Blink by Malcolm Gladwell

I was attending a lecture by my colleague in St. Louis 2 weeks ago and I really liked how he envisioned the facial aging process. He likened it to the book, Blink, by Malcolm Gladwell. For those who have not read Blink or Gladwell’s other phenomenal book, The Tipping Point, I would highly recommend both reads.

Gladwell’s thesis is that we judge another individual or almost anything in a visceral blink of an eye. It does not take 5 minutes to figure out something but we can tell almost immediately about something and we are typically correct in our initial assumptions, which are also very hard to shake if we are wrong.

That is how we view each other when it comes to aging. We can almost instantaneously tell if the other person is older, younger, attractive, or unattractive. We can tell in a blink of an eye from 10 feet away. However, when people come in to fix something, usually they are focused on the minutiae that no other human being can even see. In particular, because women put makeup on, the tiny lines around the mouth (that no one can see. believe me.), the crepiness of the upper eyelid, the dot on the right cheek, the tiny asymmetry of the upper lip, etc. are on the top of the wish list for correction even though after paying all the money to do those things nothing really looks any better.

Instead, I truly believe that overall facial shape (geometry) and proportion is how we make a judgment about another person in a blink of the eye. So, when people come to see me, I would rather help them create a favorable blink impression on all those around them than try to fix the minor flaws that only they can see. If you want to understand how we view aging geometrically, you can watch the first part of my video lecture I gave 2 weeks ago in St. Louis that discusses in my opinion an original thesis on how we see aging. Here is the link to the video.

Btw, a patient of mine told me that Gladwell’s new book is coming out in a few weeks so I checked it out on Google, and it’s called Outliers, about how successful people are successful not just because of who they are but where they are from (at least that is what Amazon says).

Our beloved Vassi just gave birth on Tuesday, October 7th, 2008, to a healthy and beautiful new baby named Elizabeth Grace, weighing in at a magical 7.77 pounds. Her family at LFP would like to extend Vassi and Stravko (aka Zak) our most heartfelt congratulations to their new addition! If you would like, click here to watch my visit to the new bundle of joy!

Reflexology Foot Chart

As a western trained physician who is very methodical in his scientific thinking, I have always been skeptical of “Oriental medicine”. Now that I have opened a spa that focuses on marrying the best from the East and the West, I have gradually loosened my narrow grip on my perceived reality. I have tried in the past to view my wellness concept to be broader than what we know in the West. However, naturopathic doctors and holistic doctors shun coming anywhere near an Occidental physician and vice versa. Fortunately, I was able to find the best of both worlds by having western-trained M.D.s who embrace naturopathic components in my anti-aging and vitality center.

As part of my weekly spa ritual, I really have been exploring the best of what the East has to offer. The thing that I really love now is reflexology. The idea of reflexology for the uninitiate is using pressure points on the foot to relieve bodily ailments that corresponds to nerves that are across the foot. Whenever I get a certain area touched that hurts on my foot, I start to realize how accurate the correlation is to the body part that aches for me. If anything, I get a great foot massage in the process! Even when I was in a hurry at the airport, I got a reflexology treatment over my standard shoulder and hand massage (which is part of reflexology too since the hands and ears can represent part of the body as well.)

I think it could be dangerous to substitute reflexology for treating serious medical conditions but I think it is a great stress reliever and I do believe that it is helping me balance out parts of my body that are not in alignment. I also tried a Shirodhara treatment which is part of Ayurvedic therapy in my spa, which involves dripping oil in different patterns across your forehead to open your “third eye”. Although I don’t know if the touted medicinal values can be of certain benefit to you, I do enjoy the treatment as a relaxing part of a spa experience. Okay, so I don’t believe everything just yet.

Silicone Lip Augmentation, Dallas, Texas

As many of you know, I perform tons of silicone injections for cosmetic purposes, including for lip augmentation, rhinoplasty correction, acne scarring correction, and minor touch ups for small facial deformities. I do not use it in bulk for facial volume but in small droplets built slowly over time. I know there is a fear as to how safe silicone is in the body.

In a previous blog, I talked about how massive studies have reviewed hundreds of thousands of women who have had silicone breast implants across multi-centers and multi-nations and shown through extensive meta-analysis that there is absolutely no causal link with silicone breast implants causing collagen vascular disease, etc. That is why in January 2007, silicone breast implants were placed back on the market. Now, of course, we are talking about cohesive models in which buckets of silicone do not spill out into the body. That is not even what I do for the face. If you want to review my first blog on silicone, click here.

I was in St. Louis a couple of weeks ago lecturing and I heard one lecturer say, “Did you know that you get silicone injected, breathed in and swallowed all the time?” Guess what, I knew that because I had heard that in the past but had forgotten about that pertinent information. What triggered me to write this blog is Emina, my hair-transplant coordinator, was saying to my hair-graft dissection team, “Don’t you like how these blades cut through the tissue because of the nice silicone coating?” And I thought, I better write a blog about how much silicone we actually ingest every day.

Did you know that every needle, knife blade, intravenous catheter is covered with silicone? Did you know medicines contain silicone? Did you know hundreds of medical devices contain silicone? Did you know the air around a copying machine contains silicone? Did you know perfumes contain silicone? Did you know that a diabetic gets approximately 2 to 3 cc of silicone per year injected directly into their bloodstream (from the repeated needle sticks)? That is oftentimes more than what I put into lips, and my droplets are not in the bloodstream but in the lips. Every time you get a needle stick or an iv catheter you get silicone. All of our pipes and water valves that carry our water are coated with silicone so when you drink water you get silicone ingested. Our hairsprays are filled with silicone so you breathe it in as well. Our food is covered with silicone. In fact, a study was performed in normal average human beings after they died and what was found is that every major organ had silicone in it, including our lymph glands and immune systems with no effect on us.

Remember that silicone has been used for cosmetic injections safely for over 40 years. The person I learned my technique from had been doing silicone for over 40 years. Now, obviously you see scary examples of bad silicone every day. I have to fix tons of silicone performed in a non-microdroplet fashion and done with both poor technical skill as well as a bad eye toward beauty and shape.

There are many competing permanent fillers on the market out there in the world with only one other one in the United States, Artefill. You can watch my video on why I do not use that product. I do not want to condemn it but want to say that nothing compares to silicone’s longstanding safety record as a bio-inert product THAT YOU ALREADY HAVE IN YOUR BODY.

Tomorrow we will be exploring the differences of the only two permanent fillers I use: silicone and fat.

I am very proud of being a member of an organization known in brief as EO, Entrepreneur’s Organization, here in Dallas, which is a part of about 16,000 worldwide members. Every month, I attend a lecture by an experienced professional in his/her field of business and have a lovely dinner along with it. Also, every month, I attend what is known as forum, which is a 4-hour dedicated time of 8 to 10 people (9 in my case), who share with each other parts of their lives and businesses so that they can become better business owners and human beings. Forum is known affectionately as “AA For Business Owners.”

It is a hardcore meeting because if you are a second late based on the displayed time on your cellphone, you will have to buy dinner. If you are 20 minutes late, you are not allowed to enter the room. If you do that twice, you are kicked out for life. If you miss two meetings in a year, you are kicked out for life. Despite our busy lives, we commit to each other that we will be there every fourth Wednesday at 3:30 pm come hell or high water.

During our time of helping each other, which we call “experience sharing” rather than advice giving, we employ a language that is derived from Gestalt psychology in which we never say, “You really should not have fired that employee. That was not right.” Instead, we use the “I’ word, “I fired this employee last year that really was not the best decision for me or my business for these reasons…” Basically, we are not here to give each other advice but to learn from each others’ experiences. In short we take the “You” out and replace it with “I”.

As a caveat, we also cannot say, “I would have done that” or “I would say the thing that I would do is…” because that also violates Gestalt. The “I” refers to what you yourself have actually experienced in the past not what you conceive of someone else should do, which is thinly veiled advice. It is working with people who “Walk the Talk”, i.e., those who don’t just spout words of meaningless wisdom but who actually have lived and experienced life lessons that you as a intelligent individual can draw from if you are attentive and open.

In a way, that is what this blog is about. It is about my giving tidbits of my life, passions, foibles, successes, and thoughts so that perhaps you as a reader can attain something valuable from it. I hope these blogs are not just inconsequential banter but help to guide one’s life in very small but substantive ways.

I think Gestalt is a great tactic to help a leader lead his/her troops. Many times, we approach an individual who has had a problem and we say, “Boy, you really should have done this better. Let me tell you how…” Instead if we open with, “Boy, I did the same thing you did last year and I have learned a valuable lesson why I would never do that again and here is what I learned.” Approaching a problem that way is entirely different and can lead to entirely different results. I hope you can use Gestalt somehow effectively in your own life whether personally or professionally.

prevelle silk

As mentioned in the last few blogs, new technology is always coming out quickly to the market. When I was in Chicago at the Fall Meeting of the American Academy of Facial Plastic & Reconstructive Surgery, I looked into Mentor’s new Prevelle Silk, which is another hyaluronic-acid (HA) based product to compete against Restylane, Perlane and Juvederm. The major benefit touted with this new product is that it contains Lidocaine in it to reduce the discomfort associated with injection. Although on the surface, this sounds good, I really do not encounter any discomfort with my patients owing to the short-acting block that I use during treatment.

Basically, Prevelle Silk contains 5.5 mg/cc of hyaluronic acid, which is a fourth of the content that is contained in Restylane, Perlane, and Juvederm. When I asked the Mentor rep in Chicago about this observation, I said, “Oh, that sounds like the exact amount that Captique had in their HA product.” He said, “Yeah, that’s because it is manufactured by Genzyme, who made Captique.” Aha! Prevelle basically is Captique with lidocaine. I used Captique in the past (which has fondly been called “Craptique”) because it simply lasts such a short time. With so little HA content in the product, longevity can be as short as 3 to 4 weeks in my experience. If you are lucky, perhaps 6 weeks or so. This is a product that I have no interest in incorporating into my practice at this time.

Here is a link to my video log on Evolence (if you missed that one) and on Prevelle Silk.

Two new cosmetic injectable fillers are arriving on the shelves: Evolence (Johnson and Johnson) and Prevelle Silk (Mentor). Today we will talk about Evolence and tomorrow we will address Prevelle Silk. Obviously, whenever a new filler hits the market, we are always interested in what this filler has to offer. Evolence has perhaps garnered the most attention in the media as a new, “longer lasting” injectable filler.

What is Evolence? Evolence comes from Israel and is a porcine product (that is, it comes from a pig). Reportedly, even though it is not “kosher” since a pig cannot be kosher, the killing of the animal follows prescribed rabbinical techniques for animal slaughter. The touted benefit of Evolence is that it may be lasting a bit longer than Restylane like close to a year. There is also reportedly less swelling during the first 3 days that follow the injection compared with Restylane and Perlane because hyaluronic acid products swell more in the first few days. Two major problems so far have already been bandied about (but may not be entirely accurate): it is hard to mold the product after the initial first few minutes to hours and it provides a lumpy injection. Speaking with a colleague of mine who has used the product, the latter criticism may be inaccurate because the product can be more evenly delivered when it is injected with the right needle, pressure, and depth. Finally, the big question out there is will an animal product create an early or late allergic reaction to it? No matter what data the company presents, I am still skeptical of the safety in regard to this issue.

Here are the reasons that I do not have any interest in offering the product (at least not for now): (1) I try not to use any animal products — not necessarily for humane purposes — but due to patient safety with the use of animal products as mentioned above (2) I really like how hyaluronic-acid based products like Restylane and Perlane are 100% reversible if you don’t like the result. That adds significant flexibility. (3) I don’t see a lot of swelling in the first few days with hyaluronic acids because I don’t put them in areas that lead to significant distortion like the lips. Since I use hyaluronic-acid products for volume balancing primarily, many patients actually do not mind the swelling because it looks closer to the volumes that I would use for fat transfer. In the long run, trading 2 to 3 days of mild swelling is worth it for a product that is not animal-based and can be easily reversed at any time. (4) The longevity that I have seen with Perlane is in many cases over a year, which competes effectively against Evolence. Also, I don’t believe that the product will last a year. I may believe it in a year from now when I talk with my colleauges not the company. For all of these reasons, I do not see any reason to use Evolence in my practice. I am not here to condemn a surgeon who decides to use the product but I am not going to be an early adopter on this one.

Here is a video log that I shot summarizing my thoughts on Evolence

I was very honored that my mentor said to me in Chicago, “Sam, you are really a great thinker. You are one of the thinkers in our Academy.” I had another individual whom I respect say to a vendor, “You must talk with Sam because he is a really respected thinker in the Academy.” Finally, I talked with another colleague of mine from Florida who said, “I really like the way you think.” I was very touched by these words and took them to heart. I think many times we pass through life “satisfied” with where we are and really don’t exercise the noggin a bit to see if what we are doing is the best thing that we could do.

In Chicago last week, I spent as much time in the exhibit hall looking at new technology as I did in the lecture hall listening to scientific papers. I will be doing the same today, as I am lecturing In St. Louis. What I have learned to develop over time is a critical skepticism about new technologies out there. It is great to go to the annual meeting and see what is the latest thing that is out there and before jumping head first to sit back and evaluate the efficacy, safety, and “long-term” benefits that a new technology may have.

I will be introducing a couple of new injectable fillers on Monday and Tuesday’s blogs that I have true skepticism about and I will tell you why. Does that mean I won’t ever be using these products? No. That may not be the case. I just want to have you understand where I see that technology today. I also was looking at some new laser/light technology that I am a year away from adopting if ever. I studiously evaluated each system by asking the individual about the pros and cons (which is obviously extremely prejudiced information) and then will be doing some clinical tests over the next year to see for myself any validity. There is a good saying, “Don’t be the first person on the block to do something and don’t be the last person on the block to do something.” Those are words to live by.

Two errors I made in the past by adopting technology too fast were the Threadlift and the Surgiwire. Both technologies proved to be useless and did not live up to the brand quality that I have established when you come to see me as a surgeon and practitioner. I have promised my patient base that I will not jump blindly into new technology but evaluate that technology over time to ensure that it is what it is touted to be. At the same time, many surgeons never go to a meeting, whereas I go to 10 to 12 meetings a year. So it is very important to keep up with the latest thinking and techniques but only to adopt that technology and technique when sufficient time has passed to see whether that technology merits incorporation into a plastic surgery practice. That is my promise to you.

This is a follow-up to a series of blogs on “Perspective”. As part of being a leader for my surgery center and for the larger wellness building, I have to sift through many perspectives and try to attain some “truth” to a problem that is presented to me. First of all, it is my job to understand each different personality with whom I work. Believe me, each person has his/her own personality differences that make that individual unique. I keep a mental scorecard on every staff member and individual in my wellness building of their pluses and minuses. We all have this scorecard, including me. I try not to look at an individual’s negatives but focus on their positives. However, by knowing their negatives, I know how to minimize their biases and to try to maintain a more balanced perspective on a given issue.

Since I have multiple layers of leaders under me, I don’t manage many of the day-to-day affairs of the building but ultimately I do. When one of my leaders comes to report a problem to me, I usually hear the voice of the last person my leader talked to. In fact, in the words used, I can truly hear that person’s voice and I can at times guess, “Oh, I see, you must have just spoken to Susan (made up name to protect the not-so innocent).” Every time we speak to someone, that individual will present himself/herself in the most glowing light since it is never that person’s fault. How ever moral and ethical we are, we have a tendency to inflate ourselves and to blame others for a problem. We are always the angel, and they are always the devil. And, believe me, I can hear the angel and devil scenario presented to me.

If you have ever seen Akira Kurosawa’s classic, Rashomon, you know the inability at getting toward a knowable truth because of the human biases involved in recounting an event. In the black-and-white film, there is a rape and a murder that are recounted from multiple vantage points. Each time the story is retold through a different person’s voice, the bias is clearly evident and the taint of the storyline is apparent.

If you are called to be a leader (in whatever capacity) or even have to deal with another human being (in other words, this blog relates to you unless you are Robinson Crusoe), I would say that we all have to deal with human bias. How, we can intelligently handle that information depends on our emotional intelligence, something that we are born with but that we can also improve upon.

There are always two sides to a story. Whenever you get too much bias from one party, try to see if you can get the other side of the story too. Just remember the truth probably lies somewhere in between two extremes presented. Then reflect on the reliability factor of that person’s commentary. There are some people that tend to be very biased in their comments and then there are some people that tend to be biased more with certain topics that are particularly sensitive to them. Reading another individual can help you break free partially from untruths toward a more enlightened reading of a problem and help to solve problematic human interactions. Don’t be a prisoner to the last person you spoke with. Don’t be subjugated by the “last word.”

In my quest to continually understand the nature of fat transfer and any kind of free graft, I am constantly thinking about the evolution of a result. Not just the result at a short time point like 1 month out but how does that result shape up over time. I am happy to report after coming back from Chicago and listening to a talk that a colleague of mine gave on long-term volumetric changes with fat transfer using computer modeling, the longevity of fat transfer is now unequivocal.

Using advanced computer modeling software, a single session of fat transfer was evaluated before the procedure, at 3 months and followed up to 18 months after the procedure. What was interesting was that at times there was such a significant dip in the result at 3 months that the volumes shown on the computer were the same as before the procedure. Nevertheless, in every case where the 3-month dip was present, the volumes steadily increased until 18 months.

This study is the first conclusive, scientific proof that validates 3 important findings that I have been observing clinically but only had photographic evidence of my thinking, namely: 1) fat transfer can dip mildly to significantly at 3 months following a procedure (and therefore a touch-up procedure should not be performed too quickly), 2) that fat grafting continues to improve between 6 months to 18 months, and 3) that a single session of fat grafting has unequivocal longevity.

Obviously, safe and long-lasting fat grafting is completely technique dependent. Many practitioners out there simply cannot attain longevity or safe, smooth results so I want to be careful with the information provided in this study. Further, the artistic interpretation is critical to attaining a balanced, youthful, and attractive result. Fat transfer is not just about making a big cheek or filling in the hollow eye. It is about a face that expresses natural beauty by emphasizing harmonious structures.