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

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Welcome to another episode of
Park Avenue Plastic Surgery Class,

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the podcast where we explore controversies
and breaking issues in plastic

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surgery. I'm your co-host Doreen Wu.

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I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,

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educator and technology innovator.

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The title of today's episode is "Telling
Tales About Plastic Surgery Telltales:

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How to Avoid the Done Look." Dr. Bass,

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most of us want to showcase our natural
beauty and keep the details about how we

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got there to ourselves.

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We all hear stories about obvious examples
of people who everyone can see has

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had plastic surgery. What are
some of these telltale signs?

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There's many, many to an experienced eye,

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but there are some that are
obvious even to lay people.

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And if we start by thinking
about the facelift,

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which is in the view of
many plastic surgeons,

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a much maligned procedure
because of these telltales

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in some poorly executed examples.

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And so I want to emphasize at the
outset that a lot of these things are

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associated with poorly
performed procedures or

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procedures in individuals who
have had way too much surgery,

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many, many surgeries. And so
they're not routine results,

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but they're things that do call out
that aesthetic surgery has been done.

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And our goal is for it to
be something nobody knows.

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So in facelift, of course,

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everyone always thinks first
about the over pulled look,

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and this can create a
couple of different effects.

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Certainly it can widen the appearance
of the mouth and give sort of a

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joker look.

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And another effect is to
create something called sweep

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a

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sweep or dip in the skin
heading from the front

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of the face to the back.

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And this is more associated with some
of the older techniques in facelifting,

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decades older,

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where the face was pulled
much more in a back direction

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and was actually

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where tension in facelifts
is something that's not used.

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And the direction of
repositioning is more vertical in

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modern facelifts.

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Another area that creates telltales is the

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appearance of the ear.

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So sometimes the earlobe can be pulled
down and this creates a look called

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pixie ears, not a very attractive look,

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and it gives away that
lifting has been done.

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And the tragus,

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which is that little button
like protrusion right in
the middle of the year at

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the front that can lose
some of its delicacy or be

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distorted or worse, be
actually pulled forward,

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letting people look more
directly into the ear hole,

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the auditory canal rather
than covering the auditory

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canal, creating a normal appearance.

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So those are a couple of
common telltales in the

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facelift. Another is

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a posterior incision along the hairline,

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particularly if the scar is widened.

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So in a lot of lifting
techniques nowadays,

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we can eliminate the
posterior incision altogether,

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but in people who have advanced
laxity, it's still necessary.

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And, and that can be
fine along the hairline,

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but to avoid distorting the
hairline and having a visible scar

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the incision is often run straight
back into the hair bearing area,

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which conceals the incision.

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There are a couple of other effects
with brow lifting, you know,

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losing the natural shape of the brow,

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which should go sweep up peak
and then dip in the outer

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third getting a surprise,

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look with the brow lift or a more
subtle change is a widening between

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the eyebrows in the global
or central forehead area.

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So those are some
examples with brow lifting

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if we move down to the neck

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sometimes there's too much fat removal,

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which skeletonize the
neck or something called

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Cobra neck.

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That area just under the chin
can become a concave if it's

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been excessively emptied.

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And it gives a very unattractive
and not particularly youthful look,

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that's sometimes called Cobra neck

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in rhinoplasty.

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There's something called the polybeak
deformity where the tip dips down

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off the top of the nose, and

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that's usually a sign that nasal
surgery has been done and alar

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retraction, a pulling up of
the side of the nostrils.

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That also is a typical
telltale that lets you know the

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nose has been operated on.

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Wow.

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I didn't realize there were
so many telltale signs when
it comes to a facelift,

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how do they occur? And more
importantly, how can we avoid them?

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So sometimes we get unnatural looking
things because too much surgery

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has been done or surgery or some kind
of treatments are being done too often,

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which traumatizes the tissues
and creates some of the

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scarring and findings that
make a visible telltale.

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Most often,

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it's probably the result of poorly
executed procedures by someone

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who's either not experienced
or not very artistic.

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Because many of the telltales
can be avoided and are

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really not a routine part
of that particular aesthetic

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plastic surgery. So again, if,

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if we look at things like pixie years
and appearance of the tragus, I mean,

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this is all about trimming the skin

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appropriately. So there's
not an excess of tension.

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That's going to distort the shape of the
face and the same thing with the over

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pulled look, when we look at brow lifting,

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I mean the brow has a natural
position and bringing it to an over

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elevated position creates
that that startled

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or surprise look,

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which is very unnatural to walk
around with all day every day.

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So sometimes people are trying with
a brow lift to take all of the slack

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in the upper lid skin out,
and that's really a mistake.

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You should only bring the
brow up to a natural position.

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If there's still excess
skin in the upper lid,

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then you also need to perform
an upper blepharoplasty

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to tailor out that excess skin and
not just keep pulling the brow up

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until it's in an
unnaturally high position.

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Things like Cobra neck. I mean,
again, it's just a question of

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reducing excess fat and
bulging in the neck,

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not cleaning out all the fat,
you know, we're Americans,

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we hate fat,

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but fat helps create facial
shape and it also helps

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create body shape. It's just,
we don't want bulging fat,

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which creates undesired
contours. So some people take,

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take the process to an extreme and
just say, gee, if I can get more fat,

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it's better. Well, it's not better.

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It creates that Cobra
neck deformity which is

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very unappealing. Rhinoplasty,

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some of the issues with
nostril retraction relate to

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if surgery has been
performed multiple times,

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but it also relates to some of
the older incision techniques

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and older cartilage trimming
techniques that were used

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decades back.

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Still people walking around having
had rhinoplasties in their youth

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that was decades ago. But
with modern techniques,

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many of these things can be avoided.

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That makes sense.

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So how can we pick a plastic surgeon
who will give us the look that we want?

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Well,

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I think a good way to figure
that out is to have them show you

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some before and after images.

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So that's not a guarantee of the kind of
result that you individually will get,

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but it gives you a good idea of what
the surgeon thinks a good result is

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and what his or her style is like.

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So if you look at a
picture and you say, gee,

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that doesn't look like a very
good result or that doesn't look

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very natural to me,

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or I don't want to look like that
then maybe that surgeon's style

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is not for you.

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And if you look and you think it looks
great and the surgeon thinks it looks

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great, at least, you know,

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your approach and your
stylistic aesthetics

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are reasonably well aligned.

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That is a great tip. So,

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so far we have only been talking
about surgical telltales,

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I'm wondering what about
nonsurgical treatments?

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So of course, you know,

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there are telltales that we
see passing us in a big city,

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like New York city
every day on the street.

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And all the nonsurgical
treatments are potentially

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subject to telltales again,

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if the treatments are
inartistically applied,

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Botox, of course being the most common
non-surgical aesthetic treatment,

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has a few of these.

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One is what in my generation
was called the Spock eye.

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Although increasingly people
are calling it Cruella de Vil.

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It's an overarching of the
outer part of the eyebrow.

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And fortunately that's something that's
very, very easy to treat by adding tiny,

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additional amounts of Botox in
the outer forehead area and very

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easy to correct.

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Sometimes the forehead
is treated for those,

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those transverse or side
to side forehead lines

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and smooths most of the forehead.

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But the very top of the
forehead is still moving

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and wrinkles as someone talks or animates,

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and that's a telltale or
giveaway that their forehead was

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Botoxed. You know, going
to the other extreme,

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there's too much Botox.

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Some patients aren't happy unless
they literally can't move anything in

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their upper face. And that
gives them a mask like look,

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which honestly is a
little bit creepy. It's,

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it's better to have some animation
with a minimum of wrinkles,

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not to be completely adynamic
because we're supposed to be able to

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move our face. When it comes to filler,

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probably the number one area
we see telltales is lips where

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some folks are walking around
with what I call the crazy lips.

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So they've gone way too big.

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It's obvious that they're
not real or natural.

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And some other telltales are the upper lip

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being too big.

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The upper lip is supposed to be
about two thirds to three quarters.

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The size of the lower lip,

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the lower lip naturally is bigger
in almost every human being.

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Also the upper lip shape tapers
as we come out to the corner

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of the lip.

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And when you see upper lips that are
bigger on the sides than they are in the

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middle, you know, that's a done lip.

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And both of these changes are
sometimes called the trout pout.

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Sometimes also that edge area between
the pink lip and the white lip,

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which is called the white
roll or Vermilion border

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that was classically injected
with collagen in the old days.

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When you over inject that
with today's fillers you

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can get an over accenting of
the border of the lip and it's

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kind of a duck bill look that again,
most people would rather avoid.

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And it's an obvious sign that
your lip has been injected

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in the face. People

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will inject the cheeks and accenting
the cheeks really looks spectacular,

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it's you, but it's beautiful you,

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but some people go too far
and they're trying to avoid

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doing surgical lifting by
taking up slack in the skin,

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adding the additional
volume of injected filler.

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And that's a mistake and you
wind up with a pillow face or

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balloon face by overfilling,

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and that's something that you can see
coming half a block away on the sidewalk

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in Manhattan every day.

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So putting back volume to
the extent that you've lost,

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it is really good idea or
modestly accenting shape

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to give a little more facial harmony,

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but just blowing the face
up like a balloon to take
laxity out of the skin is a

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big mistake.

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Sometimes laser treatments can create a,

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or chemical peels for that matter,

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can create a loss of pigment in the skin,

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kind of a porcelain like skin and
skin naturally has some texture

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and has some pigment variation.
So when you see that,

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that absolutely perfect skin,

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and sometimes it looks
waxy or glass like and

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this is more of an issue
historically than with modern laser

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peels and chemical peels,

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but that would be a telltale
that the skin had been treated.

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And finally people end up with a
mismatch between their, their face,

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which again has beautiful
skin, no age spots,

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no wrinkles, no laxity. Everything's
been done to take care of the face,

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but the neck skin, the chest skin,

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the skin on the hands
is stringy and has lost

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its elasticity and is crepey and

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covered with,

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with sunspots medically
what we call solar lentigos.

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And that's a give away that
someone's really a lot older

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than their face would
lead them to to believe.

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And that mismatched look
again is not very harmonious.

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Can any of these telltales
from nonsurgical treatments
be treated or is it too

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late?

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Well, a lot of them can
there are some treatments

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for hypopigmentation with
lasers. It's a difficult problem,

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but we can make progress nowadays
mismatch between the face

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and the neck or the
chest and hands is easy

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to address by having some degree
of treatment in these areas.

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So that there's not so much
discordance between the

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appearance of the face and the chest

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filler can be dissolved with the enzyme.

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And you can start over
or just let the filler

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naturally absorb and come
back and treat that more

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conservatively. Next time. As I mentioned,

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things like the Spock eye
or the upper forehead,

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still being animated,

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are very easy to treat with small
amounts of additional Botox,

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but if you create droopiness
or that mask like face

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you have to wait for that to wear off.

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We've been talking about the
face mostly. What about the body?

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So of course there are
giveaways on the body as well as

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on the face and, and
probably one that's that's I,

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I think is a tough one has
to do with the belly button,

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because when you do a full
abdominalplasty or tummy tuck,

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there is an incision around
the umbilicus or belly button.

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But sometimes that and that scar
is always going to be visible.

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You know, if you go out in
a two piece bathing suit,

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that scar is going to show or
people who wear, you know sorry,

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or other traditional
clothing that reveals the

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midriff of the body,

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that scar is going to show sometimes
the scar is more visible in others

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and we try to hide the scar inside the
edge of the belly button rather than on

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the outside, on the tummy skin.

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But sometimes the shape gives that away.

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It's a little too round.

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Really the umbilicus should be a
little more vertical than side to

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side and have a little hooding superiorly.

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And sometimes some of these
features were lost or a belly button

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that was an innie is flattened. It
won't become an outie generally,

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but sometimes especially in thin people,

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it can be flat and this
can be revised or you can

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reconstruct the belly button and belly
buttons that have really turned out

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poorly.

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And there are some techniques from
South America and Brazil on belly button

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reconstruction when this happens.

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Looking at other body shaping
probably the big one right now

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is Brazilian butt lift,

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basically fat grafting to
the buttocks that's overdone.

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It's always important to be
proportional and have harmonious shapes.

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So when you see someone with
a tiny waist and a really big

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protruding or shelf like butt,

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that's telling you that something
unnatural was done and some of the

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00:19:54,761 --> 00:19:59,400
folks doing that don't mind that it
looks unnatural. They like the look.

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00:20:00,080 --> 00:20:02,120
But if you're trying to look natural,

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00:20:02,380 --> 00:20:07,120
but just have more curviness
there keeping it in in range

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is a good idea, just
means not overdoing it.

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Same idea with breast implants,

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00:20:12,960 --> 00:20:17,480
somebody who's very petite
and very slender with

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00:20:17,710 --> 00:20:22,440
huge breasts that are way out of
proportion to their body is projecting

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00:20:22,840 --> 00:20:24,720
a fairly unnatural look.

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00:20:26,230 --> 00:20:31,080
Another area where in body contouring

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00:20:31,081 --> 00:20:34,760
that can show is the
technique of ab edging.

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00:20:35,790 --> 00:20:40,480
This is where fat is very
thoroughly removed in certain areas

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00:20:41,140 --> 00:20:45,720
to mimic the tenderness and subscriptions
that give us a six pack in our

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abdomen and leave fat in between.

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00:20:50,460 --> 00:20:52,880
So natural tenderness,

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00:20:53,000 --> 00:20:57,040
inscriptions and natural six
pack is not perfectly symmetric.

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00:20:57,870 --> 00:21:02,720
It's not super sharply defined and leaving

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00:21:02,721 --> 00:21:05,720
the fat can, if it's
done in two pronounced,

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00:21:05,800 --> 00:21:09,720
a fashion can look overly puffy. So again,

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by balancing the technique,

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00:21:12,300 --> 00:21:16,600
you can avoid an unnatural look
by trying not to go to extreme.

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00:21:18,520 --> 00:21:22,800
There are a whole host of
unnatural telltales with breast

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implants.

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00:21:26,280 --> 00:21:31,160
People with a great deal of upper
pole fullness or a very defined edge

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00:21:31,500 --> 00:21:36,480
to the implant all the way around
make it pretty obvious that

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00:21:36,580 --> 00:21:40,800
the patient has had a breast
augmentation with breast implants and

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00:21:41,350 --> 00:21:43,760
sometimes very slender patients

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00:21:45,710 --> 00:21:50,530
who have no baseline breast
tissue and very little

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00:21:50,640 --> 00:21:55,530
body fat will get a sort of egg on a
skillet look with the breast implant,

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00:21:55,540 --> 00:22:00,330
which again is not
incredibly natural given how

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00:22:00,360 --> 00:22:01,131
thin they are.

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00:22:01,131 --> 00:22:05,730
That may be the best it can
be done and it gives them

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00:22:06,080 --> 00:22:08,450
more of a female breast contour,

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00:22:09,030 --> 00:22:14,010
but it usually will not
show perfectly natural.

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00:22:15,350 --> 00:22:20,050
And one of the most vexing
problems is when the implant has

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00:22:20,480 --> 00:22:22,970
ripplings particularly at the outer edge.

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00:22:23,590 --> 00:22:28,130
So someone will be out in a
bikini or a low cut dress and

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00:22:28,600 --> 00:22:32,810
they will show rippling in the
implant, which is an obvious,

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00:22:32,811 --> 00:22:37,530
unnatural finding and can
sometimes be difficult to

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00:22:37,531 --> 00:22:38,364
correct.

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00:22:39,560 --> 00:22:41,460
Lastly, before we conclude Dr. Bass,

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00:22:41,640 --> 00:22:45,380
can you share some important takeaways
for our listeners about how to avoid the

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00:22:45,410 --> 00:22:46,243
done look?

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00:22:46,390 --> 00:22:47,223
Absolutely.

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00:22:48,140 --> 00:22:52,740
Everything in plastic surgery
is about creating balance and

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00:22:53,060 --> 00:22:57,020
proportion. Basically
harmony. Harmony is beautiful.

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00:22:58,210 --> 00:23:02,300
That creates a natural look,
not an extreme look. Now,

335
00:23:02,301 --> 00:23:06,820
some people are trying to create an
extreme look and they're willing to accept

336
00:23:06,960 --> 00:23:09,260
not looking natural, but again,

337
00:23:10,210 --> 00:23:14,500
they're gonna be walking around with
telltales that they've had plastic surgery

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00:23:14,920 --> 00:23:17,460
and that their appearance is manufactured.

339
00:23:18,540 --> 00:23:22,820
Most patients particularly where I
practice in the Northeastern United States

340
00:23:23,080 --> 00:23:27,980
are really not sharing that
they've done surgery with more

341
00:23:27,981 --> 00:23:30,980
than a few very close
friends and family members.

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00:23:31,560 --> 00:23:33,940
And so they'd like to look natural. So

343
00:23:35,490 --> 00:23:40,420
nuances how procedures are done
and paying attention to the fine

344
00:23:40,690 --> 00:23:43,420
details when I'm doing a facelift,

345
00:23:43,600 --> 00:23:47,560
I'm worried about getting a sharp
jawline and a very clean neck,

346
00:23:48,020 --> 00:23:52,120
but I have to think about making
sure the ear lobes are exactly

347
00:23:52,720 --> 00:23:57,080
positioned correctly, that the
tragus is very precisely tailored,

348
00:23:58,190 --> 00:24:02,040
sutured and inset so that
it preserves a natural look.

349
00:24:02,450 --> 00:24:07,040
These are all critical to
maintaining that natural

350
00:24:07,130 --> 00:24:07,963
appearance,

351
00:24:08,100 --> 00:24:12,800
not just getting a big
removal of skin or a big pull

352
00:24:12,940 --> 00:24:14,080
on the face and neck.

353
00:24:16,840 --> 00:24:21,290
Probably the most important
takeaway is to use

354
00:24:21,640 --> 00:24:25,490
each technique for what it's good at doing

355
00:24:26,510 --> 00:24:30,610
and for the degree of correction
that it's well able to produce

356
00:24:31,240 --> 00:24:35,610
when we take a modality and
push it as hard as we can.

357
00:24:36,830 --> 00:24:41,770
That's when we land up with
complications and distortion

358
00:24:41,790 --> 00:24:44,290
and unnatural changes in appearance.

359
00:24:49,850 --> 00:24:54,530
A lot of times we do have good
options to improve things if

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00:24:55,970 --> 00:24:57,090
they don't turn out natural, if

361
00:24:59,450 --> 00:25:01,130
we have some kind of telltale.

362
00:25:02,130 --> 00:25:05,850
Sometimes we have to wait until
there's some healing and settling time,

363
00:25:06,160 --> 00:25:07,570
scar maturation,

364
00:25:09,110 --> 00:25:13,010
or more time passing so
that we can rework the area.

365
00:25:14,110 --> 00:25:15,090
But, you know,

366
00:25:15,091 --> 00:25:19,490
it's very hard to completely
undo some of the surgical

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00:25:19,880 --> 00:25:20,713
telltales.

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00:25:22,430 --> 00:25:27,250
So preventing and avoiding
those problems is always the

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00:25:27,370 --> 00:25:28,203
best approach.

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00:25:28,980 --> 00:25:32,330
Thank you, Dr. Bass for sharing
your insight and expertise with us,

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00:25:32,390 --> 00:25:34,650
and thank you to our listeners
for joining us today,

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00:25:34,651 --> 00:25:38,450
to hear about telltales in plastic
surgery and tips on how to avoid them.

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00:25:38,850 --> 00:25:41,890
I hope you found this episode as
fascinating and informative as I did.

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00:25:42,230 --> 00:25:45,770
If you think of other exciting
developments or trends
in plastic surgery that

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00:25:45,771 --> 00:25:48,090
you would like us to discuss
in upcoming episodes,

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00:25:48,190 --> 00:25:51,450
please reach out via email or
Instagram. We'll see you next time.

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00:25:52,240 --> 00:25:56,090
This is Doreen Wu thanking you for joining
Dr. Bass and me for this discussion

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00:25:56,091 --> 00:25:59,450
of telltales and plastic surgery.
Be sure to tune in next time.

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00:25:59,451 --> 00:26:01,210
And don't forget to
subscribe to our podcast,

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00:26:01,550 --> 00:26:04,770
to stay up to date with all of the
exciting content that is coming your way.

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00:26:05,740 --> 00:26:09,850
Thank you for joining us in this episode
of the Park Avenue Plastic Surgery

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00:26:09,980 --> 00:26:14,530
Class podcast with Dr. Lawrence
Bass, Park Avenue plastic surgeon,

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00:26:15,370 --> 00:26:17,210
educator, and technology innovator.

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00:26:17,550 --> 00:26:20,010
The commentary in this
podcast represents opinion.

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00:26:20,200 --> 00:26:22,570
This podcast does not
present medical advice,

386
00:26:22,870 --> 00:26:26,890
but rather general information about
plastic surgery that does not necessarily

387
00:26:26,990 --> 00:26:30,170
relate to the specific conditions
of any individual patient.

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00:26:30,550 --> 00:26:35,290
No doctor-patient relationship
is established by listening
to or participating

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00:26:35,430 --> 00:26:36,263
in this podcast,

390
00:26:36,520 --> 00:26:40,530
consult your physician to advise you
about your individual healthcare.

391
00:26:40,790 --> 00:26:42,130
If you enjoyed this episode,

392
00:26:42,310 --> 00:26:46,560
please share it with your friends and
be sure to subscribe to our podcast on

393
00:26:46,561 --> 00:26:50,440
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394
00:26:50,780 --> 00:26:53,040
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