Norman Leaf MD FACS

From the Blog

Technology has advanced to truly stupendous heights: the Higg's Boson has been identified, the sound of a snowflake hitting the pavement can be recorded, our Voyager space probe has advance into interstellar space, and Miley Cyrus' twerk was seen by several billion people in 50 languages.

But not all technological advancements are as momentous as these…many are not applicable to our lives, and some can be outright misleading. I'm not suggesting that using computer imaging to simulate or predict the result of operating on a face or nose or breast (morphing) is on the same scale as hacking into government data banks, but it definitely has the capacity to deceive a patient seeking plastic surgery consultation. morphing

The use of digital photographs has been a boon to many disciplines, not just to the millions of iPhone users. Inherent in digital photography is the ability to readily alter the images. In art, this can produce wonderfully fanciful and beautiful images; in plastic surgery, image modification has become widely used to demonstrate to a prospective patient what they will or might look like after surgery. And therein lies the fallacy: will look like or might look like. The doctor, unless he or she is being deliberately dishonest (it can happen) will presume the patient understands this is a possible outcome. The patient will very often assume that this is going to be exactly the way they will look afterward. And despite all declarations, all clearly-worded pieces of paper to the contrary, most patients do come away from such a consultation with a pretty fixed idea in their heads.

We all know computer geeks who are geniuses with a mouse and a keyboard, but who cannot speak a complete sentence. Likewise, a doctor skillfully utilizing a morphing program can create an image fit to be on the cover of Vogue, GQ, or Playboy, and yet may have only rudimentary (or worse) level of surgical skills. For these doctors, such a program is little more than a marketing lure.

I don't think that plastic surgery morphing programs are completely useless or predictively deceptive. I personally prefer to talk to a patient with their photos and use a mirror to get a concept of what features he or she is unhappy with, and in broad strokes, outline suggestions for improvement. I often take a quick snapshot with a Mini iPad so the patient can see themselves as others do, not as a mirror image. I can show clearly where incisions will be placed, but I don't actually alter their digital image: I don't think it's entirely honest. No one can guarantee a result with that degree of precision.

I know respectable and qualified surgeons who do use this format, so let me add that this is my opinion only. But I'm sticking to it.


It's not even shocking anymore…tabloids and Internet sites gleefully display pictures of celebrities whose appearances are just…strange. Things have changed in the world of celebrity facial disfigurements. Time was, not long ago, that inept or ill-conceived cosmetic surgery was to blame. Now, with "non-invasive" procedures available in every strip mall, most of the facial disasters are coming from too much filler injections, or too much Botox.

Why celebrities? Being famous is a very insecure position to hold. They are subject to daily paparazzi photos, and they must compete for their roles with a constant supply of younger, prettier faces. Remember, their faces are their fortunes. The over-puffy, distorted, bizarre distortion of an otherwise attractive human face is inevitably the result of the simple equation:

Insecurity + surgical or "non-invasive" ineptitude= deformity.

Although the expressionless appearance seen with Botox overusage is distressing, one can expect a return to a more normal appearance if the face is left alone until the Botox effect dissipates. Not so with fillers, especially the longer-lasting ones. Fillers are very effective when used judiciously. They can do a great deal to improve wrinkles and even facial contours. But sometimes, including and perhaps especially with fat injections, they make the person look round-faced, puffy, and vastly different from their normal appearance. They may stave off a surgical facelift for a bit, but when they are touted and accepted as a useful alternative to a facelift, that's when the trouble starts.

I am waiting for someone to explain to me how injections of permanent fillers are considered "non-invasive." If you have ever seen a patient who has had silicone injected into their face, you will understand that "invasive" is a term subject to a massive amounts of interpretation. Injectors of silicone have managed to ignore the hard lessons of history; they have convinced themselves that because they use a trademarked, very secret method, that they won't get permanent and progressive damage to the skin. We are beginning to see these results now with over-exuberant fat injections too.

People are scared of facelifts…and understandably so. A facelift is an elective surgical procedure that has risks (small, but nonetheless present), leaves scars (essentially invisible ones) and is expensive (varies widely, usually proportional to quality.) But the result of a well-done facelift on a properly-selected patient is a natural, more youthful and more attractive appearance, with a huge boost in self-esteem thrown in.

Fear of looking "plastic" sometimes leads patients to overdoing the "non-invasive" treatments. Just because a knife or other surgical instruments are avoided is not a guarantee of a beautiful result. Best to consult with a qualified plastic surgeon who has skills in both surgical and non-surgical procedures.


The statistics are grim: More than 40,000 brave men and women have returned home wounded from Iraq and Afghanistan. They now face the daunting challenges of recovery and re-entry into civilian life. Rebuilding America's Warriors (originally Iraq Star Foundation) is a non-profit organization dedicated to providing free reconstructive surgery to our wounded and disfigured active and veteran-status warriors on a national but locally-based level.

For the past five years I've been privileged to serve as R.A.W.'s Medical Director. We've been busy. The Veterans Administration and the active duty military facilities have their hands full providing the crucial life-saving procedures that have reduced the death rate of our young warriors immensely. During the Vietnam War, we lost over 50,000 American troops in a five year span. By contrast, these two wars have stretched almost twice as long, and yet we've lost only around 6,000 of our brave troops. Of course, that's still 6,000 too many, but by comparison it's a quantum leap in life saving. This is due to both remarkable advances in front-line emergency treatment and rapid evacuation to full-scale military medical facilities.

The flip side of this reduced mortality is that now there are many more wounded striving to re-enter the civilian world. Our warriors want jobs, they want to date and fall in love, they want to raise families. The scars of war, even seemingly minor ones, can severely impede that goal. Iraq Star/R.A.W. represents a group of over 300 board–certified surgeons in 45 states who have volunteered their skills and services, and often their surgical facilities to aid these wounded warriors in their convalescence.


Our focus initially was on the minor scars, to help restore self-confidence, thinking that the VA would take care of the more serious issues. Over the past few years, this plan has expanded to include significantly more substantial deformities, and we have found ourselves calling on specialties beyond plastic surgery…including orthopedics, ophthalmology, and now, dentistry. In the latter case, we've discovered what may turn out to be the tip of a completely unexpected iceberg: some of our veterans have developed severely crippling dental disease in which the teeth all turn yellow, brown, and break off or fall out….AFTER returning home from Iraq. We haven't come up with an answer as to what may be causing this "silent epidemic," but several groups of dentists have volunteered to help. The care for these unfortunate vets usually requires full-mouth extractions and dentures, and the VA does not offer dental care unless the veteran is 100% disabled. I've been discussing this with world-renowned academic dentists and authorities from the National Institutes of Dental Health and the Centers for Disease Control…perhaps we'll figure out the cause soon.


Please go to our website,, and learn about our organization and how you can help our efforts. These young men and women did the job our country asked them to do. Whether we're Republican or Democrat or Independent, whether we watch Fox News or PBS, the least we can do is show our brave men and women how grateful we all are for their sacrifices.


My last blog post discussed "recycling plastic surgery," referring to utilizing tissue taken from one part of the anatomy and re-using it in another. That was about taking the trimmings from the deep layer of a facelift and re-configuring them to help enhance the shape of the lips. Now let's move onto the more widely-known practice of fat grafting.

Fat is a wonderful substance, and most of us have at least a bit to spare. Some of us have a lot more than a bit, but this piece is not about that. Our body's fat provides us with warmth, a bank of available energy, and desirable (and not-so-desirable) contour to our faces and bodies. It has the unique ability of being able to survive well when injected into the face, breast, and torso. It is also a surprisingly plentiful source of that mystical, multipurpose little jewel, the stem cell.

Stem cells are the modern buzzwords in both serious research and frankly commercial hype. The "Stem Cell Facelift" is essentially the injection of fat into the face. It's not clear to what extent the stem cells that exist in the transplanted fat are responsible for any improvement in appearance, but that ambiguity doesn't seem to hamper the hawkers and publicity hounds from claiming miraculous results.

In any of the fat grafting procedures, fat is carefully extracted from the lower abdomen, the thighs, or any reasonably endowed location, and injected into the face, the breast, or wherever some fullness is desired. Different techniques for treating or not treating the fat before injecting it are common, but usually there is some type of washing or concentrating the extracted tissue.

The amount injected depends on the area…in the face, small amounts can be used to fill in the dents on either side of the chin, the naso-labial folds, or the cheekbone or temple areas. Some physicians claim that simply injecting fat prevents the need for a surgical facelift: those are usually dermatologists or other non-plastic surgery specialists. Some plastic surgeons do fat grafting with each and every facelift. I am concerned that relying solely on fat injections may simply produce a "fat face," in which the normal human contours are puffed out beyond the point of beauty or normalcy. Personally, I do fat grafting when it's indicated with a face lift; but usually I find that by carefully lifting the deep layer of the face, I can reposition the existing fat that has dropped down into the jowl from its original position in the cheekbone area. I think that provides a more natural restoration of the original youthful shape.

In the breast, larger amounts are needed, also depending on the specifics. For example, after a breast lift for drooping breasts, fat grafting may eliminate the need for an implant to fill the upper part of the breast. After a post-mastctomy breast reconstruction, fat grafting can be used to fill in the edges around the implant or to smooth out the contours after more elaborate tissue-flap methods. The time may come when fat grafting will totally replace implants for cosmetic augmentation, but I don't think that's going to be any time soon.

Fat grafting is not without limitations; despite best efforts, not all the grafted fat will survive. In general we transplant a bit more than we hope to have, anticipating a 25-30% loss in the weeks following the operation. Another problem is that of "fat memory." Fat seems to maintain its relationship to whatever source it came from. If fat is used to fill in facial contours, and later, even years later, the patient gains a significant amount of weight, the transplanted fat will grow too. That can yield an odd, doughy appearance; the only remedy is a significant weight loss.

Negatives aside, we can look to fat to be a major source of contour enlargement now and for the future. The unknown quantity is what can we expect from the stem cells that we're transferring with the fat? And now that techniques to isolate the stem cells are becoming readily available, will these cells provide an answer to the many diseases as they have been hyped to do?

Time will tell…in the meantime, we can take advantage today of the ease of availability and tolerance of our friendly fat.

Recycling Plastic Surgery Part 1

Recycling might be a funny word when one thinks of Plastic Surgery, but it's really quite descriptive about several techniques that are commonly, and not-so- commonly used in practice. Perhaps a "Robin Hood" descriptive might work better: we take from the richly endowed areas of the body and give to the less fortunate parts.

Your mind is probably already envisioning fat: in fact, most of us have more fat than we want in certain areas, and other areas where a little more volume would be nice.

Good thinking, but not what I'm writing about…at least not yet. This blog piece is about taking tissue that would ordinarily be discarded and re-inserting it in a useful and esthetically pleasing manner. In this case, I'm thinking of the deep layer of the face, the SMAS layer, consisting of muscle, the fascia and the fat. In a modern facelift the SMAS is pulled up quite snugly, then trimmed, and secured fast to the boney attachments. This maneuver allows the skin to simply drape over the newly tightened infrastructure without any tension, thus avoiding a "pulled" look.

I hate throwing anything away…I am a collector, a curator, and a general packrat. Years ago, after I trimmed the excess from that deep layer, I would just discard it and move on. One day, in a moment of unexpected enlightenment, it occurred to me that it was a shame to throw away such healthy, strong tissue. Where could I utilize this strip of muscle, fat, and attached fascia (the skin of the muscle) that would enhance my patient's appearance?

I noticed that many of my facelift patients' lips were quite thin, and in some cases, almost non-existent. Lips do lose bulk with age, and fillers like Restylane and Juvederm are often used to correct, (and too often way overcorrect) that condition. Besides, those fillers usually only last between 6 and 12 months. Perhaps, this tissue could be fashioned into a graft that would offer a more permanent lip enlargement?

Voila!! The tissue can be fashioned into a strip of variable thickness, depending on the amount of corrections desired, and inserted into a little tunnel that runs across the red part of the lips. I tried it and to no one's surprise, it works beautifully.

I first published this lip augmentation article (Plast Reconstr Surg. 2002 Jan;109(1):319-26) in 2002. It actually followed my earlier article (Plast Reconstr Surgery. 1996: 97(6): 1249-1252) describing this graft's usefulness in smoothing out the ridge of the nose in patients who had poor results from unfortunate nose jobs (I never use the word "botched." Oh wait, I just did.)

This material has many useful applications in both aesthetic and reconstructive plastic surgery. It would be a great universal source for tissue augmentation…except for the fact that a facelift is required to obtain it. And not everyone is a realistic candidate for a facelift (Life-style Facelift advertisements to the contrary.)

So now, whenever I do a facelift, which is a lot of the time, I first evaluate the patient to see if the lips (or another structure that is a bit deficient) could use some help. And I know where to go for my building materials.