Telling Tales About Plastic Surgery Telltales: How to Avoid the Done Look

Doreen Wu (00:00):
Welcome to another episode of Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host Doreen Wu. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. The title of today's episode is "Telling Tales About Plastic Surgery Telltales: How to Avoid the Done Look." Dr. Bass, most of us want to showcase our natural beauty and keep the details about how we got there to ourselves. We all hear stories about obvious examples of people who everyone can see has had plastic surgery. What are some of these telltale signs?

Dr. Lawrence Bass (00:40):
There's many, many to an experienced eye, but there are some that are obvious even to lay people. And if we start by thinking about the facelift, which is in the view of many plastic surgeons, a much maligned procedure because of these telltales in some poorly executed examples. And so I want to emphasize at the outset that a lot of these things are associated with poorly performed procedures or procedures in individuals who have had way too much surgery, many, many surgeries. And so they're not routine results, but they're things that do call out that aesthetic surgery has been done. And our goal is for it to be something nobody knows. So in facelift, of course, everyone always thinks first about the over pulled look, and this can create a couple of different effects. Certainly it can widen the appearance of the mouth and give sort of a joker look. And another effect is to create something called sweep a sweep or dip in the skin heading from the front of the face to the back. And this is more associated with some of the older techniques in facelifting, decades older, where the face was pulled much more in a back direction and was actually where tension in facelifts is something that's not used. And the direction of repositioning is more vertical in modern facelifts. Another area that creates telltales is the appearance of the ear.

Dr. Lawrence Bass (02:43):
So sometimes the earlobe can be pulled down and this creates a look called pixie ears, not a very attractive look, and it gives away that lifting has been done. And the tragus, which is that little button like protrusion right in the middle of the year at the front that can lose some of its delicacy or be distorted or worse, be actually pulled forward, letting people look more directly into the ear hole, the auditory canal rather than covering the auditory canal, creating a normal appearance. So those are a couple of common telltales in the facelift. Another is a posterior incision along the hairline, particularly if the scar is widened. So in a lot of lifting techniques nowadays, we can eliminate the posterior incision altogether, but in people who have advanced laxity, it's still necessary. And, and that can be fine along the hairline, but to avoid distorting the hairline and having a visible scar the incision is often run straight back into the hair bearing area, which conceals the incision.

Dr. Lawrence Bass (04:13):
There are a couple of other effects with brow lifting, you know, losing the natural shape of the brow, which should go sweep up peak and then dip in the outer third getting a surprise, look with the brow lift or a more subtle change is a widening between the eyebrows in the global or central forehead area. So those are some examples with brow lifting if we move down to the neck sometimes there's too much fat removal, which skeletonize the neck or something called Cobra neck. That area just under the chin can become a concave if it's been excessively emptied. And it gives a very unattractive and not particularly youthful look, that's sometimes called Cobra neck in rhinoplasty. There's something called the polybeak deformity where the tip dips down off the top of the nose, and that's usually a sign that nasal surgery has been done and alar retraction, a pulling up of the side of the nostrils. That also is a typical telltale that lets you know the nose has been operated on.

Doreen Wu (05:44):
Wow. I didn't realize there were so many telltale signs when it comes to a facelift, how do they occur? And more importantly, how can we avoid them?

Dr. Lawrence Bass (05:54):
So sometimes we get unnatural looking things because too much surgery has been done or surgery or some kind of treatments are being done too often, which traumatizes the tissues and creates some of the scarring and findings that make a visible telltale. Most often, it's probably the result of poorly executed procedures by someone who's either not experienced or not very artistic. Because many of the telltales can be avoided and are really not a routine part of that particular aesthetic plastic surgery. So again, if, if we look at things like pixie years and appearance of the tragus, I mean, this is all about trimming the skin appropriately. So there's not an excess of tension. That's going to distort the shape of the face and the same thing with the over pulled look, when we look at brow lifting, I mean the brow has a natural position and bringing it to an over elevated position creates that that startled or surprise look, which is very unnatural to walk around with all day every day.

Dr. Lawrence Bass (07:18):
So sometimes people are trying with a brow lift to take all of the slack in the upper lid skin out, and that's really a mistake. You should only bring the brow up to a natural position. If there's still excess skin in the upper lid, then you also need to perform an upper blepharoplasty to tailor out that excess skin and not just keep pulling the brow up until it's in an unnaturally high position. Things like Cobra neck. I mean, again, it's just a question of reducing excess fat and bulging in the neck, not cleaning out all the fat, you know, we're Americans, we hate fat, but fat helps create facial shape and it also helps create body shape. It's just, we don't want bulging fat, which creates undesired contours. So some people take, take the process to an extreme and just say, gee, if I can get more fat, it's better. Well, it's not better. It creates that Cobra neck deformity which is very unappealing. Rhinoplasty, some of the issues with nostril retraction relate to if surgery has been performed multiple times, but it also relates to some of the older incision techniques and older cartilage trimming techniques that were used decades back. Still people walking around having had rhinoplasties in their youth that was decades ago. But with modern techniques, many of these things can be avoided.

Doreen Wu (09:08):
That makes sense. So how can we pick a plastic surgeon who will give us the look that we want?

Dr. Lawrence Bass (09:14):
Well, I think a good way to figure that out is to have them show you some before and after images. So that's not a guarantee of the kind of result that you individually will get, but it gives you a good idea of what the surgeon thinks a good result is and what his or her style is like. So if you look at a picture and you say, gee, that doesn't look like a very good result or that doesn't look very natural to me, or I don't want to look like that then maybe that surgeon's style is not for you. And if you look and you think it looks great and the surgeon thinks it looks great, at least, you know, your approach and your stylistic aesthetics are reasonably well aligned.

Doreen Wu (10:09):
That is a great tip. So, so far we have only been talking about surgical telltales, I'm wondering what about nonsurgical treatments?

Dr. Lawrence Bass (10:17):
So of course, you know, there are telltales that we see passing us in a big city, like New York city every day on the street. And all the nonsurgical treatments are potentially subject to telltales again, if the treatments are inartistically applied, Botox, of course being the most common non-surgical aesthetic treatment, has a few of these. One is what in my generation was called the Spock eye. Although increasingly people are calling it Cruella de Vil. It's an overarching of the outer part of the eyebrow. And fortunately that's something that's very, very easy to treat by adding tiny, additional amounts of Botox in the outer forehead area and very easy to correct. Sometimes the forehead is treated for those, those transverse or side to side forehead lines and smooths most of the forehead. But the very top of the forehead is still moving and wrinkles as someone talks or animates, and that's a telltale or giveaway that their forehead was Botoxed. You know, going to the other extreme, there's too much Botox. Some patients aren't happy unless they literally can't move anything in their upper face. And that gives them a mask like look, which honestly is a little bit creepy. It's, it's better to have some animation with a minimum of wrinkles, not to be completely adynamic because we're supposed to be able to move our face.

Dr. Lawrence Bass (12:15):
When it comes to filler, probably the number one area we see telltales is lips where some folks are walking around with what I call the crazy lips. So they've gone way too big. It's obvious that they're not real or natural. And some other telltales are the upper lip being too big. The upper lip is supposed to be about two thirds to three quarters. The size of the lower lip, the lower lip naturally is bigger in almost every human being. Also the upper lip shape tapers as we come out to the corner of the lip. And when you see upper lips that are bigger on the sides than they are in the middle, you know, that's a done lip. And both of these changes are sometimes called the trout pout. Sometimes also that edge area between the pink lip and the white lip, which is called the white roll or Vermilion border that was classically injected with collagen in the old days.

Dr. Lawrence Bass (13:28):
When you over inject that with today's fillers you can get an over accenting of the border of the lip and it's kind of a duck bill look that again, most people would rather avoid. And it's an obvious sign that your lip has been injected in the face. People will inject the cheeks and accenting the cheeks really looks spectacular, it's you, but it's beautiful you, but some people go too far and they're trying to avoid doing surgical lifting by taking up slack in the skin, adding the additional volume of injected filler. And that's a mistake and you wind up with a pillow face or balloon face by overfilling, and that's something that you can see coming half a block away on the sidewalk in Manhattan every day. So putting back volume to the extent that you've lost, it is really good idea or modestly accenting shape to give a little more facial harmony, but just blowing the face up like a balloon to take laxity out of the skin is a big mistake.

Dr. Lawrence Bass (14:53):
Sometimes laser treatments can create a, or chemical peels for that matter, can create a loss of pigment in the skin, kind of a porcelain like skin and skin naturally has some texture and has some pigment variation. So when you see that, that absolutely perfect skin, and sometimes it looks waxy or glass like and this is more of an issue historically than with modern laser peels and chemical peels, but that would be a telltale that the skin had been treated. And finally people end up with a mismatch between their, their face, which again has beautiful skin, no age spots, no wrinkles, no laxity. Everything's been done to take care of the face, but the neck skin, the chest skin, the skin on the hands is stringy and has lost its elasticity and is crepey and covered with, with sunspots medically what we call solar lentigos. And that's a give away that someone's really a lot older than their face would lead them to to believe. And that mismatched look again is not very harmonious.

Doreen Wu (16:23):
Can any of these telltales from nonsurgical treatments be treated or is it too late?

Dr. Lawrence Bass (16:28):
Well, a lot of them can there are some treatments for hypopigmentation with lasers. It's a difficult problem, but we can make progress nowadays mismatch between the face and the neck or the chest and hands is easy to address by having some degree of treatment in these areas. So that there's not so much discordance between the appearance of the face and the chest filler can be dissolved with the enzyme. And you can start over or just let the filler naturally absorb and come back and treat that more conservatively. Next time. As I mentioned, things like the Spock eye or the upper forehead, still being animated, are very easy to treat with small amounts of additional Botox, but if you create droopiness or that mask like face you have to wait for that to wear off.

Doreen Wu (17:37):
We've been talking about the face mostly. What about the body?

Dr. Lawrence Bass (17:41):
So of course there are giveaways on the body as well as on the face and, and probably one that's that's I, I think is a tough one has to do with the belly button, because when you do a full abdominalplasty or tummy tuck, there is an incision around the umbilicus or belly button. But sometimes that and that scar is always going to be visible. You know, if you go out in a two piece bathing suit, that scar is going to show or people who wear, you know sorry, or other traditional clothing that reveals the midriff of the body, that scar is going to show sometimes the scar is more visible in others and we try to hide the scar inside the edge of the belly button rather than on the outside, on the tummy skin. But sometimes the shape gives that away.

Dr. Lawrence Bass (18:40):
It's a little too round. Really the umbilicus should be a little more vertical than side to side and have a little hooding superiorly. And sometimes some of these features were lost or a belly button that was an innie is flattened. It won't become an outie generally, but sometimes especially in thin people, it can be flat and this can be revised or you can reconstruct the belly button and belly buttons that have really turned out poorly. And there are some techniques from South America and Brazil on belly button reconstruction when this happens. Looking at other body shaping probably the big one right now is Brazilian butt lift, basically fat grafting to the buttocks that's overdone. It's always important to be proportional and have harmonious shapes. So when you see someone with a tiny waist and a really big protruding or shelf like butt, that's telling you that something unnatural was done and some of the folks doing that don't mind that it looks unnatural.

Dr. Lawrence Bass (19:58):
They like the look. But if you're trying to look natural, but just have more curviness there keeping it in in range is a good idea, just means not overdoing it. Same idea with breast implants, somebody who's very petite and very slender with huge breasts that are way out of proportion to their body is projecting a fairly unnatural look. Another area where in body contouring that can show is the technique of ab edging. This is where fat is very thoroughly removed in certain areas to mimic the tenderness and subscriptions that give us a six pack in our abdomen and leave fat in between. So natural tenderness, inscriptions and natural six pack is not perfectly symmetric. It's not super sharply defined and leaving the fat can, if it's done in two pronounced, a fashion can look overly puffy. So again, by balancing the technique, you can avoid an unnatural look by trying not to go to extreme.

Dr. Lawrence Bass (21:18):
There are a whole host of unnatural telltales with breast implants. People with a great deal of upper pole fullness or a very defined edge to the implant all the way around make it pretty obvious that the patient has had a breast augmentation with breast implants and sometimes very slender patients who have no baseline breast tissue and very little body fat will get a sort of egg on a skillet look with the breast implant, which again is not incredibly natural given how thin they are. That may be the best it can be done and it gives them more of a female breast contour, but it usually will not show perfectly natural. And one of the most vexing problems is when the implant has ripplings particularly at the outer edge. So someone will be out in a bikini or a low cut dress and they will show rippling in the implant, which is an obvious, unnatural finding and can sometimes be difficult to correct.

Doreen Wu (22:39):
Lastly, before we conclude Dr. Bass, can you share some important takeaways for our listeners about how to avoid the done look?

Dr. Lawrence Bass (22:46):
Absolutely. Everything in plastic surgery is about creating balance and proportion. Basically harmony. Harmony is beautiful. That creates a natural look, not an extreme look. Now, some people are trying to create an extreme look and they're willing to accept not looking natural, but again, they're gonna be walking around with telltales that they've had plastic surgery and that their appearance is manufactured. Most patients particularly where I practice in the Northeastern United States are really not sharing that they've done surgery with more than a few very close friends and family members. And so they'd like to look natural. So nuances how procedures are done and paying attention to the fine details when I'm doing a facelift, I'm worried about getting a sharp jawline and a very clean neck, but I have to think about making sure the ear lobes are exactly positioned correctly, that the tragus is very precisely tailored, sutured and inset so that it preserves a natural look. These are all critical to maintaining that natural appearance, not just getting a big removal of skin or a big pull on the face and neck. Probably the most important takeaway is to use each technique for what it's good at doing and for the degree of correction that it's well able to produce when we take a modality and push it as hard as we can. That's when we land up with complications and distortion and unnatural changes in appearance.

Dr. Lawrence Bass (24:49):
A lot of times we do have good options to improve things if they don't turn out natural, if we have some kind of telltale. Sometimes we have to wait until there's some healing and settling time, scar maturation, or more time passing so that we can rework the area. But, you know, it's very hard to completely undo some of the surgical telltales. So preventing and avoiding those problems is always the best approach.

Doreen Wu (25:28):
Thank you, Dr. Bass for sharing your insight and expertise with us, and thank you to our listeners for joining us today, to hear about telltales in plastic surgery and tips on how to avoid them. I hope you found this episode as fascinating and informative as I did. If you think of other exciting developments or trends in plastic surgery that you would like us to discuss in upcoming episodes, please reach out via email or Instagram. We'll see you next time. This is Doreen Wu thanking you for joining Dr. Bass and me for this discussion of telltales and plastic surgery. Be sure to tune in next time. And don't forget to subscribe to our podcast, to stay up to date with all of the exciting content that is coming your way.

Speaker 3 (26:05):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor-patient relationship is established by listening to or participating in this podcast, consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.