The art of BOTOX

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My 2015 article from Madison Avenue Resident Magazine, NYC still holds true today. Click on the article to enlarge. 

Balanced botox is an art form. 

Each face is unique and success lies in the subtlety with which it is applied.

Your practitioners experience and good judgment make ALL the difference in the world.

The M formula applies for men and women to calculate the amount of BOTOX each person should get to look and feel natural in order to avoid a "mask like" appearance.

Subtlety is the key to BALANCED BOTOX.

Beauty Through The Eyes Of An Artist

Dr. Magana is devoted to the art and science of plastic surgery. His early background in the arts and movie industry in Hollywood furthered his deep appreciation for beauty and aesthetics.

After completing his six years of medical school, he continued with seven more years of rigorous training in general surgery.  He then participated in numerous fellowships, including two years of burn surgery at New York Hospital, craniofacial surgery at Children’s Hospital in Salt Lake City, Utah and aesthetic and reconstructive breast surgery at the Northern Westchester Aesthetic Institute in Mount Kisco, NewYork. Continuing with his extensive education, he went on to complete a two year residency in Plastic and Reconstructive Surgery at the prestigious Medical College of Georgia.  He has co-authored publications, including scientific articles and book chapters about reconstructive surgery.  Upon completion of his plastic surgery training, Dr Magana was awarded the esteemed Kenna Given Award for his dedication to excellence.

Dr. Magana currently travels on mission trips to southeast Asia to perform cleft lip and palate repairs, as well as, other reconstructive surgery for underprivileged and segregated communities.

Presently, Dr. Magana’s offices are located on Putnam Avenue in Greenwich, Connecticut and on Park Avenue in New York City.  It is here that he implements his talent as an artist and his expertise as a physician to obtain optimal results and create beauty in a subtle, natural manner.  He performs surgery at the state of the art facilities at Stamford Hospital and Northern Westchester Hospital.  Dr. Magana works hard at fostering relationships between himself and his patients, as well as his colleagues, who have often described him as being kind, knowledgeable, and meticulous.

Rafael G. Magana MD

From Make up to Plastic Surgery

Dark Eye Circles.. How to get rid of them..

NYC Cosmetic Surgeons Articles on Dark eye Circles~ Dark Circles Eyes ~ Eye Circles


Dark Circles around a panda bears eyes may be cute... but... not so much under your eyes..

                                   Courtesy of Womans fitness.net

What causes them?

-Heredity: dark eye circles may run in families

-Allergies
-Atopic dermatitis (eczema)
-Lifestyle: stress, Alcohol abuse, lack of sleep
-Nasal congestion: this may cause engorgement of the veins around the eyes that drain the region creating a ---Bluish hue from chronic venous congestion
-Pigmentation irregularities: may be more common in people of color, especially blacks and Asians
-Rubbing or scratching the area
-Sun exposure which induces formation of melanin (substance that gives skin its color)
-Thinning skin and loss of fat and collagen: this occurs with age, making the underlying vasculature more visible

How do you treat them??


Stay tuned...

Bibliography:
Skin Deep-Treating Dark Under-Eye Circles "Putting you tired look to rest". Katie Sezima; New York Times 2008. NYtimes.com. Accessed July 28, 2011

Breast Implants and Breast Feeding.

NYC Breast implant articles~Breast implants and breast feeding~Best breast implants and Breast feeding 


Is Breast Feeding after Breast Augmentation safe for your baby?


Several thousands of women undergo breast augmentation every year. Many of them in childbearing age. A frequent concern regarding silicone implants is whether or not the ability to breast feed is preserved, and if so, is it of any consequence to the baby. Fortunately, to date, there seems to be no major implication to the child in these circumstances. Studies analyzing the amount of silicone contained in the milk of lactating mothers when compared to commercial formulas have found little difference in the silicone content. The importance of breast feeding is undeniable. Medical literature has documented the nutritional and immune-stimulating properties of  of maternal milk when compared to commercial formulas. Maternal milk seems to be particularly protective against common childhood conditions such as Eczema, Iron deficiency anemia and Otitis media. Other less common and more serious diseases seem to be unequivocally mitigated by breast feeding; upper and lower respiratory infections and lymphoma amongst others.
For these reasons, it is recommendable to breast feed if the mother is able to do so. Approximately 50% of women are able to breast feed at baseline, and it is important for the physician to discuss this prior to undergoing breast augmentation with silicone or saline implants since it is unknown whether a patient is able to breast feed at baseline prior to the procedure.

                                                      Angelina Jolie Breastfeeding Courtesy of fashionexplorer.net






A study published in PRS in 1998 undertook the arduous task of comparing the levels of silicone in breast milk from lactating women with and without silicone implants.
Two other sources were also included in the study consisting of cow's milk and infant formula for silicon content.
The samples were prepared in a special class one hundred "ultraclean" laboratory and analyzed via graphite furnace atomic absorption spectrophotometry. Silicon levels were analyzed in breast milk, whole blood, cow's milk, and 26 brands of infant formulas.

-Lactating women with implants were found to be comparable to control groups when measuring silicon levels:

(55.45 +/- 35 and 51.05 +/- 31 ng/ml, respectively) 

-In blood (79.29 +/- 87 and 103.76 +/- 112 ng/ml, respectively). 

-The mean silicon level measured in store-bought cow's milk was 708.94 ng/ml, and that for 26 brands of  commercially available infant formula was 4402.5 ng/ml (ng/ml = parts per billion)

-lactating women with silicone implants are similar to control women with respect to levels of silicon in their  breast milk and blood. 

-Silicon levels are 10 times higher in cow's milk and even higher in infant formulas.

In conclusion: there is no current evidence that would suggest that silicone implants have any undesirable effect on the child in the breast feeding period.

- Do silicone implants reduce the ability to breast feed?

The breast tissue that produces milk is in reality a modified sweat gland. It lies over the pectoralis major muscle and is composed of units known as lobes. Each lobe is composed of lobules. Small ducts emanate from the lobules where the milk is produced and then channeled toward the nipple where they coalesce into several lactiferus sinus which then empty into the nipple. Silicone implants are always placed behind the gland and does not divide the ducts or damage them. If the lobules and ducts are intact, the production of milk shouldn't change. Of the four procedures to insert implants, only one may divide the breast tissue containing the ducts, namely, the Trans-areolar approach. In general, even this approach usually does not affect breast feeding.


Breast implant approaches:


-Trans-Areolar: divides breast tissue, but usually does not affect lactation
-Inframammary incision: This incision is made under the breast crease and introduces the implant behind the breast tissue, avoiding the gland alltogether
-Trans-axillary Incision: In this method, the incision is in the axilla and the implant is once again introduced behind the breast tissue without damaging the glandular breast tissue
-TUBA Trans-umbilical Breast Augmentation: this procedure is only appropriate for saline implants and it uses a scope for dissection from the umbilicus to the retro-mammary space (behind the mammary gland) and does not affect the gland.

It has been documented that a women undergoing breast implant placement have a 2.6 to 3 times greater risk of not being able to breast feed than the rest of the population. This is in part attributable to the surgical approach which may be trans-areolar, and to the possible unwillingness of the mother to lactate after augmentation.
It should also be mentioned that if a woman is already lactating and wishes to have breast implants, it is advisable to wait for 6 months prior to undergoing augmentation. Milk accumulation has been documented in the peri-prosthetic space after surgery when augmentation is performed earlier.


Stay tuned.....

Bibliography:

1.Breast Milk Contamination and Silicone Implants: Preliminary Results Using Silicon as a Proxy Measurement for Silicone Semple, John L.; Lugowski, Stan J.; Baines, Cornelia J.; Smith, Dennis C.; McHugh, Alana .  Plastic & Reconstructive Surgery. 102(2):528-533, August 1998.
2.Berlin, C. M. Silicone breast implants and breast-feeding. Pediatrics 1994; 94:546-49.
3. Silicone Breast Implants and Breastfeeding, Cheston M. Berlin, Jr. MD, Hershey Medical Center, Hershey, PA, from Breastfeeding Abstracts, February 1996, Volume 15, Number 3, pp. 17-18.
4. National Academy of Sciences Institute of Medicine, Safety of Silicone Breast Implants, National Academy Press, Washington, D.C., 1999, p. 197.

*Always consult with your plastic surgeon prior to undergoing any cosmetic procedure.Make sure your cosmetic surgeon is an ABPS (American Board Of Plastic Surgery) Board Certified or Board Eligible Plastic surgeon.

Rafael Magana MD
http://maganaplasticsurgeryarts.com/

Excess Armpit Sweat / Axillary Hyperhidrosis

NYC Plastic Surgeons Hyperhidrosis articles~NYC Cosmetic Surgeons Hyperhidrosis Articles~ NYC articles on  Hyperhidrosis


Yes.. sweaty armpits happen...


Axillary Hyperhidrosis (AH) is a condition characterized by excessive sweating in the armpit area. It is uncomfortable to patients who suffer it and can result in depression in some cases. It may exacerbated by different emotional states such as nervousness or anxiety. In the stricter sense, Hyperhidrosis is sweating in excess of the required amount normally needed for thermoregulation.
The ethiology (cause) of AH can be divided into primary and secondary. The primary has no recognizable cause for the excess activity of the Eccrine glands (Sweat Glands). Secondary Hyperhidrosis is caused by a concomitant illness or recognizable associated causes including certain medications.

What are the causes of secondary AH ?

-Diabetes Mellitus
-Pheocromocytoma
-Thyrotoxicosis
-Cancer
-Carcinoid Syndrome
-Parkinson's syndrome
-Lung Disease
-Heart Disease
-Menopause
MEDICATIONS:
-Propranolol
-Physostigmine
-Pilocarpine
-Tricyclic antidepressants
Normal Physiologic States
-Emotional excitability
-Menopause
-Hot environment and/or exercise

Prior to treatment,  a thorough history and physical exam should be done to exclude any causes of secondary hyperhidrosis.
Diagnistic tests for this condition include:

-The Starch-iodine test. In this test, an iodine solution is applied to axillary area bilaterally. Once it has dried, starch is sprinkled on the site. The combination of excessive sweat and starch results in a dark blue color yielding a positive result in the presence of hyperhidrosis. This is often patchy in nature, revealing the most concentrated sites of sweat secretion

-In the Paper test. Special paper is placed on the affected area to absorb the sweat, it is then weighed to determine the amount of sweat contained in it.

-The most accurate to determine the presence of hyperhidrosis is with a device called a VapoMeter which provides an objective measurement for the amount of sweat. It measures the relative humidity in grams per meter square per hour and is quite accurate. Three measurements are done in the clinic and a control site such as the forearm is used as a control.

What are the treatment options?
Non Surgical treatments include:
-Antiperspirants: Usually in the form of aluminum chloride hexahydrate which will occlude the outlet of the gland decreasing the actual perspiration versus a deodorant which does not address the amount of sweat being perspired
-Iontophoresis: This method is FDA approved and uses a small electrical stimulus to reduce the amount of secretion in the affected area. It is most effective in the soles of the feet and the palms. The mechanism of action seems to be mild thickening of the regionally affected skin.
-Systemic Medications:Usually in the form of Anticholinergics such as Glycopyrrolate which decrease the amount of sweat being produced. These medications may have side effects such as a dry mouth, Dizzines and sometimes produce difficulties urinating.
-Botox: Type A botullinum type toxin is FDA approved for the treatment of Hyperhidrosis. It is generally effective in decreasing the symptoms associated to AH. It's mechanism of action consists in blocking the signal from the regulating nerve to the actual gland. Downsides to this treatment are that it is temporary and should be repeated every 3-6 months, may be locally painful and also produce a some local transitory weakness. It may be applied with a pre-fabricated grid shape, or with a more targeted  fashion by following the the "Minor's Starch Iodine test enhanced sites which are sometimes scattered.
Surgical Options:
-Endoscopic Thoracic Sympathectomy : This procedure is done via 2 incisions in the axilla. The sympathetic chain is localized next to the vertebral column anteriorly and then divided, thus cutting the nerve supply to the sweat glands. In the right hands, this procedure has a high success rate of 90-95%. There may be recurrence a small percentage of the time, or compensatory sweating in other parts of the body as a result of the sympathectomy.
-Suction assisted Arthroscopic Shaving*

*Definitive Diagnosis and Management of Axillary Hyperhidrosis: The VapoMeter and Suction-Assisted Arthroscopic Shaving.

This last procedure can be done in under an hour under general anesthesia and provides lasting effects by permanently excising the local sweat glands. It is done by marking the hair bearing area of the Axilla, after which 0.5% lidocaine is infiltrated for hemostasis (to reduce bleeding). A small incision is made in the crease area and the Arthroscopic Shaver is introduced and the eccrine glands (Sweat glands) are ablated by "Shaving" them off. This procedure does not damage the hair follicles.





There are support groups for this condition such as the International Hyperhidrosis Society
http://www.sweathelp.org

*Always consult with your plastic surgeon prior to undergoing any cosmetic procedure.Make sure your cosmetic surgeon is an ABPS (American Board Of Plastic Surgery) Board Certified or Board Eligible Plastic surgeon.

Rafael Magana MD

http://maganaplasticsurgeryarts.com/

Stay tuned.....

Bibliography:
1. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004518/ : Accessed 7/20/2011 4:28pm

2.Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs. A critical analysis and long-term results of 480 operations. F Herbst, E G Plas, R Függer, and A Fritsch, Annals of Surgery 1994 July; 220(1): 86–90.
3. The use of a grid to simplify Botulinum Toxin for Axillar Hyperhidrosis;Gina M. Kavanagh, M.R.C.P.
Department of Dermatology Royal Infirmary of Edinburgh Lauriston Clinic Lauriston Place Edinburgh EH3 9YW, Scotland gina.kavanagh@luht.scot.nhs.uk. ; Letter to the Editor~ Plastic and Reconstructive Surgery • January 2006
4.Definitive Diagnosis and Management of Axillary Hyperhidrosis;The VapoMeter and Suction-Assisted Arthroscopic Shaving David L. Larson, MD,Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin. Aesthetic Surgery Journal July 2011vol. 31 no. 5 552-559

Recommended Reading:
1. Kleyn, E., and Hepburn, N. C. The management of localised hyperhidrosis. Dermatology in Practice 10: 22, 2002.
2. Simonetta, M., Cauhepe, C., Magues, J., and Senard, J. A doubleblind, randomized, comparative study of Dysport vs. Botox in primary palmar hyperhidrosis. Br. J. Dermatol. 149: 1041, 2003.
3.To¨gel, B., Greve, B., and Raulin, C. Current therapeutic strategies for hyperhidrosis: A review. Eur. J. Dermatol. 12: 219, 2002.

Asian Eyelid Surgery NYC

Asian eyelid surgery Articles~NYC Cosmetic Surgeons~NYC Plastic Surgeons

Asian eye lid surgery (blepharoplasty) has become an increasingly popular cosmetic surgery all over the world. A common erroneous belief is that the goal of this type of procedure is to achieve  a  "westernized" appearance, which is rarely the case. Instead, the goal is most commonly a natural and younger appearance.
There are of course, exceptions to this as is shown in the linked report by CNN  below
Often patients will seek this surgery because they feel that a heavy upper lid will limit their expressive ability and thus limit their ability to interact socially. This concept is often misconstrued by American, European and non-Asian individuals as a desire to appear more Caucasian.

                                                           Courtesy of  www.inimactu.blogspot.com

                                                            Click on Image: Courtesy CNN



A deep understanding of the delicate regional anatomy is essential to performing any eyelid surgery. The nuances of the Asian blepharoplasty (Lid surgery) escape many surgeons.

Basic Asian eyelid anatomy

What are some of the characteristics of an Asian eyelid when compared to an occidental eye?
-The presence in varying degrees of an epicanthal fold. When prominent epicanthal folds are present medially (on the nasal side) they can give the undesirable illusion of esotropia (cross-eyed).
-An eyelid crease which is lower set and often not visible. When present, it differs from the non-Asian population in that is parallel to the lid margin and narrows as it reaches the nasal edge of the lid
-The angle of the brow tends to be higher medially (Close to the nose) in Asian eyelids
-Shallow orbits (eye bones)
-Minimally or non Cantilevered supraorbital ridges

The so called "double lid surgery" is the commonly requested surgery make the eyelid crease a more noticeable trait.  This procedure has been analyzed over the years and modified many times over the years.

Fast facts about the double eyelid procedure
-The prominence of the epicanthal fold is decreased by doing local flaps
-A lid fold is created by applying parallel sutures that create a new crease which is parallel to the edge of the eye lid
-In expert hands the procedure takes around an hour
-There is a "non-incisional" method for Durable Suture Technique (DST). Long term follow up results on this  technique are not yet available.

Potential complications:
One major single surgeon study quoting over 6000 patients in 18 years showed the following complications

                                                                            Reference#2
During the perioperative period, the pateint may have eyelid swelling which may take weeks to months to return to a normal volume. This must be discussed in advance with the patient.

                                                           Courtesy of www.abagongfileswordpress.com

Principles of the Asian "double lid surgery"
This varies greatly between individuals since the presence of an epicanthal fold or how noticeable the eyelid crease is or isn't to begin with differs from person to person. However the principle can be reduced to addressing two key issues:
-A decrease in the prominence of the epicanthal fold
-Creation of a more noticeable eyelid crease

Conclusion:
In the right hands, this procedure yields fast and satisfying results to the patient. However it must be kept in mind that the immediate appearence postoperatively does not reflect the final outcome, which is true of so many other procedures in cosmetic plastic surgery.
Other issues should be recognized, acknowledged and addressed prior to undergoing a blepharoplasty. Amongst these are the presence of asymmetry, eyelid ptosis(droopy eyelid), disfunction or dehiscence of the levator muscle of the eyelid causing droopiness for reasons other than mere excess tissue.
Asian blepharoplasty (eyelid surgery) may be enhanced with a frontal lift.




*Always consult with your plastic surgeon prior to undergoing any cosmetic procedure.Make sure your cosmetic surgeon is an ABPS (American Board Of Plastic Surgery) Board Certified or Board Eligible Plastic surgeon.

Rafael Magana MD

http://maganaplasticsurgeryarts.com/

Bibliography
1.Aesthetic Plastic Surgery;By Sherrell J Aston, Douglas S Steinbrech and Jennifer Walden  Chapter 33
2.Asian Blepharoplasty: An 18-Year Experience in 6215 Patients; Arthi Kruavit;Aesthetic Surgery Journal 2009 29: 272  DOI: 10.1016/j.asj.2009.04.004 
3.Anatomic Microstructure of the Upper Eyelid in the Oriental Double Eyelid,Jian Cheng, M.D., and Feng- Zhi Xu, M.D. Plastic & Reconstructive Surgery. 107(7):1665-1668, June 2001.
4.A New Crease Fixation Technique for Double Eyelidplasty Using Mini-Flaps Derived from Pretarsal Levator Tissues ;Choi, Yeop; Eo, SuRak;Plastic & Reconstructive Surgery. 126(3):1048-1057, September 2010. doi: 10.1097/PRS.0b013e3181e3b72a
5.The Concept of a Glide Zone as It Relates to Upper Lid Crease, Lid Fold, and Application in Upper Blepharoplasty Chen, William Pai-Dei Plastic & Reconstructive Surgery. 119(1):379-386, January 2007.
doi: 10.1097/01.prs.0000244908.04694.32