Posted by Dr. Anil R. Shah
In the latest episode of Masters of Beauty, Dr. Shah gets the opportunity to talk with revolutionary plastic surgeon Dr. Harry Mittelman. Dr. Mittelman developed crucial techniques for facelift surgery and patented several types of chin and face implants and spearheaded the use of CO2 laser for cosmetic surgery. He is a triple board certified facial plastic surgeon located in Palo Alto. Dr. Shah and Dr. Mittelman discuss all things chin implant, celebs with the best chin, custom vs. shelf implants and more.
Transcript:
The following podcast is a discussion between two experts in their fields of beauty and not meant to be taken as medical advice. Be sure to consult with your doctor if you have any.
Dr. Shah:
We are on the Masters of Beauty, this is Dr. Harry Middleman, and so many people across the world use things that you invented, literally invented, which is why it’s an honor to speak with you by the way, talking about the chin implant, how this has been modified with CO2 laser, I mean two things that are almost always used. You can't do facial plastic surgery without these two things. And so what I want to do today, if it's okay with you, is just basically talk about your thought process on how you were able to come up with a chin implant, your modification of it, the Mittelman Implant, which in my opinion is the best implant in the world. And then talk about the CO2 laser and then why it's so rare in true innovation in facial plastic surgery. So a couple of things to talk about. Yeah, so should we just talk about the chin first, how did you come up with that?
Dr. Mittelman:
Well, let me talk to you maybe chronologically about my past and how I've come up with some of these things. Back in the early 1980s and even when I was in the military in the early 1970s, I thought about the use of the carbon dioxide laser and some other lasers for facial cosmetic surgery and for intranasal surgery for allergies where they terminate, swell and keep people from breathing. So when I went into practice in Palo Alto, I got the medical exclusive to use the CO2 laser tubes for cosmetic surgery for medical use, really. And then in 1981, I developed and started a company called Metricon, which was the very first, the idea was to have an office-based laser, not a laser that you use in the hospital, which were huge, but an office-based laser. And we developed a company with the technology to do that.
So in that process, I wrote a business plan and started the very first energy-based laser company in the world. And from that company became the multi-billion dollar industry that we have now in lasers, in office-based lasers in medicine. And my technology was good enough that Johnson and Johnson was extremely interested in it. And within one and a half years, we sold the company to Johnson and Johnson, who then used these lasers not only for cosmetic purposes, but also an OB GYN. And so we sold that company and the investors made 10 times their money in a year and a half.
Dr. Shah:
How much money do you think they made since then?
Dr. Mittelman:
Well, of course a lot more money since then. Of course, at that time we sold for $3 million or $4 million. But of course in today's world, that's like 50, 60, $70 million. But anyway, going on to the chin implant, which I know you're interested in, I've been involved academically in facial cosmetic surgery for over 35 years, 40 years. So from the very first year I was in practice, I was always involved academically and was on the Stanford faculty, clinical faculty for about 25 years. During the times that I've been practicing, I've had a fellowship program where I have a new person come in to do a fellowship that's fully trained in facial cosmetic surgery, and they've decided they want to do only facial cosmetic surgery and want one more year of mentoring. I've done about 30 people, 30 disciples around the country that I've trained. But getting back to the chin, the real reason that I started, this was again in the 1980s, the chin implant that we used to have was what we called a central chin implant.
It was a little button in the front of your chin. And when you put that into a young person, a young lady, a young man, it looks okay because there's so much soft tissue there. But with the aging process, you get atrophy and thinning of the tissues of the face. And when that happens, this thing sticks out like a little button. But what also happens is that when you do a facelift, which we did a lot of, when you do a facelift, if you get this indentation in this area, and we named this area the Prejowl groove or the prejowl sulcus, so the jowl is right here, and this is where the looseness occurs. So when I did my facelifts, they were great and people were very satisfied, but I was not because there was still a little indentation in this area, the prejowl area.
And so at that time, I recognized that the chin implants didn't look like anatomical chin implants, and I redefined their shape to match the contour of the mandible on people that don't have any chin hypo protrusion. So we wanted to take that kind of chin and make it into this much more anatomical chin. At the same time that implant or a prejowl implant would be able to eliminate that little indentation that people get, especially women with age. There's resorption of bone and thinning of the tissue in the prejowl area. So I developed two things. I developed the Mittelman Prejowl Chin Implant, which was the anatomical extended chin implant here. So instead of being round like this, it extended and thinned out as it went along the mandible. But I also invented and patented the Mittelman Prejowl Implant, which had no augmentation in the chin area, but only in the prejowl area. And that made my facelifts much more perfect than they were previously.
Dr. Shah:
Both of which are genius. Okay. So coming up with that, you recognized the difference in anatomy, then you designed it. How did you put this design into action? What did you do to say, okay, I'm going to make this new implant? How did you go from point A to point B? What was your thought process? How did you make that happen?
Dr. Mittelman:
Well, the first thing is you patent the idea, so you design it and you submit patents for it. The second thing is you contact implant companies to see if they would do what you want them to do. And at that time, there was a company called McGann Medical and they did chin implants, these little central chin implants. And so I designed this and they said, yeah, we'll do it and we'll call it an anatomical chin implant because it fits the anatomy. And at the same time, there were a couple of people that were interested in facial implants, cheek implants, as well as mandibular implants. So Bill Binder, who's a genius physician in Southern California, along with myself and a couple of other people that were interested in this area, started a company called Implant Tech. And Implant Tech is now the largest facial implant company in the world. And so we were involved in doing that, and implant tech made the middleman GY implant and the middleman pre GY HIN implant and McGann also did it. So I worked with both companies because we wanted to get these implants out, no matter which company made 'em. Those were the two biggest companies.
Dr. Shah:
Did you know you had a hit when you came up with the design? Did you know that? Did you have a eureka moment and said, you know what, I solved something. I know this is going to be a hit, or did it take you some? Was there some back and forth in the design?
Dr. Mittelman:
No, I knew that it was going to be the right thing to do right away. I never thought of it financially when I first did it, but I have an entrepreneurial side to me, especially after having done the laser company, the office-based laser, which was a big hit for me financially. Of course at that time I was very early in my practice when I developed that concept. And so I thought of it both ways. But the main thing was that it solved a problem for facelifts that was previously being ignored. And this was before the age of fillers, so you couldn't fill this in with fillers. Back then, there were no fillers.
Dr. Shah:
So I have a question in vogue right now, some people are talking about putting in fat or filler. I think even if you do fat or filler, people are saying it's the same as putting an implant. My thought is it's not the same because you lose bone, you want to mimic what's missing. You want to put an implant, so it will mimic that better. What are your thoughts? I know you've done all of them. That's right. What do you think is the best solution if someone has that prejowl groove? You're doing a facelift and you want to improve it. Tell me the difference between filler fat and implant.
Dr. Mittelman:
Well, certainly the plant implant is permanent, whereas the filler is not permanent. But the filler does a very good job. I am not maligning that at all. I think if the patient doesn't want to have a surgical procedure, an additional surgical procedure at the same time that they're having the face neck lift, but they have a pre-trial group, then doing filler is a good concept. But you tell them at the same time, it's only going to last for about a year. And then you do some more fillers, a nice little office-based situation that does a good job. And so I think the patients usually make the decision to go with a filler rather than with the implant. However, if they have a chin recession, then of course a chin implant. The fillers do not substitute well at all for chin implants, but they do make a great substitute for prejowl grooves.
Dr. Shah:
Okay. What about fat? Do you think fat's reliable there?
Dr. Mittelman:
Fat is effective, lasts longer, but has risks to it. Fat can form granulomas, which you're not going to get with fillers. They're more long lasting. So if it's not right, let's say it's overfilled, you can't get rid of it very easily at all. So you're taking a risk that you don't take with fillers. Fillers, if you overfill for some reason, you can put in some yase and it will melt the filler hyaluronidase. And so the hyaluronidase will melt the filler and then you can start over. And most of the time we're very accurate and we don't have to do that. And the same thing is true most of the time for fat. But if fat doesn't act appropriately or if it absorbs more in one area, one side and does the other side, then you have a problem to deal with that you don't have with fillers. So fillers do have their benefits.
Dr. Shah:
Yeah, I mean I'm just trying to get your thoughts on that as well. My experience with it is I think that if I had to give a best, better, worst, I think implant to me is probably best because even if you try to fill, especially with your augmentation, I agree that if you try to fill this with filler in your chin, it's going to start to spread into another area because it's under duress or stress. And if you have an implant there, as you know, I mean you designed it, you know that that's just going to be where you want it. It's where it's at.
Dr. Mittelman:
It's going to be exactly where you want it. Like I said, when you present these things to a patient, there's no question that the implant is the optimal situation. But when you present it to a patient and you say, surgery versus filler, and one can be done like this, no time off of work, no scheduling, there you go. And so they tend to do that. And like I said, fillers were not around when I developed these. And so it was phenomenal, I remember when I first did my first case with the Pregel implant and I presented it at a meeting in Newport Beach. The reaction in the office was vocal. Everybody was surprised. Whoa, how'd you do that?
Dr. Shah:
You changed plastic surgery. I mean, you literally changed the way it was done. And that's like, it's such a path that people were on a different path than you literally changed. You took the path of plastic surgery and turned it in, which is great. I mean, amazing.
Dr. Mittelman:
Yeah, we did that and we actually had to name some of the anatomy in here, which was not in Gray's Anatomy along the bone and the nerves and the fascia and things like that. So it was a very exciting thing to do. And when you look back at your practice, the things that you are proud of or things like I mentioned, and also things I said to you about developing new kinds of procedures and training fellows year after year after year, and having them learn some things and learn other ways and having them be out there and helping patients get optimal results.
Dr. Shah:
I'm going to mention some controversies in chin implants and we'll just kind of go from there. To screw or not to screw, what do you think about people who put screws in implants versus not putting screws? I'm an antis screw person, but your thoughts on this?
Dr. Mittelman:
No reason to screw it all. If you're screwing it, you're either doing it for your own psychological reasons or you're doing it because you're not making the pocket properly. But when you make the pocket, you're basically making it under the periosteum and you've got a pocket that just fits. It's like a hand in a glove. The only way you can traumatize it, the chin, is like having a car accident that causes direct injury to the chin itself and pushes it over. But it is tight as can be, and there's really no reason to put screws in. You can put a couple of sutures in and the middlemen, prejowl chin implants have fenestrations in them for two reasons. One is to again stabilize the implant because fibrous tissue grows into the fenestrations, so it stabilizes it even further. And two is if you want to put a suture between the deep soft tissue and the implant, you can do that on each side to keep the chin implant nice and low, but there's no reason to put screws in.
Dr. Shah:
Yeah. What do you think about people? Okay, another controversy. Do you think the chin recesses after an implant, the normal chin, and do you think there's a way to avoid it?
Dr. Mittelman:
Good question. We've done radiographic studies, and we know from going back in future for some other reason, that there is resorption of the superficial cortex of the bone. So there is erosion of bone that occurs that has nothing to do with any kind of complications or anything like that. But there are some so that you would have to say that over a period of years there is the result you get initially is going to be slightly like a millimeter difference afterwards. So there's like a millimeter of resorption in the anterior portion. And one of the ways to try to minimize that, I wouldn't say totally eliminating it, but definitely minimizing it, is to leave the periosteum over the front part of the mandible intact and then making a cut and going subperiosteal the rest of the way along the mandible. By doing that, you have a little bit of periosteum between the implant and the bone, and that minimizes any resorption of bone in that area. It makes it a more difficult procedure to do, a little bit more difficult, but it's doable. And so some people do that, but the scholastic material that you use is the least reactive material that we have in medicine for implants, and it works incredibly well. And you can avoid any infection or anything like that by placing an antibiotic solution in the saline solution in which you are bathing the implant prior to implanting it on the patient.
Dr. Shah:
That's exactly what I do. I leave that periosteal cuff. Do you think radiographically and clinically, there's two different things that are happening. If you look at chins, patients who have chin implants, if I look at them, I might see, I might like their chin, but if I have to go back there for some other reason, I think the impact might a little bit more than I'm seeing when if you take out the implant that's there. But clinically, if I look at them, if I never had to go in there and never looked at it, it feels like the implant's doing what it's supposed to do many years later. Do you notice that phenomenon?
Dr. Mittelman:
Well, absolutely, because if that were not the case after all these years since I've developed them and done them, and the same thing with Dr. Binder and other people who have pioneered the field, we'd be having these people come back and saying, Hey, this worked well for 10 years, but look at it now. That type of thing. And that doesn't happen. So I think that you get the result that you want, but radiographically you know that there's about a millimeter of difference.
Dr. Shah:
Okay, cool. Cool. That's super interesting. And that's been my feedback as well. When you watch a facelift and you see it, you see something, you say, oh my gosh, you're in the audience. This isn't one of your patients, it's someone else's, or you're seeing a revision facelift, can you tell right away this person should have done an implant? Like this person should have done a pre gy, they should have done something through there. Is that kind of in your checklist when you're looking at them or is that, and can you tell exactly which implant they should use?
Dr. Mittelman:
Well, the implants come in four sizes, small, medium, large, and extra large. So you have to make that judgment initially. You want to be a little bit more aggressive. In males, it looks really good and you want to be a little bit less aggressive in females, but still you want that chin to come out about the level of the lower lip when somebody is looking straight ahead that the chin comes out about as far as the lower lip. So I think that you're making your judgements in that way. Plus I've done people who have asymmetrical faces and they need more on one side than the other. And I will not uncommonly take a larger size that fits the most hypoplastic size and then trim and contour the other side by hand in order to make it fit both sides in the proper dimensions.
Dr. Shah:
And I tend to go like that route with asymmetries. Now, some people talk about customized implants, which I think is kind of very different. They talk about going all the way to the angle and going all the way across and all that. For some reason, as much as I love chin implants, there's something about the angle implant where I feel like it, I don't know, it seems like it's a very niche product that doesn't seem like there's other things that are less risky, and it seems like it's not as high of a satisfaction rate as like a chin implant. Your thoughts on angle implants and custom implants?
Dr. Mittelman:
Okay, let me talk about the angle implants first. And I think I find the same thing as you, which is that you have a percentage of patients who would be less satisfied with more risk of hip anesthesia in the area, that type of thing. And it's something that can again be done to some degree with fillers, custom implants are really good in the right kind of patient. So for example, there's one patient that we did that had trauma on one side of the face and the asymmetry in the face was way too dramatic to use an irregular implant and car. And we sent in the MRIs, we sent in all the studies to show the difference. And then implant tech has the ability to recontour that whole thing and make both sides the same in one implant. And you can go through the same approach with a wider, longer incision. And you put that in. And I'll tell you, it is remarkable how well they do not only the patient, but how well the implants are made by implant tech in those kinds of situations. Dr. Binder has done a lot of those and we send them in, they send them back, and we can put 'em in. And people are doing that all around the country and it's very impressive in the right patients.
Dr. Shah:
The right patient. That's the key. It's that patient who definitely needs that component or major asymmetries. But for I would say not the average person, but the typical person coming in off the shelf solution seems to be at least in my hands, and me looking at it, maybe I'm looking at it differently, seems to be adequate.
Dr. Mittelman:
I would more than agree with you. I mean, you would have to see a really, I mean I live in an affluent area, and you probably do too in Chicago. Are you in Chicago?
Dr. Shah:
Chicago and New York. Yeah.
Dr. Mittelman:
Chicago, New York, yeah. And you're probably in a very affluent area that you're practicing in and you just don't see those kinds of patients. I mean, if I see something like that once every 5, 6, 7 years, that would be it. And so in those situations, you make the proper adjustments and do what you need to do. But otherwise, the implants that we've designed definitely do the job.
Dr. Shah:
Yeah, I get a lot of patients asking about custom implants. I mean, it just sounds better if someone says a custom suit versus a regular suit. I mean, of course I'd rather have a custom suit. They fit amazing, but then they actually, when they understand what it actually is, very rarely do I find that, hey, you're going to do much better with the custom implant than this off the shelf solution.
Dr. Mittelman:
That's so very, very true. So you just explain it to 'em because if you do a custom implant and those people just come back and look just like the implants off the shelf that you have.
Dr. Shah:
Exactly. You have an awesome chin, by the way.
Dr. Mittelman:
I have a Mittelman chin implant.
Dr. Shah:
Oh wow. Wow. There you go. Can I see your profile real quick? Let's look at that.
Dr. Mittelman:
See here.
Dr. Shah:
Wow, that's a great chin. I love your chin.
Dr. Mittelman:
I have a small Mittelman chin implant because with age I had a little resorption. I had a strong one in youth, and then with age I had a little resorption. So we put in a middleman, small middleman, prejowl chin implant.
Dr. Shah:
So here's this interesting phenomenon
Dr. Mittelman:
I did a pre implant on my wife.
Dr. Shah:
There we go.
Dr. Mittelman:
Because she had a prejowl groove. She had a good chin, but a prejowl groove. And I actually put in a prejowl implant on my daughter. One of my daughters.
Dr. Shah:
Love it. Here's an interesting phenomenon. When artists draw people, when artists draw people, they often have, their inspiration is a little bit of themselves. Even if you don't mean to do it, it's subconscious. So I was going to say, fortunately, you have a great chin because when you put that through there, there must have been a little inspiration from your chin that kind of went into your implant and looking at that and saying, wow. And you probably didn't do it on a conscious level, but I'm wondering if subconsciously that kind of corrupted in there.
Dr. Mittelman:
Well, on a conscious level, when you've developed what you've developed, you're looking at that on every patient. When we do a new patient evaluation, we're always looking at the pretrial in the chin and we have it marked down. We do everything from a scale of zero to five in terms of the degree of laxity, the degree of recession in the chin, the pretrial, even the mandibular grooves and things like that. So yeah, we think of that definitely.
Dr. Shah:
Who's the best, if you had to pick an archetype, chin actors, all that stuff, if you had to pick who's your favorite chin, do you look at the chin and you're like, oh my God, that is a great chin. Do you have a handful of, we'll start with some male actors. Men are sometimes easier to think of that way. Do you have some chins in there? Like, wow, that's a great chin. I love that chin. I love that chin.
Dr. Mittelman:
Well, I think Clooney has a really good chin, solid, solid chin, nice jawline.
Dr. Shah:
So it makes him Clooney, right?
Dr. Mittelman:
Yeah. So Clooney is what we want to make.
Dr. Shah:
You want to make Clooney.
Dr. Mittelman:
And as a woman, I would love to make Melania Trump.
Dr. Shah:
Melania. Yeah. Yeah. Melania's. She's got a nice jawline. She's got a great jawline.
Dr. Mittelman:
Really great. Incredible.
Dr. Shah:
I think for guys, I actually, do you ever watch Suits?
Dr. Mittelman:
Yes, I have.
Dr. Shah:
Yeah. Yeah. So Harvey, I dunno the actor's name, but I love his jawline. And it's just like, you see the presence that a chin brings in there. And there's something guys, girls, but especially in men, if you have that chin and you walk into a room, there's something very, I'll say the word commanding, and it is something you can't help but looking at, you're like, wow, this is a presence.
Dr. Mittelman:
I think it's commanding to a man and sensual to a woman.
Dr. Shah:
There you go. So cool. Well, there's so much information here. I appreciate you spending a busy day. You're super busy. Busy and spending that time. Are there any last thoughts you want to share with everyone about chins? So we can just kind of go on that positive note about chins.
Dr. Mittelman:
I would like to share something else with you that I think is unique that I developed that I'm trying to popularize. Can you bring that stuff in with the horizontal, the pictures? Yeah. Dr. Morin, who's my fellow this year, who I'll introduce you to in a minute, but I developed a procedure for the lower neck, which is unique.
Dr. Shah:
Oh yeah.
Dr. Mittelman:
I remember a time we were both on a panel for a facelift surgery and I presented a procedure, which I called the horizontal neck lift. When you improve the neck in a facelift, you can improve the upper part of the neck, but the lower part of the neck in people who have it, most patients aren't candidates for it, but people who have the sort of increased creases, etched lines, and redundant skin in the lower part of the neck, almost sitting on their clavicle, those patients cannot be improved adequately with any kind of facelift.
Dr. Shah:
For sure.
Dr. Mittelman:
And so we developed a procedure that we call the horizontal neck lift. And so here is a patient, for example, can you see all the lines in her neck here.
Dr. Shah:
Or it's a little out of focus. You have it now? Yeah, I can see that now. There you go. That's a huge improvement. What did you do there?
Dr. Mittelman:
Okay, so you see both of them. Okay, so we do a line, Hey, I'll show you one more and then I'll show you what it is. See this young lady.
Dr. Shah:
It's a little out of focus. Let's see if it grabs it. There you go. Right there. Okay, cool. You can see that lower stuff down here and it's nice and clean on the top. Yeah.
Dr. Mittelman:
I did a mini lift, a submentoplasty and a horizontal neck lift. And if you look carefully, you can see a horizontal line, which is her scar.
Dr. Shah:
I can't see it on the top, but maybe we'll try to get that off somewhere, but yeah, so, so wow, ingenious.
Dr. Mittelman:
You can go from that to this on a patient doing an excision from 17 centimeter excision from here to here, and you take out about an inch and a half to two and a half inches of skin, and you can even do a plasmo plasty at this level, which you can't do from the submental incision. And it's a very simple operation. And so very effective. I mean, how can you go from this very undesirable looking, undesirable looking neck to the other one without doing that procedure? There's no way to get rid of all those lines. You do that. That's an operation that I really wanted to add to the armamentarium of all facial cosmetic surgeons in order to improve the lower neck in patients where that's indicated.
Dr. Shah:
So what I have to do is I have to interrupt you again. I'll have to find you there so that we'll go back on and talk about it. So I really appreciate you spending time on it. This was so amazing. I love the way your mind thinks and how innovative you are. And one of the constant complaints I hear from people who attend meetings is that they're not hearing something new and fresh. And so I imagine that when you presented your original talks about CO2 lasers and chin implants, and now this, that when you can see people's faces light up and then you see them doing this on a daily, daily basis, thousands of people doing this on a day worldwide, that has to make you feel especially proud.
Dr. Mittelman:
It does. It does. I mean, when you look back on your practice, the thing that shines out is not the financial success and things like that. It's what you've made. What kind of contribution have you made to that specialty and make them feel very good?
Dr. Shah:
Lasting impact. And that's the part that has an impact that goes beyond our years on earth. That kind of goes on. And people, I truly do believe people are affected, not just this part. Sometimes people have to say something to be affected, but you can feel their presence. And I think that with an implant, you can almost see that someone poured their heart and their soul into this. And so I appreciate you doing that because there's a lot of different things we could do. And some people are like, oh, it's plastic surgery. Who cares? You literally change people's lives when you do that. You're making them more successful, you're making them happier. And I mean, what would be a benefit to everyone?
Dr. Mittelman:
I totally agree with you. So many stories that show a direct relationship between a surgery and a confidence level that brings them out socially and makes them happier outside in.
Dr. Mittelman:
Thanks so much.
Dr. Shah:
Thank you. Have a good night.
