Jonathan Sykes, MD, FACS, is a well-known mover and shaker in facial plastic and reconstructive surgery research, and most recently he has been serving as the president of the American Academy of Facial Plastic Surgery (AAFPRS). Sykes’ research, much of which has been published in more than 100 articles in scientific journals and textbooks, has done much to help guide the facial plastic surgery field.
In addition to running a private practice, Sykes is professor and director of Facial Plastic and Reconstructive Surgery at the University of California (Davis) Medical Group in Sacramento. In practice since 1985, he has performed more than 17,000 aesthetic, functional, and reconstruction surgeries. In addition to being a fellow of the American College of Surgeons, Sykes is certified by the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology.
When PSP wanted a comprehensive and authoritative view on the state of facial plastic surgery, Sykes was an obvious go-to guy.
PSP: What do you see as the latest advances in traditional facial plastic surgery and minimally invasive procedures, including endoscopic forehead lifts, mini facelifts, and microfollicular hair transplants?
Jonathan Sykes, MD, FACS: As physicians, the initial consultation is paramount to determine the specific desires of all the patients. It is important for the physician to understand the patient’s expectations and to match these expectations with the specific procedure(s) that can accomplish patient goals. Additionally, the physician/surgeon should carefully explain to the patient the limitations of the given procedure.
Patients always want the maximum result with shorter scars and less downtime.
As I like to say euphemistically, patients always want mini lifts but they don’t want mini results. There is always a desire from patients to make shorter or fewer scars. Take endoscopic brow lifts. This technological advancement resulted in shorter scars, less scalp numbness, and greater patient acceptance.
In the midface and lower face, many patients can get significant improvement with shorter skin scars. These minilift procedures are well tolerated and have less healing time than do longer scar and flap procedures.
I think a really important realization by physicians is that improving facial in the face is an important component in rejuvenating the face. In my practice, I do a lot of simultaneous volume enhancement combined with surgical lifting. Some patients want only volume. Some patients want only lifting. But to globally rejuvenate their face, volumizing their face is very key in achieving the result. Along that line, we have made a lot of advances in fat transplantation—fat transfer from one part of the body into the face. It gives the face a fuller look, more of the look we had in our youth. Placing volume into various regions of the face can be performed with the patient’s own fat or with “off-the-shelf” fillers.
One big advance is we now have in the US many fillers that increase the options of the practitioner and of the physician to volumize the face. This can be performed for wrinkles and folds, and for global volumization. It used to be that we only had collagen. If we needed to do more global volumization, it meant using a lot of collagen. The disadvantages of collagen were that it required a skin test and associated waiting period, and that it had a relatively short length of effectiveness. We now have products that last longer, look natural, and we get more global volumization instead of just filling a fold.
There are some aspects of injectable medicine that partially replace surgery. A good example of this is the junction between the lower eyelid and the cheek. In this region, surgery never provided a perfect aesthetic answer, and the patient often required a lower blepharoplasty and a cheek lift to achieve a good aesthetic result. Now, we are able to volumize this tear trough region, between the lower eyelid and the cheek. An indentation or concavity in this area lengthens the lower eyelid and makes the individual look aged. We are able to easily place volume in this area with a small injection, avoiding surgery and improving appearance. The results are natural, and the injection has little to no healing time.
I think the largest steps have been, 1) the physician’s realization of the importance of injectables and of fat; 2) the greater availability of more product; and 3) the patient is asking us for a little bit more or a little bit less invasive procedure.
PSP: What are the safest and most effective products, and which are to be avoided?
Sykes: It’s interesting. I don’t think that these products are inherently safe or unsafe. I think the safety is on the other end of the needle. It’s in who injects them. And as such, it’s really important that doctors understand the potential risks, they discuss them with their patients, and they do things to avoid risks.
It’s not as if a single product is safe and another one is not. I think in the hands of people that are not careful, any of these products can become unsafe. But in the hands of careful practitioners who understand the limitations and who understand the potential complications, most products and cosmetic procedures are extremely safe, with complications being extremely uncommon.
Unfortunately, the injectable arena is not really well regulated. As such, one of the scary things for me—and I think for many doctors—and I don’t think this is an economic turf thing, is the person who is out there in a salon without good physician supervision who is injecting fillers and botulinum toxin. Often, patients don’t know the qualifications of the person who is injecting them.
It is common that I will see somebody in my office and I will ask who injected her, and conceivably she will say, “Well, I had it done in a mall, and I don’t really know the person’s name.” This lack of patient education is fairly odd to me. It is important for patients to become educated consumers and ask specific questions such as what is the individual’s training and board certification.
Some practitioners would like to hide behind being an aesthetic doctor or an aesthetic nurse. There is no board certification in aesthetic medicine. There is board certification in facial plastic surgery, and I know the high quality of that. There is board certification in plastic surgery. There is board certification in dermatology and in oculoplastic surgery.
I feel that it is important to create truth in advertising in order that the public be aware of the physician’s training. Physicians need to be direct and honest in their advertising in order to maximize the informed choice of the patient.
PSP: What is the state-of-the-art in the use of lasers in facial rejuvenation?
Sykes: There are a number of new lasers that have come on the market in the past several years. The main classes are the fractionated lasers, which selectively injure the skin in certain areas and do not create a lesion in the adjacent tissue. Instead of injuring the entire facial skin, as with past technology, fractionated lasers allow faster healing times with less exposure to potential complications. The facial skin doesn’t look as red for as long, and the patient doesn’t deal with a long and extended healing time.
The other advances in laser therapy have included the IPL (intense pulsed light) technology, which has allowed us to target specific colors and treat rosacea. We now have very good lasers that selectively improve the pigment of skin.
I think lasers, in general, have a certain sex appeal to the public. The public likes the idea of laser technology. Laser products often get overhyped to the public prior to having a large amount of data regarding efficacy and safety.
PSP: There are many technologies, devices, and wavelengths for doing facial and body work. What technologies hold the most promise, and where are we headed in how technologies can help the plastic surgeon create better outcomes? Think of radiofrequency energy, ultrasound, different laser wavelengths, and cryolipolysis technology.
Sykes: We often come up with some technology and end up not studying it really well, and then market it and hype it before there is adequate information. I think that has gone on with these radiofrequency devices that were designed to tighten the face. Is this potentially promising technology? Yes. I would like to see us study these devices before we bring them out and start telling the public that they are good.
We have seen a lot of products enter our field that come in and have been hyped by a company, only to find out they don’t work that well. Then we get disappointed patients and doctors that have these machines that they have paid for and are looking to use.
I think the progression ought to be the idea, the study, efficacy and safety proven, and then bring the product out and market it. Currently, it’s create the product, market it heavily, and then let’s see if it works. I would say that this is one area where a lot of companies (and physicians) have been guilty of doing this.
PSP: What are the characteristics of the new facial plastic surgeons that you see coming out of training?
Sykes: I think our training is exceptional. If you look at a person’s training now versus 15 years ago, it’s far superior now—unbelievably superior. It’s really quite amazing what we have in terms of what we teach and how quickly a young physician gets to an advanced level now versus in the past. There is nothing that replaces experience, for sure, but in general I think our training is very, very good. I think it’s probably good across specialties, not just in facial plastic surgery.
PSP: How can universities and other learning institutions better serve the needs of the next generation of plastic surgeons?
Sykes: There are a lot of ways that we can—and are—improving our methods of educating and training physicians. Contemporary physicians often want to be able to learn at home and through the Internet. The AAFPRS is creating streaming online videos that will enable the doctor to learn at home and not have to travel to meetings. The next generation of doctors will be learning a lot from home.
Physician education is changing in multiple specialties, and the AAFPRS certainly will be at the cutting edge of educating and training our members.
I think that’s the direction.
PSP: What, if any, new approaches and procedures are you seeing, or working on yourself, other than what we have touched on?
Sykes: We are really incorporating volume into rejuvenative surgery, and that’s a cross-specialty thing. I am doing that a lot in my own practice.
PSP: How did you get involved in going to other countries and providing surgical care for children?
Sykes: My practice is a mix of aesthetic and reconstructive surgery. Care of children with deformities is very important to me. This includes children with congenital and cleft-related defects. I perform these surgical procedures in my practice at University of California, Davis, and in other countries. I like to travel a lot [and] have taken a number of trips in my life to other countries relating to performing surgery on children. I have taken over 25 mission trips to countries including China, Russia, the Philippines, Bolivia, Honduras, El Salvador, and Ecuador.
Some people are trying to change the world. I am only trying to change the lives of a few people. My perspective is that if I can improve the appearance of a few children and educate local doctors to also perform these procedures, I will have made a small difference in the world.
Janine Ferguson is a contributing writer for PSP. She can be reached at firstname.lastname@example.org.