There's an interesting series of aging studies on twins in the literature recently.

The first (see here) was a series of observations made on the contributions of different factors on aging. These factors included

• smoking
• both obesity and being thin at different ages
• sun damage
• depression (?)
• divorce

The relationship of body weight is interesting, but kind of intuitive. A heavier body weight before the age of 40 was associated with an older appearance. However, in the women over 40, a heavier body mass index (BMI) was associated with a more youthful look. In plastic surgery, we've known for awhile that the aging face is not just loosening of the skin, but is driven by a progressive "deflation" of the fatty tissue, recession of the bony prominences of the cheek/midface, and thinning of parts of the skin
with simultaneous thickening of other parts from sun damage. Fat grafting and the use of off the shelf dermal fillers are now routinely used to complement face lifts.

I think this picture from the series is most illustrative of that principle.



Notice the deeper lines by the cheek (nasolabial folds) in the gaunt twin.

The other study is published in this weeks' Plastic Surgery journal and is titles "Identical Twin Face Lifts with differing techniques: A 10 year follow up". It was basically a bet among some of the heavy hitter face lift surgeons about which techniques would hold up best, with the gimmick being it would be performed on identical twin volunteers.

When the procedures were done in 1995, the debate was really about whether newer more invasive techniques being written about like the "deep plane facelift" would hold up better then older,simpler techniques ("SMAS flap" and "SMAS plication" procedures).

What's interesting is that all the twins looked better and the results were fairly well maintained, even 10 years out from surgery. The following editorial was very diplomatic (excellent results can be obtained from different techniques...yada, yada, yada)and not very conclusive, but seemed to talk past the elephant in the room.

Sometimes you have to call a spade a spade:
Looking at a study like this how could you plausibly still assert that the added risk of facial paralysis from the more complex surgery type is justifiable when it's not clear there is any maintained advantage in results. None. Zero. Zilch.

Dr. Dan Baker of Manhattan, face lift god, has been evangelical about this safety issue going back 15 years. He should know. As a young surgeon in the 1970's, he developed a reputation for fixing severed facial nerves from face lifts referred to NYU. Dr. Baker has a wonderful talk about his personal evolution on face lift surgery that I saw as a medical student 13 years ago that was seared in my brain. His simple theorem on risk/reward with complex face lifts has now clearly been validated in print. All the pictures are good results, but I'll be damned if Dr. Baker's patient in this twin series (the one on the far left)doesn't look the best and most natural 10 years out.



Rob

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Now that you've been roped in with a salacious post title, the answer is kind of boring and mundane.

So what do they have in common? Trademark issues.

This type of Lesbian on lesbian action involves the tiny Aegean Sea island of Lesbos, home to the ancient Greek poet, Sappho, who famously praised romantic love between women 2700 years ago and gave us the origin of the term lesbian, has been threatening to sue to protect it's name from being used by Gay rights groups.

Similar to other old world cities, and most often involving foodstuff or liquors, these areas do have some legal claims on words derived from the area if they've trademarked them in a concept known as "protected designation of origin".


Image Source: Slap Upside the Head Blog.

Think of things like

• champagne - which can only come from certain areas of France


• Bourbon whiskey - which has to come from Kentucky and be distilled a certain way


• Roquefort cheese - cheese must be made from milk of a certain breed of sheep, and matured in the natural caves near the town of Roquefort in France, where it is infected with the spores of a certain fungus that grows in local caves (Ick!)


• Budějovický Budvar beer from the Czech Republic city of Budweis which had brewed a budweiser (literally a "beer from Budweis") style of beer since the 13th century, had a 20 year lawsuit settled with American corporation, Anheuser-Busch Co. over their popular Budweiser brand. This Czech beer, praised by beer aficionados, is now available in the USA as the brand, Czechvar. (Good stuff!)

The concept of trademarking surgical procedures has caused a little controversy in recent years. In particular, a number of facelift variations have been given catchy monikers like QuickLift, ThreadLift, S-lift, MACS lifts, E-Z lift, Lifestyle lift, etc.... Some surgeons have even had enough gumption to send cease & desist letters claiming intellectual property violations for surgeons performing these procedures. They were actually asking for royalties to do these operations.

The "Lifestyle Lift", a minor variation of the "short scar" facelift procedures has been commercialized by a chain of clinics and is advertised heavily in print and media. There have been an inordinate number of complaints (see here) among patients with these clincs which may represent who is doing the surgery (often not plastic surgeons at these clinics) rather then some inherant flaw in the technique. You can get OK results in very modestly aged faces with these procedures, but I get the impression it's being used on people that need "real" facelifts. A popular variation (and one I like), the MACS lifts, is a little more powerful tool for trying to get by with shorter scars on some of these patients.

This practice goes against a long history of our profession disseminating ideas & innovations around the world. Cosmetic surgery is probably one of the only industries where businesses publish and lecture on their trade craft for free! In addition, many of these "new" surgeries have been described many times before if you know where to look. John McGraw, the father of modern reconstructive surgery, has quipped "If you think you've invented some new operation in Plastic Surgery, you probably haven't looked in German surgery journals from the 1920's!"

Rob

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In a story that brings to mind John Woo's "Face-off" which starred John Travola and Nic Cage as an FBI agent and drug dealer/terrorist who "switched faces" via plastic surgery comes this news off the wires.
Ramirez Abadia, a leader of Colombia's biggest drug cartel who had his features deliberately altered by plastic surgery, was identified by Brazilian and American anti-drug agents using advanced voice recognition technology.

A write up can be found here from the Washington Post.

U.S. intelligence agencies have used voice recognition for decades, but the technology has become much more effective in recent years through improvements in software that rapidly analyzes vocal frequency patterns, said Jim Hunter, a partner in the Merlin Risks security firm in Sao Paulo.

"The way you use your voice is as individual as fingerprints," Hunter explained. "If they have a sample of a known voice and they get an unknown sample of sufficient length, they then test the unknown against the known."

The process is more complex than fingerprinting because peoples' voices are different when they speak normally, yell or whisper _ but the software breaks down different frequencies and uses statistical analysis to make matches

Good plastic surgery should not be able to make you unrecognizable to family, friends, or intelligence agencies. How would you alter yourself to evade detection? Let's look at Mr. Ramirez to get some ideas.

If you look at the difference between the "new & improved" drug dealer on the left with some old FBI stock photos on the right & you can see some rather obvious stigmata of plastic surgery.

He apparently was once a handsome man who has been altered into a vaguely humanoid thing. It looks like he's had

• rhinoplasty - note the excessively narrowed upper part of the nose & I think you can see a red scar inside of the left nostril on the upper picture
• Face lift & neck liposuction - his face is kind of globally distorted. On the underside of the neck there appears to be a "dent" which can be from sutures or liposuction. He's also got a very prominent chin cleft which wasn't evident (to me) on the old blurry photos.
• blepharoplasty (eyelids) - he's got a rounded eye and clear ectorpion or "scleral show" (scar contracture which pulls the lid down and shows more of the 'white of the eye') on his left lower lid which a not infrequent complication of lower eyelid surgery
• facial implants - these are made from silastic (silicone rubber). I say this because his face has assumed all these weird geometries along the cheek, chin, and jawline. Facelifts and/or fat grafting can do this to some degree, but my money's on implants.

Rob

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There's a great,great interview with him about "volumetric facelifts" and fatty stem-cell injections on Make Me Heal that got me thinking. A reprint of a 2004 article on this concept from the Aesthetic Surgery Journal can be read on his website here.

Dr. Ellenbogen, who was famous within Plastic Surgery circles prior to his Dr. 90210 gig, has been an innovative visionary in my field since I was just out of diapers. I've never had the pleasure of meeting Dr. E, but the more I observe in practice, the more of his ideas about facial aging I find myself coming to independently. Dr. Tony Youn featured his mentor on his blog in April which can be read here.

Concepts of how facial volume loss (both fatty tissue and bony wasting) contribute to the aging face are becoming increasingly in vogue now in the Plastic Surgery literature. Dr. Ellenbogen has been preaching this for nearly two decades against a tide of "wind swept" facelifts as mocked in director Terry Gilliam's 1985 opus "Brazil" on actress Katherine Helmond.

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