This “milestone” study, according to American Society of Plastic Surgeons President Dr. Phil Haeck, brings surgeons one step closer to understanding why skin tightening alone with procedures such as a facelift, eyelid lift or brow lift may not be enough to restore a youthful appearance.

“The original thought was that skin goes through changes, such as a loss of elasticity and fat, so the primary approach to facial rejuvenation was skin tightening procedures,” study co-author Dr. Robert Shaw Jr. told HealthDay News.

“But a lot of faces never looked like they did when they were younger. Patients bring in pictures and say they want to go back to that look, but they can never really go back to that look just by tightening their skin alone. If there are changes to those underlying structures it’s going to change the appearance of how the skin looks.”

Study results, which are published in the January issue of Plastic and Reconstructive Surgery, indicate that bone loss and recession is most pronounced in women over 40 and men over 65. Study authors performed CT scans on 120 Caucasian patients (60 men and 60 women) split into three age categories—20-40 years, 41-64 years and 65 years and older.

“We saw changes around the eye, and then in the cheek area and in the jaw,” study co-author Dr. Howard Langstein told NPR. “And if you think about it, it kind of makes sense. When people age, the eyes appear hollow, deep-set. And, in fact, that’s what we found. The cheek bones right beneath the eye socket descend somewhat and come back in. As a result, they don’t give as much support to the lower eyelid.”

Langstein also said that chin recession and thinning of the jawbone were also major contributors to facial aging, explaining the slack-jawed appearance of some of the study’s oldest participants.

To combat the effects of bone loss on facial aging, Dr. Shaw suggest combining skin tightening with other cosmetic procedures designed to restore the facial structure, such as fat grafting, injections with fillers like Restylane or Juvederm and facial implants for the chin, cheeks and jaw.

“It’s not ever possible to bring someone back to how they looked when they were 20 years old, but adding volume back to the face can improve results for some patients,” says Dr. Shaw.

Since bones makeup the underlying structure of the skin and provide a sort of scaffold to support facial tissues, the study results are no surprise to cosmetic surgeons.

“It’s one of those things that, in retrospect, you sort of say, ‘Duh, I should have known that!’” says Dr. Langstein. “Nothing stays the same on the body. Everything ages.”

Brandon Alleman and his team of researchers at the University of Iowa surveyed 45 companies that facilitate medical tourism for U.S. patients and found that these companies have referred only about 13,500 U.S. residents to healthcare and cosmetic surgery facilities outside the country.

These companies represent about 70 percent of the market serving U.S. medical tourists, so if, say 23,000 American patients traveled abroad for medical treatments, that makes up only a tiny fraction of the number of patients treated in the U.S. each year.

This is good news to Indiana plastic surgeon Dr. David Robinson, as he and many of his colleagues, as well as respected plastic surgery organizations like the American Society of Plastic Surgeons, discourage American patients from traveling abroad for cosmetic procedures like liposuction, breast augmentation and even injectables for a number of reasons.

For instance, countries outside the U.S. where plastic surgery is less expensive often do not have adequate standards of care and official oversight designed to prevent avoidable complications and poor outcomes.

There is also concern over whether medical tourists actually receive treatment with the products or devices they think they are getting, and that they paid for. Many patients think they’re getting Botox or Restylane, but end up getting cheap knock-offs of the real thing, along with poor results.

In addition, most plastic surgeons agree that it is important to receive follow-up care from the physician who performed the procedure, which is not usually possible weeks or months after surgery, when patients have returned to their homes in the U.S. In fact, the study results showed that 93 percent of companies brokering medical tourism packages expect follow-up care to be performed by U.S. physicians.

Given the fact that many physicians are uncomfortable providing follow-up care to patients on whom they did not perform the initial surgical procedure, it can be not only difficult to find a physician who will provide post-surgical follow-up care for patients who have traveled abroad for cosmetic surgery, but costly to hire a new physician as well, especially if complications arise and revision surgery is needed.

To avoid the potential risks and difficulties with follow-up care that can arise from medical tourism, it’s best to first choose an accessible, board-certified plastic surgeon who performs surgery and other cosmetic procedures in appropriately accredited U.S. facilities.

Let cost be your final consideration in choosing a surgeon, as paying slightly more for a great outcome the first time can end up being much less expensive than paying separately for follow-up care and multiple revision procedures down the road.

There are also a number of financing options available to Americans who do not have the cash in-hand needed to pay for plastic surgery, so there is little reason to travel abroad when some of the world’s best surgeons are in your own backyard.

While some say they merely want to look and feel better in the wake of the stress and emotional turmoil caused by divorce, others hope their enhanced curves or rejuvenated face will help them find a new mate and even serve as a form of revenge against their former mate for discarding them.

Dr. Michael Cohen said one of his breast augmentation patients, a woman in her 20s who had recently discovered her husband had cheated on her, “suggested to the people preparing her for surgery that it was sort of payback.”

Divorce-inspired plastic surgery is becoming so popular that some physicians have even created “divorce packages,” according to the Washington Post article, which offer discounts to patients seeking plastic surgery after a breakup. One such plastic surgeon, Dr. Stephen Greenberg, says that of the patients taking advantage of the divorce package offered at his practice, about 70 percent are women.

Anne Soriano, a 49-year-old divorcee, said she was motivated to seek Restylane injections to put her best face forward upon re-entering the dating scene. She is also considering liposuction to slim and contour her mid-section.

Soriano’s attitude is a common one, according to Seattle plastic surgeon and American Society of Plastic Surgeons president Phil Haeck, who said many of his patients come in saying, “I’m going back on the market, and I’m afraid how I look right now isn’t going to work.”

“The first thing [people notice] is the look, unfortunately,” says Soriano, underscoring the reality that finding a potential mate after passing your physical prime can be difficult.

But Dr. Haeck is quick to point out that while having plastic surgery can boost the confidence of men and women looking to make romantic connections, choosing to undergo cosmetic surgery or other procedures during an emotionally unstable time, such as during or immediately after a divorce, can lead to unrealistic expectations and disappointment.

This is especially true for the small handful of patients who think plastic surgery will offer some sort of vengeance against those who rejected them, or an instant connection with their dream date.

“There’s a discussion that has to be had – do they expect to find Superman or Superwoman the next day after they change their appearance? Because that person may not suddenly drop into their lives just because they’ve had something done,” says Dr. Haeck.

However, Haeck agrees, as do patients like Soriano, that surgical and non-surgical cosmetic enhancement can produce subtle changes in appearance and self-esteem, which make it easier to attract and engage strangers and potentially

Galderma plans to make its offer public in January, and Q-Med’s board has unanimously recommended that its shareholders accept the cash payout offer of 75 kronor a share, which is 13 percent more than Q-Med’s Dec. 10 closing price of 66.25 kronor per share.

All shareholders would purportedly receive this buyout offer with the exception of Q-Med’s founder and Chairman Bengt Aagerup, who would receive 58.94 kronor a share in cash for his 47.5 percent stake in the company.

The one condition of the offer is that Medicis Pharmaceutical Corp., the U.S. company that licenses the Restylane family of injectable fillers and serves as a business partner to Q-Med, must also accept Galderma’s offer, presumably so the Swiss company can achieve its goal of investing in more cosmetic treatment products.

The products that make up the Restylane family of fillers include Restylane, Restylane-L, Perlane and Perlane-L, which have been approved for cosmetic use in Europe since 1996 and in the U.S. since 2003.

Each of these products is derived from hyaluronic acid and used by doctors like Indiana plastic surgeon Dr. David Robinson to fill in wrinkles, plump thin lips and restore volume to facial features that have inadequate projection, such as the cheeks and chin.

Nestle SA and L’Oreal SA, the two companies that own Galderma, would each be paying half of the billion-dollar bill to acquire Q-Med, a relatively small amount of the 5 billion Swiss francs ($5.1 billion) that Nestle plans to spend on investments this year.

The acquisition would balance out Galderma’s other cosmetic holdings, such as Cetaphil skin care products and Azzalure, an injectable wrinkle-relaxer similar to Botox approved for use outside the U.S.

The most widely criticized aspect of the surgical makeover Dr. Ryan performed on Montag wasn’t the pair of nose jobs, liposuction or mini brow lift the 23-year-old had done, but rather the gigantic G-cup breast implants Dr. Ryan gave her after surgically-enhancing her breasts for the first time about two years prior.

Heidi Montag has publicly denounced her obsession with plastic surgery and cartoonish new breasts since undergoing multiple plastic surgery procedures for the second time in November 2009, however prior to his death Dr. Frank Ryan expressed shock and surprise that Montag was experiencing buyer’s remorse.

“When I asked him how he could have been so foolish as to operate on someone like [Montag], he mentioned he was completely taken aback when she went public in such a negative fashion,” a source close to Dr. Ryan told Joan Kron in the December 2010 issue of Allure.

Dr. Steven Hoefflin, another colleague and friend of Dr. Ryan’s, said of the situation, “Frank said he had expected Heidi Montag would get publicity, but he was surprised at the tone and concerned about his reputation.”

While some surgeons defend Frank Ryan’s decision to perform the breast implant revision surgery and more on Montag, others feel it was unethical, especially given Montag’s notorious attention-seeking behavior and outlandish cosmetic goals. In fact, many plastic surgeons agree that ensuring good plastic surgery outcomes and avoiding post-procedure regret is largely dependent on patient selection.

“Plastic surgery obsession is a danger made all too real by television reality shows, Hollywood tabloids and glamour magazines,” says Indiana breast augmentation specialist Dr. David Robinson. “One warning sign I always look for is a patient with unrealistic expectations. It is very important for a plastic surgeon to distinguish between what a patient desires and what is realistically achievable.”

According to Dr. Robinson, trouble and patient dissatisfaction typically follow situations where plastic surgeons don’t first consider patient safety and ethics. In fact, Dr. Robinson shares the sentiments of many plastic surgeons who feel that it is better to decline to perform breast revision surgery rather than move forward with a procedure that may unnecessarily increase surgical risks and jeopardize aesthetic results.

“In terms of how I would address a patient presenting to my office to discuss a revision on a procedure I felt achieved a successful result, such as a breast augmentation patient who wanted to go much larger, I would review the discussion and expectations we had during her two preoperative visits. If the patient remained insistent on wanting to proceed with the revision, I would decline reoperating on the patient and offer them a referral to another plastic surgeon,” says Dr. Robinson.

According to the 111 patients ages 19-72 (51 average) who were surveyed by the APSI, a doctor’s board certification status is the most important consideration in choosing a plastic surgeon.

This may be surprising to some who believe that cost is the most crucial or deciding factor for patients considering plastic surgery, however this study shows that cost is actually the least important consideration in plastic surgeon selection.

In addition to board certification status and cost, study participants were also asked to measure the importance of other decision-making factors, including:

• Method of referral
• Travel distance from home to office
• Office décor
• Experience, or number of years in practice

The study asked 10 men and 101 women which of these factors was most important and found that the average importance of a plastic surgeon’s board certification status was nearly 40%, followed by method of referral at 23.5% and travel distance from home to office at slightly over 13%.

Of least importance on average were office décor (9%), experience, or number of years in practice, (7.5%) and procedure cost (7.2%).

Plastic surgery organizations, such as the American Society of Plastic Surgeons, have long underscored the importance of selecting a surgeon certified by the American Board of Plastic Surgery for cosmetic and reconstructive surgery procedures, and the results of this study indicate that patients seem to have taken notice of this principle.

Cost, of course, is an important consideration for everyone in the current economic climate, but most plastic surgeons also agree that it should be the final consideration in the plastic surgeon selection process.

“It is much more expensive to try to fix a bad result than to get it done properly the first time. So make […] prices a part of your decision process, but definitely not the top priority,” advises Seattle plastic surgeon Dr. Richard Rand.

Pop star Anastacia recently had a lumpectomy and breast reduction surgery performed in a Manhattan plastic surgery office in hopes of maintaining her privacy until she was ready to publicly discuss her bout with breast cancer.

Dr. Andrew Kornstein, the surgeon who facilitated Anastacia’s in-office lumpectomy and performed her breast reduction, said that his office sees about one breast cancer surgery patient per month.

Once word got out about the success of her procedures, more and more New York plastic surgeons are quietly adding breast cancer surgeries followed by immediate breast reconstruction to their menu of services.

Dr. Kornstein also noted that most of the breast cancer surgeries performed in his office are done after patients have come for cosmetic surgery consultation and found that they have breast cancer.

Although it is legal to perform breast cancer surgery procedures such as mastectomies outside hospitals in accredited surgical centers, many plastic surgeons feel that doing so may be unsafe for patients.

Dr. Tracy Pfeifer, a plastic surgeon who specializes in breast reconstruction and breast implants in New York City, said of the new in-office breast cancer surgery trend, “I believe that patients receive more comprehensive care when they are managed by a team of physicians who specialize in breast cancer.  I don’t know of any teams that do this in the office.”

Dr. Pfeifer also expressed concern over the lack of pathology facilities available in office-based surgical suites and noted that in-office breast cancer surgeries are simply “not the accepted standard of care.”

Other critics of in-office mastectomies suggest that some plastic surgeons are encouraging the trend to move breast cancer surgery out of hospitals to line their own pockets.

“When you look at the economics, you know that if a plastic surgeon owns his own operating room, it’s [financially] better for him to do the surgery there,” said Dr. Evan Garfein of Montefiore Medical Center.

Dr. Garfein added, “You have to ask, ‘Why is this being done?’ If there’s a trend like this, it should be because patients are demanding it. Plastic surgeons shouldn’t be driving a trend to get patients out of hospitals.”

Vancouver breast surgeon Dr. Allen Gabriel recently used Botox injections for breast reconstruction pain management in clinical trials and reported that the injections successfully made trial participants more comfortable.

Chris Durst, a 58-year-old breast cancer survivor and one of Dr. Gabriel’s patients, reported feeling zero post-operative pain following Botox injections.

“They’d [medical professionals would ask] say, ‘On a scale of one to ten?’ I’d said, ‘I’m a zero.’ Then they’d say, ‘You’re kidding?’ and I’d say, ‘Nope, I’m not, I’m just completely comfortable,’” said Durst.

Dr. Gabriel looked to Botox to help mastectomy patients who choose to have their breasts reconstructed using tissue expanders and breast implants, as the process of stretching the skin and muscles of the chest can be quite painful.

“As you’re pressing against a very thick muscle that’s very active on a daily basis, that’s when the pain and discomfort occurs,” said Dr. Gabriel.

During the trials, which included 30 breast reconstruction patients, Dr. Gabriel administered Botox injections to the chest muscles of a test group and injections of saline solution to a placebo group. The test group was reportedly more comfortable and experienced less pain after surgery than the placebo group.

“It’s been very exciting to see something that we read online; thought that it was a problem and now we have a solution,” said Dr. Gabriel.

As the millions of patients who have sought Botox injections for wrinkle reduction, excessive sweating and migraine treatment already know, Botox cost is not insignificant, especially when several units of the product are needed to achieve pain relief.

However, given the fact that the cost of Botox injections is often covered by insurance when used for FDA-approved pain management purposes, it is likely that Botox used for breast reconstruction pain management would also be covered if the procedure gains FDA approval.

“It is important for us to remember, unfortunately we are taking away part of their femininity; that’s how people look at it and [so we need to] do everything we can to support what’s going to make them [the patient] happy,” said Dr. Gabriel.

Reports indicate that the drug designed to treat hair loss is similar to the Latisse formulation, which according to hair restoration specialist Dr. Alan Bauman has already been used off-label by some and produced “modest hair growth” along the scalp.

Given Latisse’s overwhelming success in promoting eyelash growth and the product label’s warning that it can cause hair growth on other parts of the body that come in contact with the drug, it’s no surprise that Allergan created a product purposed to do just that.

Information on the FDA Clinical Trials website indicates that the Phase One trials for the hair-growth drug will focus on testing the safety of two formulations of bimatoprost, the same active ingredient found in Latisse at only a 0.03% dosage.

Dr. Bauman suggested that Allergan’s new hair loss treatment will likely use a higher concentration of bimatoprost, however the exact amounts contained in the drug being tested are not yet known.

Phase One trials are designed only to test the safety of the drug, so consumers will have to wait until Phase Two and Phase Three of testing are complete before any proven indication of the effectiveness of the hair loss treatment are known. But if the effectiveness of Latisse for eyelash growth is any indication, a higher concentration of bimatoprost is likely to stimulate hair growth on the scalp.

A new treatment for baldness would be a welcome advancement for the estimated 60-100 million Americans suffering from alopecia or thinning hair, as only a handful of other drugs have been approved for hair restoration.

“…bimatoprost could become the third FDA-approved drug for the treatment of baldness in men and only the second FDA-approved drug for women with hereditary hair thinning or female pattern baldness,” according to Dr. Bauman.

The new refinement technique, which essentially involves joining and rebuilding Botox molecules, may also improve the production process for Botox-based medicines such as Botox Cosmetic, which is commonly used to smooth forehead wrinkles, frown lines and crow’s feet.

“It will now be possible to produce Botox-based medicines in a safer and more economical way,” said Bazbek Davletov, the leader of the study that uncovered the new refinement method.

The refining technique discovered by Davletov and his research team could allow scientists to create new and improved forms of the drug, expanding the practical medicinal uses for Botox, for instance as a long-term painkiller that could last four to six months.

“This is the first time we have been able to treat protein molecules like Lego building blocks, mixing and matching them to create the basis for treatments that would not previously have been possible,” Davletov said.

Although Botox has been used for years to smooth wrinkles, as well as treat problems like excessive sweating (hyperhidrosis), migraines, Parkinson’s, cerebral palsy and other diseases that cause spasms, tremors and chronic nerve pain, this latest scientific breakthrough will likely make the drug even more widely used.

It remains to be seen whether the “more economical” production process for Botox made possible with the new refinement technique will trickle down to doctors and consumers. It seems unlikely to decrease the cost of Botox injections, given the fact that the introduction of Botox-competitor Dysport to the cosmetic medicine marketplace didn’t lower the Botox cost.

Botox is currently FDA-approved to treat wrinkles, dystonia and migraines, and Botox will likely become even more widely used as scientific advances continue to improve and expand its uses.