Trillium Cosmetic Surgery

Now, for a limited time, all cosmetic surgery procedures are 15% off!

Deposit must be made by May 1, 2008 surgery must be completed by July 1, 2008

*Laser Fractional Resurfacing at Trillium is now only $1995.00 for a package of 4 full face treatments! Offer expires May 1, 2008.

Since 1995, for over 350 patients, I have used a CO2 laser for skin resurfacing. The results have been uniformly very good, but the “downtime” involved weeping and redness for 1-2 weeks, then pink skin discoloration for 6-8 weeks. It was a controlled 2nd degree burn that healed from the “outside in,” and the results were exquisitely sensitive to the type of laser used and the surgeon’s skill. As the years passed, fewer and fewer patients were willing to hassle with the downtime and missed work, despite the results. Other methods and lasers were touted, but none ever delivered the results of the CO2 laser.

The Fraxel laser has recently been developed and marketed to the public, with, at best, mixed results. First, Fraxel treatments are very uncomfortable, and many patients require anesthesia. Second, the markings are placed on the skin, and the “downtime” is, at least, 3-5 days. Third, while the results have been compared to the CO2 laser by dishonest and/or ignorant practitioners, patients have been disappointed by the results of 1-2 very expensive, painful procedures. Consequently, in many areas of the country, the Fraxel laser has lost much of its initial popularity.

At Trillium, we now have the Palomar 1540 Fractional Laser for facial resurfacing. It is FDA approved for “soft tissue coagulation & skin resurfacing” and, to my knowledge, is the best available treatment for skin rejuvenation without significant “down time.” This is the “next generation” fractional laser, a new laser delivery process based on the erbium laser used in the late 1990s for resurfacing. Targeting the dermis and collagen, a tiny grid of laser beams penetrates the skin, heating the water of the deeper skin to cause inflammation and tightening. By shooting laser beams through very small holes in a grid, a “mesh” of laser beam skin damage is created, allowing several important advantages over all previous skin lasers. Most of the laser energy is delivered to the dermis of the skin, below the surface epidermis, allowing heating of the skin without removing its protective layer.

Patients rightly ask, “So what, how does that help me?” The advantages are significant. First, the discomfort is mild, and requires no anesthesia. Those of us who have had both the IPL and the fractional treatments usually think that the IPL is more uncomfortable. The laser tip is water cooled, and an entire face is usually treated in one session. The skin changes are not as dramatic as those following CO2 laser treatment, but most of the possible complications of CO2 laser use are also minimized or eliminated.

Second, the “downtime” is very minimal, with 3-4 hours of initial redness, then pink skin for 36-48 hours, as if you were at the beach a little too long. This pinkness is easily covered with make-up. Many patients can, and do, return to work the same day, or the next. Some will wait for 1-2 days before returning to work. I (Dr. Ehrlich) have worked the day after my first three treatments, with very few comments from patients. Most of them don’t even notice.

Although the post-operative changes are much less than those after CO2 laser resurfacing, the healing process must still occur. While the CO2 laser causes a 2nd degree burn which must heal from the outside in, the fractional laser causes heating below the skin, which must heal from the inside out. Therefore, instead of occluding the skin as with the CO2, the pores should be kept open, so that the damaged portions can “work their way out” to the skin’s surface. This is why it is important to use only water based cream, lotions, and cleansers after your treatment.

After 3-5 treatments, wonderful changes in the skin are possible, including smoothing of wrinkles, decreased discoloration, and improvement of acne scarring and pore size. We usually recommend 4 treatments spaced 3-4 weeks apart for maximal improvement. The final skin improvements will not be visible until at least 6-8 months after the last treatment is completed, a very subtle, but very significant change in the skin texture.

We are delighted to offer Fractional Laser resurfacing to our patients, and our initial results have been wonderful.

Is the treatment painful?

There may be some mild discomfort during the procedure in some areas of the face, the lips, near the nose, and the lower eyelids. Applying numbing cream and cold to the skin minimizes discomfort. You may also take either 600 mg. of ibuprofen (Motrin) or 1000 mg. of acetaminophen (Tylenol) one hour before your treatment. Most patients who have had an IPL treatment believe that the fractional laser is more comfortable.

Will I need more than one treatment?

Yes, if you want to be happy with the results. For maximal effect, 4-5 treatments spaced at least 3 weeks apart are recommended. A mild change of the lip line and eyelids may be present after 1-2 treatments, but this is unpredictable. The final changes in skin collagen will take 6 months to develop. In other words, your results are not instantaneous, the skin will continue to improve for at least 6 months, slowly and subtlety.

What is the “down time” involved?

As outlined above, you will be mildly swollen and red for 4-6 hours, then pink for the next 36-48 hours. You may apply make-up after 18-24 hours. Unless you cannot or will not allow other people to see your mildly pink skin, you should be able to do almost everything that you normally do.

Are there any “long term” side effects?

Almost always, the only long-term effects are those that we all want, an improvement in the skin. Rarely, there may be some increased pigmentation in a treated area. This can be treated with creams and IPL.

How do I care for my skin after the procedure?

You may apply cool, moist washcloths when you get home, use cool packs, frozen peas, or frozen corn in a baggie. There is aloe cream with lidocaine (sunburn cream) available in many stores. After 4-6 hours, you may wish to apply a water- soluble moisturizer every 1-2 hours while awake. Gently cleansing once or twice per day with a water-soluble cleanser will also help the inflamed areas and pores clean themselves.

The FRAXEL laser is very painful. Is this the same thing?

No, it is not at all the same. The discomfort is minimal, the heat is decreased, no markings are needed, and the results should be as good or better.

How is this different from the IPL machine that you use to treat blood vessels and pigment?

This laser will not improve facial vessels, but the IPL does. This is a laser, not intense pulsed light, and will tighten the skin and wrinkles much more than the IPL, especially after 4-5 treatments. If the facial pigment is significant, we may recommend IPL prior to the fractional treatment. By itself, the fractional laser will also lessen pigment.

Will the fractional laser treat acne scars?

Yes. In fact, it may be the best available treatment for acne scarring. It is better than the CO2 laser, because it can get the deep portions of the pits and scars without causing a 2nd degree burn and changing the skin pigment. By causing the acne scars to heal from the inside out (instead of the outside in, which causes very little improvement), a much better skin appearance is created.

I don’t want anyone to know that I had this done. Is that possible?

The initial redness and swelling is moderately noticeable up close for the first 24-48 hours, resembling sunburn, or after a mild skin peel. Without cover-up make-up, people will know that your skin is pinkish red for some reason, but it is not horribly messy.

Do different areas of the face respond differently to the laser?

With almost any superficial skin treatment, the thinner the skin, the more the wrinkles will improve. The lower eyelid skin and lips respond the fastest, and have the most noticeable changes.

If I have one or two treatments, will I still see changes?

You may notice some improvement, particularly in the eyelid and lip area. It should be obvious that 4-5 treatments will cause much greater changes. We suggest that you consider 4-5 treatments to achieve the full benefit of the fractional laser.

How much skin improvement can I expect?

The improvements are subtle, but very nice. Fine lines and wrinkles may improve 30-50%, while larger creases and deeper wrinkles may improve 10-25%. This depends upon your skin type, where the wrinkles are on your face, and whether or not you are willing to change how you care for your skin. If you smoke, drink, sunbathe, eat poorly (or all of these), do not expect as much improvement as you might have if you cared for your body and skin. For a treatment with virtually no “down time,” the results are usually very gratifying. Please do not expect significant improvements with 1-2 treatments. Even CO2 resurfacing or very deep peels cannot “erase” facial lines.

William W. Ehrlich, M.D., F.A.A.C.S.

On July 6th to July 8th of 2007, I was the invited speaker, guest surgeon, and anatomy instructor at a FAMI (facial fat grafting) course in Manila, Philippines. Twenty surgeons from Korea, Singapore, Australia, Germany, and Italy attended the three day course, organized by the Korean Aesthetic Surgery Society.

The first day included seven hours of my FAMI lecture and a welcome dinner with all attendees. I reviewed the basics of FAMI patient selection, the essential surgical techniques, and my patients’ results over a five year period.

The second day I performed live FAMI surgery for two female patients from Manila. During the first surgery, ten surgeons observed me in the operating room, while the other ten watched a “live” video feed of the surgery to an adjacent room. For the second case, they switched places, giving all of the surgeons the opportunity to observe live surgery and question me while I performed the surgery. This is a wonderful way for experienced surgeons to learn a new procedure, and I learn something new each time that I teach this way.

The third day was reserved for cadaver dissection in the Anatomy Department of the Medical School of the University of the Philippines in downtown Manila. I guided the surgeons (four doctors per cadaver) while they practiced injecting the facial muscles, then helped them dissect the muscles to view their injection results.

The course was very well accepted, and I thoroughly enjoyed teaching a wonderful, enthusiastic, international group of cosmetic surgeons. They were very attentive, grateful, and cooperative. The patients continue to E-mail me pictures of their progress, and they are looking more beautiful each week. Just as I found all of the Philippine people, the patients were genuine, sweet, extremely gracious, and very intelligent.

Not a complete stranger to Asia, I was the invited speaker and guest surgeon at a FAMI course in Seoul, Korea in 2005. My lectures were attended by over 75 physicians, while the live surgery portion was seen by 20 doctors. My 2005 demonstration of live FAMI surgery was the first such course ever given in Korea. I was chosen for that honor after I presented a paper regarding FAMI to the annual scientific meeting of the American Academy of Cosmetic Surgery.

Facial fat grafting (FAMI) is just beginning to be appreciated by patients and the cosmetic surgery community. After being taught by Roger Amar, M.D. (one of the pioneers of facial fat grafting and the developer of FAMI) in 2002, I have continued to perform (and teach) this amazing procedure. If I could perform only one cosmetic surgery, I would probably choose FAMI. The benefits are multiple, it is completely customizable for each patient’s face, and the results continue to improve for years after the procedure. Positive facial changes include volume enhancement, skin improvement, and wrinkle reduction. There is no other facial procedure which can provide these subtle but remarkable results without scars, sutures, or incisions. FAMI is not the same as “injecting fillers,” but is actual grafting of your own living fat to enhance your own facial structures.

Most amazing of all, we are almost certainly grafting adult stem cells to the facial muscles during FAMI procedures. We now know that adult fat has an abundance of stem cells, and these stem cells are retained in the purified and centrifuged fat used during FAMI. Grafted onto the facial muscles, around bone, and under skin structures, they may be able to rejuvenate facial tissues for many years after FAMI is completed.

Several of my FAMI patients who had surgery over 4 years ago have noticed that their facial skin has continued to improve since the surgery, even though it was many years ago. Recent research suggests that adult stem cells may have regenerative properties for many different tissues, and may remain active for at least 8-9 years after placement. An excellent stem cell article for non-scientists was published in National Geographic of July 2005.

I hope to continue to perform and teach the FAMI technique for many years (and many more patients) to come.

William W. Ehrlich, M.D., F.A.A.C.S.

Cosmetic surgeons who begin performing autologous fat transfer for facial volume restoration should be prepared for a steep learning curve and some surprisinging results, said William W. Ehrlich, M.D., at the annual meeting of the American Academy of Cosmetic Surgery.

“The FAMI technique is powerful and versatile and can enhance the outcome of other cosmetic procedures and even be a useful alternative to incisional browlift, allow plastic facial contouring, and some facelift or tightening procedures. However, excellent doctor-patient rapport is critical since facial autologous fat transfer results in an initial postoperative appearance that may be shocking to both the patient and the surgeon, especially after injection of large volumes,” said the assistant clinical professor of surgery, College of Human Medicine, Michigan State University, East Lansing.

Dr. Ehrlich, who has a private practice in Okemos, Mich., specializing in cosmetic and reconstructive surgery, spoke of the surprises he encountered and lessons he learned in his first 20 cases of facial autologous fat transfer. The procedures were performed between July, 2002 and September, 2003 as in-office surgeries. All of the patients were female and their average age was 52 years.

Under full tumescence produced with Klein’s solution, fat was harvested using low vacuum pressure and a 10-cc Coleman cannula. After centrifuging at 3500 rpm for 10 minutes, the fat was transferred into 1-cc blunt-tipped cannulas and implanted along muscle planes using the FAMI technique of French plastic surgeon Roger Amar M.D.

This 57-year-old woman received 44 cc of fat in one tx. Here she is before (left) and two months after the surgery (right).

For the fat transfer, patients received local infiltration anesthesia, nerve blocks, an oral sedative, and in a few cases, IV sedation. The average volume of fat transferred was 57 cc (range, 13 to 103 cc).

Discussing the early postoperative sequelae, Dr. Ehrlich explained that patients need to be forewarned their face will appear moderately to markedly distorted for two to three weeks after the procedure. In addition to evaluating whether patients fully grasp and seem willing to tolerate that consequence, the preoperative patient selection process should also identify candidates with realistic outcome expectations. “For example, I found out after the surgery that one patient who was moderately dissatisfied was hoping the augmentation procedure would improve her acne scars,” Dr. Ehrlich said.

More specifically to autotogous fat transfer, however, patients should be evaluated for features that adversely affect graft viability. Smokers should be strongly discouraged from undergoing the procedure as well as people with eating and body image disorders, who are at risk for being dissatisfied if they insist on dieting to achieve a lower than ideal body weight.

Dr. Ehrlich noted he encountered one postop infection in his series. Based on that experience, he strongly advocated an antimicrobial prophylaxis regimen consisting of an oral drug begun the day before surgery and continuing for one week postop combined with an IV antibacterial agent given perioperatively. The patient who developed an infection was treated only with an oralcephalosporin for prophylaxis, but the infection responded well to treatment with levofioxacin (Levaquin).

Dr. Ehrlich acknowledged that his preferences for using full tumescent anesthesia in the area of fat harvesting and to avoid tumescent anesthesia in the face represent technique differences compared with the approaches used by other surgeons. He does not use tumescent anesthesia at the recipient site because it distorts the architecture, but finds it has several advantages for harvesting as it allows that procedure to be done comfortably in the office and yields a product that contains little blood.

However, surgeons who choose to harvest fat under tumescent anesthesia must realize that about two-thirds of the volume is lost during processing and about onethird of the grafted volume is lost during the first two to three weeks after surgery. In addition, fewer of the swollen fat cells collected under full tumescence are able to fit within the close proximity to the vascular nutrient supply that is necessary for their survival.

Dr. Ehrlich indicated he plans his surgery using a diagram of the facial muscles and a grid marked for volume to be injected at each site. That volume needs to take into account the harvesting technique, regional differences in fat survival (least in the perioral and glabellar areas), and be individualized to the patient’s needs.

However, as a rough guideline for use of fat harvested with full tumescence, Dr. Ehrlich indicated the average total volume injected into the upper one-third of the face ranges from 18 to 28 cc while 50 to 60 cc would be injected into the lower twothirds of the face. For most individual muscles, however, the volume injected does not exceed 5cc. Dr. Ehrlich cautioned against injecting within the bony orbital rims, where there is a potential space into which the fat may be transferred, and not to overcorrect excessively.

“Given the limited capability of the 3-1) matrix of facial muscles to support viable grafts, one likely reaches a volume threshold which if exceeded would result in no benefit. In addition, there is a chance of causing a lasting overcorrection that is difficult to fix,” he said. With that caution in mind, Dr. Ehrlich said two conservative grafts are better than a single aggressive graft, and surgeons may approach the surgery with the idea of dividing it into two sessions spaced about six months apart. Among his first 20 cases, five were undercorrected and three had a second procedure.

In performing his first cases of facial autologous fat transfer, Dr. Ehrlich mentioned he also found the procedure provided some additional benefits. Most of the patients reported significant, persistent improvements in the tone, texture, and appearance of their facial skin, and several patients had a significant positive change in the appearance of the nose that nearly mimicked the results of a septoplasty.

“It is often said that the nose and ears enlarge with age, but in fact those structures only appear larger because the rest of the face shrinks away from them. As a result of fat injections, the face gains volume and the now looks relatively smaller,” he said.

We are located in Okemos, Michigan, which is in the Lansing Michigan area. Other towns within a 50-mile radius which we service include: East Lansing, Haslett, Williamston, St. John’s, Grand Ledge, Mason, Charlotte, Brighton, Jackson, and Howell. Our 4400 square foot office is equipped with 3 exam rooms, a comfortable waiting/reception area, a secluded area for patient counseling and scheduling, 2 aesthetic skin care rooms, an IPL treatment and hair removal treatment room, a pre-operative and recovery room, office surgical suite and several staff rooms. A confidential entrance and exit is available for post-operative patients and those patients wishing to preserve their anonymity.