News and trends: Interview with Dr. Lorenc 

Dr. Z. Paul Lorenc from Aesthetic plastic surgery: „Unless you incorporate non-surgical modalities in the future, you risk becoming dinosaurs." The next generation symposium in New York.

What brought you to aesthetic plastic surgery?

I started being a cardiac surgeon many years ago and the reason that I switched to aesthetic surgery instead of plastic surgery was because it is innovative in nature that makes it so different patient to patient. It is still surgery but it is very different than open heart surgery or gall bladder surgery. Every patient is very different, and I do a different operation from patient to patient. The other thing is that you can really change someone´s life. I do nott mean physically but we have seen many changes psychologically, where patients feel much better about themselves with more confidence. There is a lot of science behind this theory that has already shown this to be possible.

I know that you do endoscopic surgery that is done with the endoscopy technique that you have pioneered in your field. Can you tell me more about it?

Yes, I have several patents in this area. One of the patents is an absorbable device that is made of polylactic acid which is a completely bioabsorbable, biodegradable material that is put into the bone, into the skull, and the skin tissues is suspended from it. The screws are not made of metal; they are made of the polylactic acid and the suspension device looks like a number of tiny little hooks. You drill an incision into the skull and then put the device in and suspend the soft tissues from it.

Are the results better than with the use of the metal screws?

Well, they are better because it is easier for the patient. You do not have to go back and remove the screw from the patient. That is the big advantage that it completely disappears in about six to eight weeks and the tissue is already suspended in the new position. You do not have to perform a second procedure to remove any hardware.

Is this technique mainly used for forehead lift?

It is used for browlifts and for facelifts as well.

We have heard about many new techniques at the Aesthetic Plastic Surgery: The Next Generation symposium. If we look a bit more into the future, into the year 2010, which three innovations or techniques do you personally see as the top ones we will hear about? Which are the ones with the most added value for patients and surgeons?

 As far as facial surgery goes there is something unique that I have been working on with Ethicon at Johnson & Johnson for a number of years. It has just received the CE mark and actually I am heading over to Germany just next week to help with the initiating of the clinical trial. The NUVANCE system is a very minimaly invasive facelifting procedure that uses a very unique designed mesh from Johnson & Johnson which is inserted through the hairline underneath the skin and the skin and soft issues are elevated. So that it is a lifting procedure that falls right in between the non-invasive to minimaly invasive fillers and a facelift, which is skin rejuvenation using surgery. It is minimally invasive with very little downtime and conceptually a very different way of thinking. Instead of just lifting the tissue it is redistributing the tissues and it is just because of the design of this particular product. It is truly fascinating. It is partialy absorbable mesh.

Dr. Z. Paul Lorenc MD FACS

So you are just starting the clinical trials?

Yes, clinical trials are starting first in Europe and then in the USA.

When do you expect this new technique to be used widely?

It will most likely be available within the next year or two.

Can you please name two more new interesting techniques?

I think as far as body contouring, or as far as fat dissolving techniques go, I think it is going to be in the transcutaneous form. Some of the modalities will be either radiofrequency based or ultrasound based. If I had to bet I would probably bet on the ultrasound based devices. We speak about focused ultrasound here which is focused specifically underneath the dermis which causes fat necrosis and then your body eliminates the fat from the system which causes skin shrinkage. So I think we are certainly heading towards less invasive techniques where it is invasive. The ratio of procedures in the US of less invasive to most invasive is already at 5-6 to 1.

And it is obvious where it is going ...

Without a doubt. If you are a patient and you have a choice between more invasive and less invasive the answer is obvious. So as far as body contouring goes, I think it is going to be a transcutaneous non-surgical way to dissolve the fat. And the last one is really about the degree of skin shrinkage. I do not know if you have been to the session this morning, but that it is the issue which has not been answered yet. Right now in my practice I use a system that is an internally delivered laser. It is 989 wavelength laser that is delivered to a small incision underneath the skin and it delivers energy or heating effects to the undersurface of the skin or the dermis causing shrinkage and coagulation of the skin. I think we are in the early stages of that. If you ask me what the future is at this moment or in 2-3 years, it will be internaly delivered device. But I hope in the near future it will be a device that does not have to penetrate the skin to deliver enough energy to the dermis to cause shrinkage.

In Europe there seems to be a bigger barrier between cosmetic plastic surgery and aesthetic dermatology. Some plastic surgeons perform an excellent job in the field of reconstructive and aesthetic surgery, but they do not perform any less-invasive or non-surgical techniques, such as radiofrequency or ultrasound based treatments. They feel these treatments are more from a field of dermatology rather than real plastic surgery. What is your opinion?

There is much more crossover right now between the specialities. There is a tremendous integration as you can see at my meeting right here at the Waldorf. You can see I have invited many prominent dermatologists to speak at my meeting because I think there should be an exchange of ideas. And there will be eventually. It is actually a combination of the ideas I learned from dermatologists, and they tell me that they learned a lot from me. I think it is a joint effort to obviously get the less invasive, best result for the patient. I feel there will be more integration in the future and that we are co-dependent on each other.

Do you think that in these days a plastic surgeon can survive without incorporating non-invasive treatments into his practice?

I think that it is very smart of a plastic surgery practice to incorporate the non-surgical and minimally invasive modalities into the practice. I mean, look at the ratio: six to one. The answer is obvious and it is what consumers want. Unless you incorporate non-surgical modalities in the future, you risk becoming dinosaurs.

What is your opinion on physicians of other specialties performing cosmetic surgery treatments such as tumescent liposuction?

My opinion is that first question the patient should ask the physician that is considering surgery should be: What is your training? Do they have training in that particular procedure? How many of that particular procedure have they done? And probably the most important issue there, and not many people address this issue, is the physician capable of treating a complication? There will always be complications. And I think it is very healthy for the patient to know what they are upfront. For instance, if you have a liposuction and you go to someone who does not have the training and does not know how to take care of a wound infection or hematoma that is a problem. So I think it is very healthy for the patients to ask those questions upfront. Do I see myself as the aesthetic plastic surgeon having to police other physicians doing what they are doing in their offices? No, it is not my job. Should it be my job? No. I think it should be the responsibility of governmental offices, state health departments, medical societies and so on. Because of patient safety I see this as very important for patients to know what kind of experience the particular physician has had.

Is it regulated in any way here in the US?

Very loosely. In effect anyone who has a license to practice medicine can do this. I think that the regulations will have to be formulated in order to keep patients safe but at the moment anyone who has the medical license can do the procedures, of course.

Do you see more specialization? If a surgeon focuses on one particular procedure, e.g. purely on rhinoplasty? What is the upside and downside of it?

Many years ago I came to realize I cannot be an expert in everything. No one can be an expert in every procedure. So I stopped doing hand surgery. I have a fellowship in hand and microvascular surgery and even within the aesthetic surgery I do certain things and choose not to do others. For instance, I do not do bodylifts because I just choose not to do it. I specialize in facial rejuvenation, I do breast surgery and abdominoplasty. So I don´t think you should be so super specialized you do only one procedure, but I think you should limit the number of procedures in order to be excellent at it.

Where do you think injectable fillers are heading to? What is the future of injectables?

The future of fillers is in large volume injection. Without a doubt, for body contouring or breast contouring it will be large volume injections. I do not think the right filler has been designed yet. There is a variation of hyaluronic acid fillers or some sort of stimulatory agents such as Sculpture are just the beginings of that. Whether it will be breast augmentation, body contouring, buttock augmentation, that is where we are heading. I know it seems a little bit futuristic but it goes along the minimally invasive or non-surgical procedures. There will always be a place for surgical plastic procedures just like in my practice and I still do a lot of facelifts, still do a lot of body work but I think it will end up being fillers in a different use and different way we are thinking about them right now.

Do you think that advertising on cosmetic plastic procedures should be regulated in any way?  A group of plastic surgeons have come up recently with an opinion that the demand for cosmetic plastic procedures is created partly by media and by advertisements and that is not ethical and it should be somehow regulated?

Well, I agree. Some consumers are driven by media. But if it should be regulated, and I think it is almost impossible to regulate it, it definitely shouldn´t be up to us physicians to regulate it.

What is your opinion on medical tourism? What do you think about US patients travelling abroad for medical treatment? Do you have personally any experience with medical treatment? Do you have patients from abroad?

Lets fist talk about US patients leaving the States to go to e.g. the other countries for treatment. You have to keep several factors in mind when travelling abroad for a medical procedure. I think it is important to meet the physician first before they get operated to make sure the facilities are credited and sometimes it is difficult to assess that from long distance, to check the qualification of the physician, the safety records and one of the probably most important factors and what happens if there is a problem, what happens if there is a complication. I personally have patients from all over the world. A large percentage of my practice is international. Patients come here, a lot of them also have apartments or homes in the States and visit New York very frequently and even if they don´t I make sure they stay in the N.Y. for a long enough period, usually 10 and 14 days. So that when they go home, whether it is London or South America, they are basically healed to the point they can travel and the stitches can be removed. There are a lot of factors, including DVTs on the plane, increased risk of pulmonary embolism when they are immobilized on the plane for longer period of time, etc. so we have to readjust to it.  I have patients come in several days before the procedure, they are always dehydrated, so there are several factors to consider.

What are the main reasons people come to the US for medical treatment?

I think it is because we are forefront in the aesthetic surgery and they also hear about the new technologies being developed here in the United States.

Dr Lorenc, thank you very much for your time.

Injection

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