Plastic surgeons are most notably sought after to perform tummy tucks, face lifts and breast augmentations but they also treat more subtle conditions such as adult acne, cellulite and varicose veins.
“[Treatment] can really make an impression on someone’s psyche,” says Dr. Christopher D. Knotts of the Austin-Weston, The Center for Cosmetic Surgery. These elective treatments may bring comfort to patients who may not be going to the beach because of cellulite or spending time with friends in social situations due to adult acne. “A subtle improvement in cellulite, a slightly larger bra size, a slightly tighter neck can really give people the confidence to live their life the way they want to live it.”
While a dermatologist may be the first doctor you think of to treat skin ailments such as these, plastic surgeons can also be a good option “due to their extensive knowledge of skin, its healing properties and the wide variety in surgeries, treatments, lasers [and] injectables performed at their offices,” says Dr. Timothy Mountcastle of Mountcastle Plastic Surgery & Vein Institute. “Plastic surgeons have extensive knowledge of the skin and wound healing in general.”
Adult Acne Scarring
When looking at present-day adult acne scar care, Bitar Cosmetic Surgery Institute’s Dr. Larry Lickstein notes a combination therapy approach is most effective. “For years and years and years, we’ve had patients come to us who are quite frustrated,” he says. “They are saddened that they got bad acne. They are further depressed that they have permanent scarring from it and then they tend to be frustrated because by the time they have seen a physician, they have often tried multiple over-the-counter treatments or salon-based treatments,” says Lickstein.
“We are starting with a frustrated patient population and, to be candid, I think to some degree, as physicians, we have been frustrated also because we like to fix things and make things look as perfect as possible. And I always caution my patients that with acne treatment, this is a treatment to produce meaningful improvement but it is not a cure. We can’t make your skin alabaster smooth but we can make a meaningful change.”
The first step is laser resurfacing where the outer layer of skin is removed to trigger more collagen to be made by the body—resulting in smoother, tighter and more youthful looking skin. Lickstein says the procedure, which leads to about a week of downtime, provides patients with some improvement. “That used to be where the story ended,” he says. “Nowadays, that is the starting point. Now we will have patients come back after that and instead of having downtime associated with lasering, we will do a series of medical grade microneedling where we are using a mechanical group of needles to further injure the skin and stimulate more healing, more collagen growth. … That [procedure] doesn’t have anywhere near the downtime. A day later, people are out and about.”
These procedures are then supplemented with biology by using platelet-rich plasma (PRP). “The concept in a lot of this skin repair is that we are creating an injury and asking the body to heal,” Lickstein says. “Much like when you go to the gym and work out, you are, to some degree, injuring your muscles for them to heal and get stronger and be better. We are doing that to the skin.”
Platelets release growth factors, causing collagen growth and repair so plastic surgeons take a patient’s blood and put it through a PRP generator—basically a centrifuge that separates the different components of blood. The portion that contains platelets and growth factors is placed on the wounds to take advantage of the body’s biological processes to further improve healing.
Bellafill is another treatment option where doctors take a needle and put filler under a depressed scarred area.
“The problem with traditional fillers is they tend to go away in a few months and people don’t like the process and the continued investment of needing to put more and more filler in,” Lickstein says. Bellafill is different from previous fillers as it combines bovine collagen with polymethyl methacrylate microspheres to stimulate the body into building collagen under the scar.
Sometimes the skin color at the base of acne scars is different, so plastic surgeons are able to treat that as well. Patients are put under a broadband light (BBL) along with applying topical skin care products to help lighten the skin to make the pigment become more uniform.
The number and length of treatments vary by patient including three to six sessions recommended for the needling and two to three for Bellafill. “I also emphasize to patients that this isn’t an all-or-nothing proposal,” Lickstein says. “It is a daunting thing to say to somebody ‘Here. We are recommending five different things that you can do.’ That can be overwhelming to them. It can be burdensome in terms of their time commitment, in terms of expense, but I tell patients to think in the long term. If they want to get more and more improvements, we have more things that we can offer them.”
Rarely does Lickstein see patients do every treatment in a short time frame. Rather, he sees them pick one and then come back in six months for more. He believes this multi-pronged approach to treating acne scars is beneficial. “It’s this dedication to looking at that process of acne scarring and trying to get integral improvements through several different modalities that really produces much bigger improvements in the appearance of acne scaring now than we have ever been able to achieve before,” he says.
Cellulite
Cellulite can be hard to treat because there are not many successful products and techniques on the market, plus it often returns. Septae, little fiber attachments, go from the deep tissue like a little rope up to the skin. When the rope tethers down, the cellulite divot is born. “The thing is—there is going to be more than one rope creating a divot,” Knotts says. “There might be 15, 20, or even 100 little bitty tiny ropes pulling down on the skin in that area that is making it look depressed … and so, really to get it to go away completely, you have to have all of those septae or those fiber attachments lysed. Mechanically lysing them can work but that is very labor intensive to go back and cut all those little hundred attachments underneath there. It takes a lot of work for that one little bitty bump and then just because you have cut them doesn’t mean it’s not going to reform.”
At Austin-Weston, they treat cellulite by placing a needle underneath the skin and using the back and forth motion of the needle to break up some of the septae bands and then come back and either do fat grafting into that area or just use foam and let the area heal. Knotts says they do not do many cellulite procedures but usually add it on when patients get a thigh lift.
“The concept of why cellulite is so hard to treat—we are plastic surgeons here,” Knotts says. “We are used to getting pretty amazing results. You put a breast implant in, someone’s breasts are suddenly two to three cups bigger in a single, one-hour operation. Cellulite is an underwhelming treatment in terms of the patient satisfaction. With cellulite treatment, just across the board, [satisfaction] is much lower than with lots of other surgical treatments. When you look at even what is considered a good result from before versus after, if you get 50 percent resolution, people consider that a good result.”
Treatment is usually confined to one spot, and the procedure may take an hour or two under local anesthesia. Knotts notes it is physiologically normal to have cellulite but as we age, we may see an increase because the skin is not as taut.
He cautions against people using creams because he has not had good experiences with them. “Most of the creams that are out there are short-lived if anything,” he says. “I would tell people to be very cautious about anything that causes swelling because swelling makes cellulite look way better. If you are doing something that is agitative to the thigh that causes a fair amount of swelling, as long as you have the swelling there, the cellulite will look really good and then when the swelling goes away—all the same cellulite will be present. If you are not treating the underlying physiological [issue], if you are not lysing those bands or treating them in some way, it is probably not reasonable to expect the cellulite to get better.”
Varicose Veins
The mainstays of treating varicose veins include radiofrequency ablation (RFA), lasers, injectable sclerotherapy and ambulatory phlebectomy, according to Mountcastle.
Typically, a person gets varicose veins due to refluxing in their great saphenous (GSV) or short saphenous (SSV) veins. “Refluxing means that the vein no longer properly works and the blood, instead of going back to the heart, is pooling in the leg and thus creates increased pressure. And thus, varicosity starts to grow to decrease the pressure in the GSV or SSV,” he says.
Through ablation or the laser, the vein stops leaking and takes pressure off the varicose vein, which then sometimes disappears on its own or requires an injection of sclerotherapy or ambulatory phlebectomy to resolve the bulging vein. Treatment procedures may vary from 30 minutes to an hour.
“A happy patient is every single plastic surgeon’s desire,” Mountcastle says. “That is why we go into the field of medicine: to help others and fix problems and get results for our patients.”