Q. I had a facelift several years ago and I still have fine lines on my cheeks and around my mouth that did not disappear after the facelift.  What can be done to improve these lines? 

A. Facelift surgery often does not completely smooth out fine lines of the cheek area, and certainly does not do much for the vertical lip lines around the mouth.  For these lines, which are usually caused by environmental damage (sun) or heredity, the treatment that I recommend is to start a skin care program that is medically directed in order to stimulate collagen and smooth the skin by improving tone and texture.  Once the skin has been maximally improved with a skin care program, the next step to consider is either laser resurfacing or chemical peel, depending on  how much wrinkling remains.  The laser is more aggressive and will typically diminish more wrinkles while leaving the skin smoother.  The laser resurfacing can be performed with topical anesthesia or general anesthesia, depending on the depth of the wrinkles.  Recovery after laser can be in as little as 8 or 9 days or as long as 2-3 weeks, depending on how aggressive the treatment must be.  Most patients can return to work after about 2 weeks, although some makeup may be required to tone the redness down.  In addition to laser resurfacing as a treatment of  facial wrinkles, fillers such as Restylane® can be used to fill some wrinkles that do not respond to laser.  An individual consultation with your plastic surgeon is required to discuss the results of your facelift and design a plan to smooth your skin.

Q. I had a breast augmentation when I was 34 years old.  I am now 60 and my breasts are hard and somewhat distorted in shape.  The implants are silicone.  I have not seen a plastic surgeon in many years.  What should I do about these implants?

A.  Your situation is quite common.  What should a patient do with relatively old silicone gel implants that may or may not be aesthetically pleasing anymore?  I am presented with this scenario weekly in my practice.  I start by asking the patient if she is happy with her implants and if she likes the way her breasts look.  I also like to know if the patient would be comfortable  with smaller breasts and if she thinks she would be happy with no implants at all, meaning, remove the implants with no replacement.  My experience removing several hundred patient’s silicone implants over a 25 year practice is if the implants are more than 20 years old, there is a very high likelihood that the implants have  leaked or have ruptured.  This is not a certainty, but the incidence of failure is quite high in older  implants.  With that knowledge in mind, my recommendation is almost always to remove old implants if your health is good.  Removal of the implants is a procedure that is performed under general anesthesia and can take anywhere from a little over an hour to several hours to complete, depending on whether the implants are on top of, or underneath the pectoralis muscle (under the muscle is more complicated).  The complexity of the surgery can be affected by whether the implants have ruptured, and whether the silicone leaked in the implant pocket or within the breast tissue itself.  Once a patient has decided to remove her old implants, the next question is whether she wants them replaced.  In most of my patients where explantation is recommended, my advice is to leave the implants out, reassess the breasts after 6 months, and then decide whether to get new implants.  Most patients (greater than 90%) decide that re-augmentation is not needed after the six month waiting period, and are very happy with the appearance of their breasts after removal without replacement.  The biggest concern that patients with old silicone gel implants have is whether their breasts will be distorted, saggy, or too small after implant removal.  It is usually predictable pre-operatively whether there is a significant chance of breast distortion after implant removal, and if there is a high likelihood, then immediate re-augmentation can be considered.  As for whether old silicone implants are a health risk, there is no hard evidence that old implants, whether they have leaked or not leaked, pose any risks to your health.  The reason I recommend removal of old implants is that once they have leaked they are not in the condition in which they were meant to be.  I recommend any patient who has silicone gel implants more than 20 years old visit the surgeon who originally placed the implants or another board certified plastic surgeon if your original surgeon is not available.  It is helpful, though not mandatory, to try to get the information about your implants if you can before you see a new surgeon who was not involved in your original surgery.

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William Byron Barber II, M.D. has been practicing plastic surgery in Greensboro for 20 years and is certified by the American Board of Plastic Surgery.  He is Chief of Plastic Surgery for Moses Cone Health System, and is an active member of numerous local, regional and national plastic surgery associations.

Visit his website at: www.BarberPlasticSurgery.com or e-mail him at: AskDrBarber@BarberPlasticSurgery.com