An Interview with Miami Plastic Surgeon, Dr. Rian Maercks
Rian A. Maercks is a premier plastic surgeon with a successful practice in Miami, Florida. He has developed a number of innovative, advanced surgical techniques and performs a range of aesthetic/cosmetic procedures.
Dr. Maercks specializes in early interventions for facial aging, Stem cell and fat grafting therapies, eye and brow aesthetics, facelift, rhinoplasty (nose refinements and corrective procedures), neck and chin correction, breast enhancements, and body contour including tummy tuck and liposuction, and also provides effective nonsurgical options for both restoring and improving the face and body.
In the following interview with Dr. Maercks, he discusses many common questions and unique procedures offered through his practice:
Dr. Maercks, you have developed an underlying philosophy — and a signature set of unique, advanced plastic surgical techniques — that you refer to as 'Histiocentricity.' Please explain what this means for individuals considering a cosmetic procedure.
I incorporate this way of performing plastic surgery of the face and body into every procedure that I do. In essence, 'Histiocentricity' means that my work is tissue-centered or tissue-focused, relying upon a set of surgical tenets that incorporate precise, thoughtful design and involve minimal tissue invasiveness. Using this method, I am able to consistently achieve results, while minimizing swelling, complications, and recovery time. This way of understanding and working (histiocentricity) has enabled me to design and refine radically new techniques in the subspecialties of facial aesthetics, breast aesthetics, craniofacial reconstructive surgery, and reconstructive microsurgery.
How is your approach to surgery utilized in the MAERCKS-Lift, a facelift technique that you developed?
The MAERCKS-lift is a facelift technique I've developed that was influenced by the work of numerous mentors (including Dr. James Stuzin, Dr. Fernando Ortiz-Monasterio, Dr. Fernando Molina, Dr. Franciose Firmin and others). Over time, I've modified and refined this technique with a Histriocentric approach, leaving a robust blood supply intact while achieving a complex multivector restructuring of the deep facial tissues. This surgical technique yields a beautiful, natural appearance, and enables me to maintain the entire blood supply by utilizing three thoughtfully designed directions of pull.
What does this mean? Essentially, using this approach, I am able to redefine the natural angles and planes of the face and re-sculpt them so that they're most natural looking and aesthetically pleasing. This, in turn, means there is no need to pull on the skin, which would result in the unnatural stretched appearance that has become the visual stigma of an obvious facelift featured so prominently in today's media. Many widely publicized techniques that claim a lunch break is all you need, create an unnatural, poorly distributed, and non-aesthetically directed 'pull.' When patients age after these poorly planned procedures, very unnatural deformities can result that are difficult to correct.
With my approach, the naturally beautiful deep structure of the face is overlaid by relaxed, redraped skin in a way that eliminates tension in the face — thus avoiding the "pulled tight" and unnatural appearance that actually makes the face look more aged and peculiar. Another significant benefit to my patients is that the incisions are hidden and placed so that the telltale signs of the typical facelift — abnormal skin folds, ear deformities, hairline displacement and scars in the hair bearing scalp — are not evident.
What else would you like us to know about this new procedure?
First of all, when done by a highly-trained plastic surgeon with good judgment an aesthetic eye, amazing aesthetic improvements can be achieved without making you look unlike yourself. This is important information for those who worry that they will end up looking like someone else. But a facelift is not always the answer. Often, advanced minimally invasive techniques can deliver the subtle, yet powerful, aesthetic changes many patients are looking for, resulting in a more rested, refreshed, and happier-looking appearance.
It's important to realize that there isn't one facelift procedure that's right for everyone: it needs to be custom-tailored to the individual patient. The selected technique is dependent upon many factors including age, skin quality, quantity and location of the facial fat pads, degree of skin excess, neck contour, and periorbital (around the eyes) signs of aging. This is why it is so important to choose a plastic surgeon who is well-versed in all current and conventional techniques, and who has the judgment and experience to select the right intervention for you. Many practitioners learn a single technique to enter the realm of cosmetic surgery, but remember, 'if all you have is a hammer, the whole world is a nail.'
When deep tissue restructuring and significant repositioning of facial fat and neck contouring are needed, I use a personal technique I developed that is based on my experience and influenced by the best of what I learned from my mentors across the globe. I'm well grounded in the SMAS (deep structural supporting tissue of the face) -based support of enduring facelift. But I combined this knowledge, along with the innovations of different thoughts from leaders in Europe, Central and South America, and came up with the 'histiocentric' SMAS lift or MAERCKS-lift. This technique enables me to restore the aesthetic qualities that optimize a person's appearance, subtle convexities and concavities that serve as visual cues for perception of beauty. It's safe, it's extremely precise, and my patients are very happy with the results.
The short answer is simply there is not one universal "right time." Greater cultural acceptance and a wide array of choices for improving one's appearance have resulted in a higher prevalence of young people interested in treating the first signs of facial aging. They don't want to wait, and if simpler procedures can postpone the obvious signs of aging, they want to consider them. If someone is thinking about an elective cosmetic treatment or procedure, the question is almost already answered. The pertinent question becomes, "What is the right procedure for me and do I need it now?"
Unfortunately, misinformation and monetary motivation have really polluted the meaning of terms like "noninvasive," "nonsurgical" and "overnight results." New products — coupled with heavy direct-to-patient marketing and big marketing dollars behind them — appear everyday, adding to the public's confusion.
Early interventions for facial aging can be appropriate as early as the 20s in the right patient; however, proper selection and execution of the correct treatment or procedure are critical factors. For those who want to look their best, this issue is how to avoid making a bad decision. The answer is to find a practitioner who is capable, has a large skill set to choose from, and will honestly offer you feedback and options that are in your best interests. There's a time for certain procedures, depending upon how your face and body are affected by your own aging process. A new cosmetic surgery technique inevitably gets a lot of media attention—that doesn't mean you need it or that it will be the procedure that will give you the best results. Even the newer procedures that are truly nice interventions are heavily based on procedures of the past and dependent most on the skill and experience of the doctor who performs them!
With regard to facial fillers, are newer advertised products better?
There's an old saying: "If all you have is a hammer, the whole world is a nail." This explains the ever-expanding number of patients seeking secondary plastic surgical corrections from the misapplication of injectable products. On the face of it, 'off the shelf products' are very attractive for some patients and physicians because they can be done quickly, they generate quick money for the practice, and they claim to require a shorter recovery time. These are seductive claims for many busy people who want to look better, find a solution that seems to be quick and easy, and get back to their normal lives as soon as possible.
The fact is, many of these new products are far from perfect and shouldn't be used in place of other tried-and-tested treatments that are proven to be safe and effective. While absorbable hyaluronic injectable products are safe and reliable, they are temporary and require ongoing treatments every 6-12 months. If you have minimal facial aging changes, and don't mind spending the time and money required for "upkeep," they are very well tolerated.
You have said that artificial fillers are less than ideal. Please explain.
Problems can sometimes occur when shortcuts are attempted and semi-permanent or permanent off-the-shelf fillers are used. There's a complication rate associated with this classification of fillers that is largely hidden from the public. Why is it hidden? It's generally not a matter of intentional deception; rather, it's often a result of the natural history of these products. The most devastating complications are not necessarily apparent right away and patients who experience them rarely return to their original physician for correction. As a result, practitioners with complication rates are frequently unaware of these outcomes. So, they keep offering these treatments, believing that they're safe and effective.
Anything placed inside the body, no matter how inert, elicits a response from the body and its local tissues. The properties of any injectable or implantable product are very different from the body's native tissues. This means that even under ideal conditions, these products may cause resorbtion and atrophy of the body's tissues, fat and skin. In other words, these products can actually advance the signs of facial aging. When these changes occur, even well placed products will migrate to unnatural positions – potentially creating bigger reconstructive and aesthetic problems. For example, we commonly see permanent artificial malar (cheek) filling that sinks into the midcheek under the now atrophied skin creating, a mid-facial 'rock in a sock.' Unfortunately this common mistake obliterates the mid check concavity that guides the eye to perceive beautiful human facial form. It is not uncommon for practitioners with no aesthetic training or judgment to simply fill the face like a balloon, resulting in smooth skin that has a strangely 'inhuman' appearance.
In addition, a foreign body has a chance of causing a granuloma (a noninfectious area of chronic inflammation that can cause pain, redness and tissue destruction). Even hyaluronic acid injection can rarely cause granuloma. Luckily, hyaluronic acid is usually not present in the body long enough to cause severe problems, even if a granuloma were to occur. Infection is an even worse complication and can happen at any time, with the possibility of devastating consequences. On a daily basis, plastic surgeons are correcting problems caused by the trendy injectable products that were used 1-3 decades ago and correcting mistakes with current products is becoming more and more common. Complications include silicone migration through the skin, destruction of tissue vascularity, late infection, chronic inflammation, pain, and/or redness from granulomas, inappropriate placed volume, superficial show and many more.
What do patients who choose non-permanent injectables need to know?
Selection and application of injectable fillers requires scientific understanding, artistic vision and experience. Yet, many people will put their faces and bodies in the hands of someone without appropriate training. The number and diversity of practitioners offering these services is only growing with expanding 'weekend courses' to teach 'everything you need to know.' Getting a relaxing facial done in a spa is one thing; letting an untrained person inject a foreign substance into your lips or face is quite another. I want those who are interested in any aesthetic enhancement to ask questions, to choose a highly trained and specialized physician, and to fully understand their options.
What about injectable fillers that claim to 'create new collagen' and be long-lasting?
It may be an attractive pitch, but it's a bit unethical in presentation. To begin with, there are no naturally occurring large masses of collagen in the deep layers of the face where these fillers must be injected. Secondly, the "new collagen" referred to is essentially SCAR TISSUE. Who would pay for a procedure designed to create a whole bunch of scars deep in their face? Well, these are some of the most requested procedures. A concentration of firm scar is less likely to cause a granuloma, but you have to understand that an area of the mouth or face that has a firm scar underneath it often results in an abnormal appearance and the decreased elasticity of the tissue that makes the face look older. The long term consequences may include atrophy of facial fat, the most important element in a youthful appearance, and premature skin aging.
Given the risks you've mentioned, are there any temporary injectables that you recommend and, if so, do you offer them to your patients?
Yes, there are certainly techniques and products that give wonderful results when they're selected and placed by an experienced practitioner. I use them selectively to produce wonderful results. But I don't just give my patients what they read about and think must be best because it's new; I evaluate carefully and am discerning in the options I consider on their behalf. For instance, I only use hyaluronic-based 'off the shelf' products for certain patients. They may not want a permanent change, but feel comfortable with a temporary improvement. If they're good candidates for an off-the-shelf hyaluronic product, I make sure they fully understand the limitations of the product and the commitments of time and money they will have to undertake in order to maintain the correction they attain. In other words, it's a process of careful evaluation and discussion.
What about volume correction that lasts? Can it be done?
Yes. I am very pleased with the results achieved by doing a procedure referred to as an autologous fat transfer. It results in lasting volume correction in areas of the face and body and is ideal for those who have lost fullness in areas of the face or body over the years, which results in a sunken, more aged appearance. This procedure involves injecting a combination of fat, growth factors, and stem cells that are derived from the patient's own body. It is absolutely essential that the aesthetic contours of the human male and female face are understood and analyzed when grafting to the face. These procedures are developing a bad name because some practitioners think simply that volume is good. It is important to understand that the goal is not to stretch the skin and erase wrinkles, but to subtly create the visual signals of beauty and youth. Subtlety is essential to avoid making patients look unnatural! Once again, technique and judgement are the most essential ingredients!
What are the advantages of autologous fat transfer?
The result is beautiful correction, with relatively unlimited volume correction at no additional cost (as opposed to off-the-shelf filler products). I find fat transfer very rewarding because I can always achieve a complete correction, giving the patient exactly the volume they need in exactly the right places without worrying about excessive cost to my patients. The advantages include permanent correction, actual improvement in the quality of the overlying skin(instead of deterioration) thanks to stem cells and growth factors in the graft. It is truly amazing to watch the skin texture improve, pore size reduce. etc. I really prefer this natural intervention because of the relative absence of long-term complications, and significant cost savings for the patient. The average patient spends more money on injectable products in less than 2 years than the cost of this procedure. With injectable products, the patient is eventually left with nothing, and there is an ongoing risk of complications. With autologous injections, the patient receives a permanent rejuvenation that will change naturally with their body over time.
You do genioplasty (chin correction) procedures in your practice. How are they done and what are the aesthetic benefits of this procedure?
Genioplasty is the technical name for repositioning the vertical and/or horizontal position of the chin. Though commonly indicated to correct a facial imbalance, it's often overlooked as an option. For example, some patients who dislike their noses are unaware that the problem is their chin. The chin is seldom recognized as a factor in beauty, so the perception is that the nose is the problem. Did you know that the human eye and brain, working together, generate an aesthetic opinion in about 350 milliseconds? That's much faster than we have time to think about on a conscious level. Adjusting the chin position can be a powerful adjunct to rhinoplasty and the facelift.
Many patients would benefit from this procedure, but they miss out because quite a number of doctors that perform facelifts do not do genioplasty surgery. Some offer the substitution of a silicone implant to adjust facial harmony. While this sounds preferable to moving a skeletal component, the limitations – and potential for early or later complications – make it the wrong choice in the majority of young patients.
Over time, the implant will always thin the soft tissue of the chin and erode the underlying bone, which can compromise the structure and appearance of the face. Genioplasty is safe and, if well planned, can dramatically improve facial appearance. I have developed a minimally invasive technique using ultrasonic technology that is so gentle and non-traumatic that it can be performed with the patient awake and comfortable, thus eliminating the need for general anesthesia. The added advantage to this technique is reduced discomfort and swelling post-operatively.
How can the area around the eyes be refreshed for a younger, more attractive appearance?
The periorbita (the gentle oval that surrounds the eye) is one of the most important aesthetic elements of the face. Our brains are programmed to take small cues from everything that is presented by the eye. If you are in a crowded room and glance around the room, in a matter of seconds your brain automatically attempts to decode the age and beauty of every face that you see. Many of these important cues come from viewing the area around a person's eyes, which is defined by the eyebrow, the aesthetic lines of the nose, and the tear trough (that dark indentation that suggests a tired or unhappy face.)
Ideally, the aesthetically pleasing face has the eye centered in this oval. But as we age, the periorbital oval descends, placing the eye high in the oval- triggering the perception of fatigue or advancing age. Aggressive or poorly planned plastic surgery commonly places the eye low in the periorbital oval. This creates a strange surprised or even 'robotic' appearance and is one of the easily recognizable visual signs of poorly done plastic surgery.
I like the challenge of performing eye rejuvenation procedures, which call for thoughtful planning and precision. After studying the patient's face, I determine what is needed to bring the face into better balance by designing a treatment plan that is customized to the patient's unique features. During the surgery, the eyes are "centered," by adjusting the shape and position of the brow to a more pleasing (and natural) position. I then eliminate the dark tear trough by raising the lid-cheek area to its former, aesthetically appealing position. Finally, fat is either added or removed to specific areas around the eyes, which restores their youthful contours so that they are, once again, 'cues of beauty.' The result is a face that still looks like your original face – only happier, younger, and more rested.
Determining which procedure is best to rejuvenate the eye area requires careful consideration (by me and by my patient) of both surgical and non-surgical options. For example, I can achieve the same results in appropriate patients using only Botox and fillers to correct volume loss and "open" the eye area up. This non-surgical option is temporary, however, and requires recurring treatment over time. Still, for those who prefer to postpone an actual surgery but want to reap the benefits of more youthful, fresh eyes, it may be a viable choice. Surgical corrections are different, in that they are enduring and require little to no maintenance over time.
Dr. Maercks, you do many breast enhancement procedures in your practice, including a fat grafting enhancement that requires no incisions or implants. What does this involve?
I perform a range of different breast enhancement procedures, because there are many factors to consider when deciding on the type and technique that's best for the individual patient. Some are good candidates for non-implant breast augmentation using their own body fat. I use fat grafting techniques extensively in my practice, for facial rejuvenation and combined with other facial aesthetics operations such as facelifts, rhinoplasty and brow lifts. But, it's also very effective in contouring and augmentation of the buttocks and breasts. The procedure basically involves a special technique of liposuction that preserves the living cells (including fat cells), and the components of the cells are gently separated out. The resulting refined fat can then be precisely injected into different areas to add volume and a beautiful shape in a way that is simply not possible with implants. With fat, I am not restricted to augmenting predefined areas.
There are several additional advantages to this type of breast augmentation, including the fact that the limitations of implant shape and location do not apply. This means the shape and positioning of the breasts can be highly customized to the patient's frame and shape. In addition, the injected fat feels like normal breast tissue. In fact, the procedure usually gives the breast an even nicer 'feel' then before the procedure. Since it is your own fat, there's nothing about the created breast that looks or seems 'unnatural.' With this technique, I am able to create volume and form where the patient wants it to create as ideal of a breast as can be achieved.