West principles throughout the process of Image Enhancement?
An Integrative Approach to Facial Cosmetic Surgery and Rejuvenation Medicine
Leonard A. Rubinstein, M.D., F.A.A.C.S., F.A.A.Oto-HNS/F
Medical Director – Gulf Coast Cosmetic Surgery Center, Sarasota, Florida, USA
Medical Director – Center for Integration in Cosmetic Surgery and Rejuvenation Medicine,
ENT, Allergy and Skin Wellness, Sarasota and Surfside (Miami), Florida, USA
Medical Director- Allergy Clinic of Sarasota, Florida, USA
Visiting Professor – Dept. of Plastic and Cosmetic Surgery,
Zunyi College of Medicine, Zunyi, Guizhou Province, P. R. of China
Visiting Clinical Faculty – Lake Erie College of Osteopathic Medicine
Visiting Faculty- East/West College of Natural Medicine