Regardless of the cause of the dark circles, my experience over 20 years has proven that fat grafting is the only consistent and reliable means of treatment that has persistent, long term benefit.

The one unifying anatomical factor is the lower lid and cheek being in the same plane (angle) resulting in the appearance of a relatively flat cheek. Without the benefit of anti-gravity support a projecting cheek can provide, the under eye skin, muscle and fat undergo the additional stress of unopposed gravitational force. This makes it difficult for the skin to function optimally. The muscle must hypertrophy (thicken) in response to lack of support. The lower lid eye muscle is actually a deep purple color that can trans-illuminate through thin eyelid skin as a dark blue color. Prominent eyelid fat pads can compound the strain to this area leading to progressive dysfunction of the skin, darkening it in response to chronic stress.

Fat grafting when properly performed allows fat cells to be vascularized and survive as living cells. More powerful than stem cells from blood or bone marrow, adipose-derived (from fat) stem cells are the most potent stem cells in the body and do the best job in rejuvenating tissues. When grafted to the lower lid region they provide both a supportive and aesthetic function by enhancing anterior cheek projection. Over time, the combination of anti-gravity support and stem cells results in physiological benefit to the skin reducing the dark circles. The skin— an organ— repairs itself. The muscle no longer has to work overtime and can reduce its volume and depth of color. Finally, fat placed at the lower lid cheek junction changes the angle of the inclination of the lower lid altering how light is reflected off the lower lid. In addition to eliminating the dark hue, adipose-derived stem cells may be more directly responsible for the rejuvenation in these overly stressed tissues restoring a more youthful contour and balance to the face.

The good news is that CoolSculpting, the latest technique in fat freezing and fat removal, is uniquely suited to the two areas men care about most.

First, a quick lesson in anatomy and physiology. Did you know the number of fat cells in your body and their distribution are locked in during adolescence? The bad news is that it is impossible to kill or remove these fat cells through diet and exercise. More bad news if you are 40 or older…metabolic rates peak at age 30 and then decline. This makes it more and more difficult to keep fat under control.

Up until now permanent loss was only accomplished through liposuction. Today CoolSculpting gives men an easy “in and out” alternative for the long term control of body contour.

If after a consultation you are considered a good candidate, CoolSculpting works very effectively to remove genetically programmed fat cell numbers. The advantage of CoolSculpting over conventional surgery is three fold:

• There is no downtime, bruising, recovery or pain. It is a one hour procedure during which you can relax or use your laptop. You can return to work or full activity immediately.
• After the procedure, fat cells are programmed to undergo cell death over a period of 2-4 months. This slow well-controlled process allows skin adequate time to react and therefore minimizes issues with skin descent because of poor skin quality or elasticity. Poor skin elasticity is most commonly seen in men of older age and in men who have had significant weight fluctuations.
• While liposculpture is not considered a painful recovery, it does require some time away from the office and the use of a post-operative garment. This garment is essential to support the skin after the removal of the underlying fat cells which are there in part to provide antigravity support to skin. In CoolSculpting fat cells are not removed immediately but undergo a slow transition so the skin can adjust without a garment.

It’s important to note that in addition to fat cells in the subcutaneous (under the skin) position that are amenable to permanent removal men may also have an issue of significant intra-abdominal fat deposition. This fat is under the abdominal wall surrounding the organs and is not amenable to surgical removal but can only be controlled with diet.

If diet is truly the key to improving your shape, our nutritionist has many fans. Therefore an assessment between a prescription for an anti-inflammatory diet or physical removal of fat cells from the body is predicated upon an accurate physical examination that takes place during a consultation.

Dr. Kornstein has been at the forefront of hand rejuvenation. Short term methods include using fillers such as Radiesse, which “plump” up the skin and lasts about a year. A more permanent solution involves harvesting fat cells from other parts of the body and injecting them into the hands. The fat lasts 10 years. There is strong scientific evidence that it acts like stem cells, increasing circulation and causing new cells to grow, rejuvenating the skin on the back of the hands. Dr Kornstein is now looking into the use of Ulthera as an adjunct treatment to tighten and smooth the skin over the knuckles.

Below are two sets of before-and-after photos of patients who had their hands treated by Dr. Kornstein.

“The biggest fear most patients share with me is looking unnatural or “done.” It’s difficult to dismiss their apprehension because bad results are everywhere. Even celebrities are not immune to less-than-desired aesthetics. In addition to looking obvious, the fact is poorly conceived and performed cosmetic surgery can actually make the patient look older. And in some cases they might not have needed the procedure to begin with.”

Dr. Kornstein goes on to discuss how he works with patients considering revisional surgery. He is often struck by how brave such patients are as they are “taking yet another chance to get their lives back on track.”

Follow this link to read: Revisional Aesthetic Surgery.

A woman’s inner thigh contour should be an object of beauty. Realistically inner thighs can be a vexing source of concern and stress when they don’t look or feel toned or proportional when compared with the rest of the body. They are just as challenging for an aesthetic surgeon. It is important to recognize that an inner thigh is not a flat surface but a 180 degree curve and optimally treated from both anterior and posterior approach. Thighs are most commonly an amalgamation of fat cell enlargement and skin descent from where inner thighs attach to the groin crease.

Recently, new technologies have helped rescue aesthetic inner thigh emergencies without the need for removal of skin. Ulthera is a focused ultrasound modality that tightens skin while restoring elasticity and reducing fat cell volume.

CoolSculpting facilitates skin shrinkage and is an option in certain patients whose inner thigh circumference fits the existing applicator dimensions allowing for the number of fat cells to be reduced over the course of a few months.

Unlike other areas of a woman’s body where fat cells enlarge with age and adequate skin elasticity, lipoplasty can restore a youthful contour. When treated early in life, reduction in fat cell volume restores smooth contour as long as skin elasticity exists without significant skin descent.

People who have too high a proportion of skin descent realize the best result through surgery. Think of it the same way you would about a tummy tuck addressing extra skin. Inner thigh lifts have undergone a renaissance in my practice. I have modified both the technique and the support system for the inner thigh lift resulting in a smoother inner thigh contour post procedure as well as a more secure and long lasting scar placement in the inner thigh and the groin. I distribute the tension more evenly to the buttock crease and scars are located where the inner thigh meets the crotch. The distortion resulting from wide scars involving female genitalia and annoying post-op pulling seem to be a complication relegated to surgical history.

The mode of treatment for the optimal result can only be recommended after your consultation. In summary, two key elements determine your treatment plan—establishing what proportion of inner thigh is due to extra fat and what proportion is related to skin descent. If the skin has lost its elastic quality, the best results will be found using Ulthera or CoolSculpting. If excess fat is the primary concern, liposuction is the best choice. If however there is predominant skin descent from the groin attachment, an inner thigh lift is indicated. Cellulite in the upper half of the thigh is minimized and often surgical intervention is combined with liposuction around the knees and Ulthera to tighten the skin above the knee cap. This trilogy does a beautiful job of correcting descent and delivering an overall aesthetic contour.

An interesting phenomenon accompanies aging where Botox® alone becomes less effective in reducing wrinkles and lines and frequently leads to a lowered brow position. Many erroneously feel they have become “immune” to Botox. ® They attribute brow lowering to their body “fighting” the cumulative effects of Botox® as it tries to elevate the brows.

What is really going on is clear to aesthetic plastic surgeons who understand the aging process.

Atrophy of facial bones and fat typically begins at age thirty. As the aging process progresses, atrophy of the frontal (forehead) bone is evident as there is less antigravity support for the forehead. The body responds with more forehead muscle activity to lift the falling forehead. This, along with thinning of the skin, results in more visible forehead wrinkles. Using more Botox® initially may be effective; however, wrinkles caused by increased muscle activity are critical to maintaining brow position. Therefore Botox® actually leads to a lowered or aged brow position.

The correct way of treating the aging process and forehead wrinkles is to treat the cause—forehead atrophy. Fillers work well but do not slow the aging process and can be expensive due to the large area of the forehead. Fat grafting works best; the stems cells in body fat slow the aging process, but the procedure is quite technique dependent. Today, another alternative is available.

Ulthera ®has been used successfully to elevate the brow position by tightening the forehead skin and muscle. It also increases the collagen content of the skin improving elasticity and reducing wrinkles during animation. Using Botox® between the eyebrows and for crow’s feet releases these muscles resulting in additional brow elevation.

This combination approach has given patients a dynamic duo that treats both the symptom and the cause of aging in the upper third of the face, cost effectively and with no downtime.

The more medicine moves away from its roots, the more critical the need to return to our roots.

As a major physician-consumer of breast implants in NYC for nearly 20 years, I have been approached by many companies, and even offered free implants. For my patient’s sake, and my adherence to a heartfelt basic principle, Primum non nocere—Latin for “above all do no harm,” I have avoided these pitfalls and my instincts appear to be correct. The implants I use have performed as I have expected, to the highest standards.

To my knowledge, I was one of the very first physicians to recommend replacement of implants at ten years, as that is when the implant shell (the wall around the implant silicone gel) tends to weaken and rupture rates increase. While there is no medical reason for replacement, ruptured silicone implants can cause scarring in the breast and therefore possibly interfere with mammography. Be aware than the vast majority of ruptures, the silicone stays in the implant capsule( the scar tissue sack around the implants that the body produces) and therefore there is little or no risk of altered mammograms. You are only at risk for scarring and altered mammograms IF you have BOTH a ruptured implant AND a ruptured capsule, called a “double rupture.” Silicone implant rupture is the reason sonograms and MRIs are routinely recommended. In my personal experience implant rupture is over diagnosed leading to false positives. I make my decisions on a case by case basis and still rely mostly on an “old fashioned” physical examination.

Medicine has changed significantly since I was trained. I still hold true to the fact that I am a doctor first and foremost. It is up to me to use my training, knowledge and instincts to help guide my patients. My reputation has always been one of great care and conservatism leading to the trust my patients place in me which I never take for granted.

Foreshadowing is defined as “…an image of something suggestive of what is to come…the organization and presentation of events and scenes… so that the reader or observer is prepared…for what occurs later…”

In this particular presentation of events, I was the writer. The subject was skin and nipple sparing mastectomies. But no amount of foreshadowing could have prepared me for what was to come.

My writing career is focused on professionals and publications dealing with health, beauty and wellness. Many of my clients are cosmetic surgeons. Last summer I wrote an article featuring the latest surgical technique available to some women with breast cancer called “skin and nipple sparing mastectomies.” Earlier in the year I worked with Dr. Andrew Kornstein featuring unique procedures on his website including the same surgery with one exception—it is done in-house in his office surgical suite. “How far we‘ve come,” I thought—light years from the maiming, virtual amputations and long hospital stays—an exponential leap from replacing breasts with flaps, mounds and tattoos. My second thought was, “How lucky I was to have been spared.” I spoke too soon.

In 2006 I discovered a small lump, undetected by a mammogram. It was cancer, Stage I. After absorbing the initial shock, I opted for a lumpectomy followed by 7 weeks of radiation. Except for a small divot on the side of my breast, I was physically unscathed. Breast cancer for me was more a mental illness—a hole in my armor. How can someone who doesn’t even catch colds get cancer? The answer according to the great medical minds is they simply “don’t know.” Only 3% of those diagnosed with breast cancer have the infamous BRAC gene. The rest of us? A veritable lightning strike. In July of 2011 I celebrated my 5 year anniversary. No more looking over my shoulder.

In September 2011, just as my article hit the stands for breast cancer awareness month, and Dr. Kornstein’s site was complete, I felt a lump. Once again, it did not show up on a mammogram. I learned that when breasts are dense like mine, it can be as difficult to visually detect as a snowball in a snowstorm, even using digital imaging. Lightning struck twice—another Stage I cancer but this time in a radiated breast. The suggested treatment was a double mastectomy or take the chance I might not be lucky enough to find the next lump until it was too late. While the diagnosis was beyond upsetting, the serendipity of being privy to the latest, least invasive surgery and my working relationship with Dr. Kornstein dialed down my panic.

Dr. Kornstein arranged a meeting between me and his cancer surgeon partner from a prestigious New York institution where I was pronounced a good candidate. According to the cancer surgeon who has done hundreds of these procedures, there is no data to suggest a recurrence when opting to keep the shell of the breast. Removing tissue only and replacing it with a silicone implant is safe. A radiated breast, however poses a bit of a hurdle due to the potential for poor circulation. It could require a two step operation to retain the skin and nipples. Dr. Kornstein arranged several meetings and calls—some international—with other physicians who’ve worked with radiated breasts to be prepared either way. This clearly demonstrated his dedication and commitment to doing the right thing and anticipating any surprises. Fortunately my circulation was acceptable when examined during surgery. For extra reassurance Alloderm (donor skin full of stem cells) was placed between my skin and implant to expedite healing.

It was very important to me to emerge from this experience looking and feeling whole. I had seen Dr. Kornstein’s photo gallery. I interviewed him on his philosophy and approach to in-house mastectomies well before the subject became personal. Dr. Kornstein will tell you that reconstruction deserves no less emphasis on an aesthetic outcome than cosmetic breast enhancement. That attitude sets him apart from others who might share his technical genius, but not his judgment, vision or compassion.

I stayed the night in his recovery room with his nurse and left the next morning, very comfortable. Tylenol was all I took for mild soreness. One week post op I looked as though I’d had a breast augmentation, not reconstruction. I will never have to look into the mirror and be reminded of what was taken away. My only memory will be the body given back to me by Dr. Andrew Kornstein. It feels good to write a happy ending—especially my own.

Isabel Stoltzman
Dallas, TX

There are two potential issues with liquid silicone. First, is its’ purity. Many practitioners use low grade silicone in lieu of the FDA approved ophthalmologic silicone. Second, and most importantly, as facial structures surrounding the areas of silicone injections undergo their normal atrophy, the areas injected with silicone become disproportionally large and unnatural looking. Since silicone in general is not a reversible procedure, you can become permanently distorted.

The liquid silicone beads encased in scar become extensively intertwined with the subcutaneous tissues. In the lip this would be the lip muscle where the silicone not only makes the lips larger but influences how they move when you speak or smile. Removing silicone from the lips is difficult at best. Any surgical intervention to remove the silicone also removes muscle tissue and leaves a trail of post operative scarring in its place. The recovery from this surgery can be painfully long with profound swelling continuing for months. Some physicians use steroid injections to soften the scar but the result is rarely a normal size or aesthetically shaped supple lip. Obviously the best solution is to avoid any permanent fillers in the face however for many that decision has already been made. Until now there have been few options for those wanting to reverse the aesthetic damage done with silicone. The good news is that today there is an answer.

I recently treated a young woman with silicone lip deformity using Ulthera and have been successful in reducing lip volume including the unnatural anterior projections with no downtime typically associated with surgery. Ultrasound therapy—the hallmark of Ulthera—heats collagen and creates micro thermal “burns.” This gentle heating reduces and softens the scar volume so as lips move the scar becomes more linear and less bulky. Using a dental block eliminates any discomfort during the procedure. Ulthera ultimately influences the shape of the collagen resulting in the scar tissue becoming malleable and eventually adopting a more functional shape. The presumed mechanism is a remodeling and contraction of the scar tissue associated with the silicone beads. Think of a potter with a clay pot. While the clay is still wet, it can take a different shape depending upon the potters hands. Similarly, Ulthera reverses the “hardening of the clay” formerly present in the lips. As the mouth moves, the effects of Ulthera essentially help reshape the lips. Several sessions are necessary, but lips show an improvement immediately with more positive changes evident at 2 weeks and beyond. Apart from discovering Ulthera to be a cosmetically viable option, by far the biggest advantage is dodging the post operative trauma associated with surgical “correction.”

One of the most frequent concerns expressed by my patients on a virtually daily basis is that their facial surgery will result in a natural aesthetic, one that makes one see themselves in the mirror and not a stranger. I take great pride in having the ability to reverse undesired outcomes, giving patients the opportunity to regain the “identity” they thought was lost.

If you have saline implants…

Your risk of rupture with saline is no greater than that of silicone. However, when a saline implant ruptures it is obvious, leaving you with one full breast and one that is flat. Most women lead extraordinarily busy lives. Chances are a rupture will happen at the least opportune time—a business meeting, during vacation or right before an important holiday or event. [Read More...]

If you have silicone implants…

While the rupture rate between saline and silicone is no different, the consequences of a potential rupture with silicone are different. First, understand silicone ruptures pose no systemic health risk whatsoever. In 1992 the FDA took silicone off the market to investigate claims against its safety. As an investigator for an implant company, I was one of a few doctors able to use silicone during the moratorium. [Read More...]