We live in an age in which decreasing wrinkles, plumping up our lips and cheeks, and even eliminating fat doesn’t have to equal going under the knife.

Advances in technology, numerous non-surgical, minimally-invasive treatments are available are making cosmetic procedures safer than ever.

At Napa Valley Plastic Surgery, some of the most popular non-surgical treatments include Botox, soft tissue fillers, laser resurfacing and chemical peels, according to Dr. Tyler Street. Nationwide, Street said, Botox and soft tissue fillers are the two most popular non-surgical cosmetic procedures.

“The interest in non-surgical procedures has always been present but as the technology continues to advance, these procedures are becoming safer, better tolerated and more effective,” Street said.

In 2017, about 7.2 million Botox procedures were performed across the U.S., up 2 percent from the year before, according to the American Society of Plastic Surgeons.

Botox injections work by blocking signals from the nerves to the muscles.

“When certain muscles on the face contract, such as when someone furrows their brow, they form lines in the skin with time,” Street said. “Botox relaxes the muscle underneath the skin and softens the overlying lines.”

The full results of a Botox treatment can be seen in about 10 days, Street said.

The American Society of Plastic Surgeons reports that soft tissue fillers — the second most popular cosmetic treatment in the U.S. — had a 3 percent increase in 2017 for a total of about 2.7 million procedures.

Soft tissue fillers — often used on the lips and cheeks — help create a smoother, fuller appearance through the injection of an absorbable or temporary material.

Over the past decade, injectable products have become increasingly popular, Street said.

“Soft tissue fillers, such as Juvederm, are made from a sugar and are used to address the volume loss people experience as they age,” Street said. “Filler has instantaneous results, which patients really love.”

Dr. John Zimmerman, who leads the Aesthetic Surgery Center of Napa Valley, said facial fillers may be used for acne scars, fine lines around the mouth, smile/crease lines, other wrinkles, or for added fullness over the cheekbones and chin.

Fillers may last six to 12 months around the mouth (because of the frequent muscle activity), or up to five years or more depending on the type of filler used and the area being treated, Zimmerman said.

The key to achieving natural-looking results with cosmetic treatments, like Botox, is to not look “over-injected,” Zimmerman said.

“No matter what you do, strive for a refreshed look — as if you’ve just returned from vacation,” he said.

Like Botox, facial fillers should be used conservatively, Zimmerman said.

“Too much volume does not look natural and is worse than no treatment at all,” he said. “Overuse of fillers may reduce wrinkling, but will make the face fatter in appearance. Less is more — you can always have more at a later date.”

Another popular treatment, laser resurfacing, has become safer and more effective over the past two decades.

Depending on the type of laser, the treatment can be used to eradicate or reduce wrinkling, shrink skin, remove brown spots or dilated vessels, as well as small vascular lesions, Zimmerman said.

“No ‘cutting’ or incision is necessary, although for significant wrinkling, some anesthesia, healing, and recovery time is involved,” he said.

One of the biggest benefits of non-surgical cosmetic treatments is the recovery time — often minimal to none, doctors say.

Injectable treatments may cause a temporary redness or swelling at the injection site, or a small bruise—all of which should resolve within a week, Street said.

People typically seek cosmetic treatments to look more youthful and refreshed. According to Street, patients often say they look tired, angry, or sad, when they don’t actually feel that way.

While cosmetic treatments are typically sought by women, Street and Zimmerman said men are becoming more comfortable using aesthetic procedures, like Botox and soft tissue fillers.

“The variety of non-surgical aesthetic procedures available is amazing, and increasing on an annual basis,” Zimmerman said. “Although women comprise the biggest segment of patients presently undergoing these treatments, men are catching up rapidly.”

Do your homework

While a minimally-invasive procedure can be a safer option, doctors are quick to caution consumers to do their homework before committing to a treatment or choosing a provider.

Zimmerman said he has treated numerous patients who have come to him for help after undergoing a non-surgical procedure gone horribly wrong.

“Over the years, I have often seen patients who have had some of these non-invasive procedures done elsewhere and they are unhappy with their result,” Zimmerman said. “They have required revisionary procedures, including surgery or reversal of injected fillers and subsequent appropriate injection.”

The state of California requires any non-physician administering these types of cosmetic treatments to be under the direct supervision of a doctor. According to Zimmerman, patients should find out what the credentials are of that supervising physician.

“As these techniques are offered by so many, and advertised everywhere, the average consumer has no way of knowing what the doctor’s training or experience is,” Zimmerman said. “Ask questions. You have a right to be informed.”

A physician — whether he or she is directly administering the treatment or acting as a supervisor — should ideally be certified by the American Boards of Plastic Surgery, Facial Plastic Surgery, or Dermatology, Zimmerman said.

“These doctors have specialized training in the aesthetic needs and corrections necessary whether it be the face, trunk, or skin,” Zimmerman said.

If a provider is not certified by one of these three Boards, according to Zimmerman, that’s a red flag.

To determine a provider’s Board certification, consumers can ask the provider directly or visit the Boards’ websites to look up the doctor’s credentials.

While non-invasive procedures are generally well-tolerated and safe, Street agreed that patients should do their research and pay careful attention to a practitioner’s qualifications before choosing where to have a procedure performed.

“Physicians who are board-certified plastic surgeons or dermatologists are specially trained to administer these types of procedures,” Street said. “It is that training that helps us achieve consistent natural appearing results and, more importantly, do it safely.”

Other practitioners, including nurses, Street said, may not have had the same formal training. He said it can be confusing to know who has received appropriate training and who has the best interest of the patient in mind.

“It can be hard to choose the right person for injections. There is a lot of misleading information out there,” Street said. “Most often, people who advertise the lowest prices to entice patients don’t have sufficient training. My best advice is don’t go to someone who makes you uncomfortable.”

Additional red flags include a practitioner who looks “overdone” with obvious cosmetic treatments, or any practitioner who pushes patients to undergo treatments they’re not comfortable with, Street said.

“In those instances, it’s best to hold off on treatment, do some more homework, and seek a second opinion,” he said.

Zimmerman agreed that selecting the right provider is crucial.

“Do your homework and choose the best practitioner available,” Zimmerman said. “Training and experience are mandatory. Results vary, and complications are possible.”


To eliminate fat, liposuction is the surgical treatment most often performed.

But for certain patients who meet a specific set of criteria, a non-invasive treatment known as “CoolSculpting” may be an option.

CoolSculpting is a non-surgical procedure that eliminates fat cells by freezing them. It does not reduce as much fat as a liposuction or abdominoplasty procedure, Street said, but it can be effective for some patients.

During a treatment, a gel pad and CoolScultping applicator are positioned on to a patient’s targeted area of fat.

“As the cooling begins during the first few minutes, you will feel pressure, tugging and intense cold. This soon dissipates,” said Karen Jenanyan, owner of Body Beauty Advocates. “Many people read, watch videos, work on their laptop or even take a nap during their treatment.”

CoolSculpting works on multiple areas of the body: upper, middle, and lower abdominal areas, under the arms, under the chin, thighs, and the upper backside of the thighs.

“Once the treated fat cells are crystallized (frozen), your body processes the fat and eliminates these dead cells,” Jenanyan said.

The results of CoolSculpting can be permanent as long as patients maintain their weight within about three or four pounds from the day of treatment, Jenanyan said. Many people, after experiencing the CoolSculpting results, are motivated to take better care of themselves, she said.

CoolSculpting is offered in several locations throughout Napa County, including at Vibrant Body Sculpting inside the Napa Valley Medical and Esthetics office on Trancas Street, Jenanyan said. Vibrant Body Sculpting has offered CoolSculpting for more than two years, she said.

The ideal candidate for CoolSculpting is someone who, despite diet and exercise, cannot get rid of unwanted fat, Jenanyan said. This procedure is not for obese people, she said.

“Good candidates generally are about 5 pounds to 35 pounds maximum overweight,” Jenanyan said. “Good candidates have bulges in certain areas they’d like to get rid of once and for all.”

CoolSculpting was developed at the Wellman Center for Photomedicine at Massachusetts General Hospital in Boston, a teaching affiliate of Harvard Medical School.

While it is safe and well-tolerated by most patients, physicians caution that CoolSculpting is not for everyone.

“I think it’s best for small, targeted areas on a young body with healthy skin — and in simple areas like the belly underneath the belly button,” Street said. “If skin is overstretched or thin, or if someone is looking to treat complicated contours or hard-to-reach areas, it’s not as effective.”

Neither Street, of Napa Valley Plastic Surgery, or Zimmerman, of the Aesthetic Surgery Center of Napa Valley, offer CoolSculpting in their offices. They do, however, offer comprehensive surgical options like liposuction and abdominoplasty.

Plastic Surgery Specialists in Marin County, which attracts patients from across the Bay Area, including the Napa Valley, has offered CoolSculpting for nearly five years.

“Coolsculpting is a body contouring procedure, not a prescription for weight loss,” Dr. Stanley G. Poulos said. “It works best when smaller areas can be contoured to improve the overall figure, as opposed to a debulking.”

Poulos said his office in Marin offers “Dualsculpting,” which means they have the ability to use two CoolSculpting machines simultaneously — cutting the treatment time in half for patients.

To improve patient results, Poulos said his office also offers non-invasive skin-tightening treatments that can be used concurrently with CoolSculpting for “even better results.”

“With anybody contouring procedure there is always a balance between fat removal and skin laxity,” Poulos said. “The better the skin tone is to start, the better the result will be after.”

According to Poulos, CoolSculpting does not cause any permanent effects on the skin and, typically, there is no bruising. A small percentage of patients may develop temporary nerve pain after treatment, but this is “very rare,” he said.

“CoolSculpting is no longer a novel procedure,” Poulos said. “It has well-demonstrated safety and efficacy in tens of thousands of patients in all areas of the country.”

CoolSculpting patients may experience a fat loss of 15 to 25 percent in the treated area, Jenanyan said. In many cases, the body will continue to flush out fat cells for four to six months after treatment, she said.

“You may start to see changes as quickly as three weeks after your treatment, and you will experience the most dramatic results after two to three months,” she said.

Set realistic goals

Any medical professional offering cosmetic procedures, according to Zimmerman, should be meeting six specific goals:

— Make the patient happy

— Make the patient look natural

— Do it safely

— Make the patient comfortable, and alleviate discomfort as much as possible during the procedure

— Address the patient’s concerns and expectations

— Be honest

Zimmerman stressed the importance of honesty and setting realistic goals with patients. Injectable treatments are not a substitute for surgery, he said, adding that surgery is sometimes what is required to make a patient happy.

Before undergoing any procedure, Zimmerman said patients should discuss their expectations with their provider to make sure they’re receiving the appropriate treatment to achieve the desired result.

When surgery is the better option, products like Botox and soft tissue fillers are sometimes still used as “icing on the cake,” he said.

“Many good non-invasive plastic surgery treatments are available,” Zimmerman said. “They may or may not provide the answer to your concern.”

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