Scott R. Miller, MD, FACS, attracts patients—and the press—with his contour thread-lifting procedures

Not so long ago, plastic surgeons tended to eschew mass media as a vehicle for informing the world about themselves and their practices. It’s different today. Now, television and radio appearances by plastic surgeons—and newspaper and magazine coverage of their views and latest techniques—are a fairly common occurrence.

For some physicians, garnering press notice takes hard work. Others—for example, Scott R. Miller, MD, FACS, a solo practitioner at Miller Cosmetic Surgery in the upscale San Diego district of La Jolla—draw attention with appreciably less effort.

As Miller explains, it helps if you have a good story to tell. In his case, one of the stories that most intrigues members of the local news corps is contour thread lifting—a technique at which Miller has become so adept that he is one of only three Southern California physicians qualified to instruct other plastic surgeons who want to be certified in it.

“Contour thread lifting involves elevating different parts of the face without the kind of surgical incisions used in a traditional facelift,” Miller says, repeating a message he delivers to television and radio talk-show hosts and news anchors who interview him about the subject. “The contemporary advances that have been made to traditional techniques are great and, in the right hands, provide an outstanding and definitive result. However, a thread lift offers the ability to nonincisionally produce a modest, natural elevation of different areas of the face.”

A Stitch in Time
Miller insists that contour thread lifting does not replace conventional facelifts. “It’s a good alternative for people who aren’t ready for a traditional surgery of the face, for people who cannot for medical reasons have a facelift, and for people who have recurrent signs of aging after a surgery years earlier,” he says. “Thread lifts allow people to be proactive about their aging so that they don’t have to wait for a dramatic difference in how they look to become evident before they can do something about it. Thread lifts also are ideal for people who don’t want to be at work one day looking one way and then show up a week or two later looking dramatically different.”

Common areas for treatment with contour thread lifting in younger patients are the cheeks and brows, because these tend to be areas where ptosis is first most apparent. However, Miller contends that contour thread lifting is not the same thing as a mini-facelift. “A mini-facelift involves the same incisions as you would make in a full facelift,” he says, adding that, in contrast, minimally invasive contour thread lifting is performed in a procedure room—rather than in a surgery suite—and requires no anesthesia.

The contour thread lift procedure entails placement of thread strands along various layers and planes under the skin to support the face’s soft tissues, Miller explains. Two different types of threads can be used: smooth or barbed. Miller prefers the latter; they are self-supporting and require no suspension devices to hold the lift. Barbed threads are classified as convergent or divergent—depending on whether the barbs are oriented toward or away from one another—and are customarily made from polypropylene.

Quick Bounce-back
Contour thread lifting is performed with the aid of a thin needle to guide the barbed threads into the subcutaneous fatty tissues. The access points are 1 mm apart and follow—as the name implies—the contours of the facial section marked for attention. Following insertion, the thread barbs serve as tiny anchors; as the thread is pulled up, it causes a slight elevation of the skin. Miller explains that the number of threads needed to treat an area varies from patient to patient, but, generally, two threads are used along each jawline or eyebrow and three for each cheek.

Positioning of the threads is quick—the entire procedure can be accomplished in 30 minutes to 1 hour, depending on the number of areas treated. Also, because of its minimal invasiveness, patients bounce back faster.

Miller says that only one of every four patients experiences any sort of bruising, and many feel like returning to a normal routine the next day, although he instructs all of his thread-lift patients to take it easy for 1 to 3 weeks after surgery.

“No hard chewing, no getting really animated, no strenuous activity during that time,” he tells them. “By 3 weeks, the patient should be back to no restrictions.”

The procedure is only about half the cost of a conventional facelift, which makes it an especially appealing solution to younger, less affluent patients. Still, “It’s not a procedure for everyone, so the onus is on the surgeon to differentiate who will benefit, whose needs will be met, and whose expectations will be reached,” Miller cautions.

Even so, he marvels at the way that contour thread lifting is catching on. “The response to it has been amazing,” Miller says. “The interest is high, and well-selected patients are very pleased. Clearly, for appropriate patients, it is an exciting option.”

“Low-tech, High-touch”
It is in part because procedures such as contour thread lifting are offered at Miller Cosmetic Surgery that the practice has enjoyed remarkable growth in the years since it debuted in 1998. But credit must be given as well to the vibrancy of San Diego as a plastic surgery market.

“Like my hometown of Las Vegas, San Diego is one of the biggest small towns around,” Miller says. “By that, I mean it has a sizable population and a dynamic economy; however, it’s still a fairly close-knit community where word of mouth travels fast, and good work and compassionate care go a long way.

“Granted, the San Diego market for plastic surgery receives less publicity than Beverly Hills, which is just 100 miles to our north. But, as San Diego has grown and become more financially and artistically sophisticated, I think the lines between this town and Beverly Hills have blurred. In fact, a number of my patients come from Los Angeles, Orange County, and other communities closer to Beverly Hills than to San Diego.”

Patients who flock to Miller’s practice—which is almost entirely focused on aesthetic surgery services—come not just for the full spectrum of facial-rejuvenation procedures, but also for breast surgery and body contouring. “I enjoy performing facial skin cancer reconstructions as well,” Miller mentions.

Miller Cosmetic Surgery is located on the campus of Scripps Memorial Hospital. The 3,500-square-foot office is tastefully appointed with furnishings, lighting, and original artwork intended to soothe and relax patients. The office includes several private exam rooms, a couple of procedure rooms, and an outpatient surgery suite bearing the seal of quality bestowed by the American Association for Accreditation of Ambulatory Surgery Facilities.

Although his office is equipped for most major aesthetic surgery procedures, one of Miller’s most frequently used instruments is an ordinary endoscope. “Overall, I try to keep things fairly simple. I love advanced technology, but I’m also a big believer in ‘low-tech, high-touch,’” he says.

Another extensively used instrument is Miller’s own hands. “I have a preference for gentle and precise tissue handling as a primary tool for reducing postoperative pain, limiting bruising and swelling, and speeding recovery,” he says. “Using ‘soft hands’ is a very underestimated tool, but one that is very much in our control.”

Virtual Consultation
Miller’s case volume is sizable enough that it takes 3 to 6 months to get in to see him for an initial consultation. On the one hand, he sees that as a sign of practice success. On the other, it concerns him that patients eager to begin the process of surgically improving their appearance must endure such long waits.

To enable waiting patients to put momentum on their side, Miller uses a consultation model that lets those individuals perform certain information-gathering and assessment tasks at home that normally would be handled in the office.

“When patients call to schedule an appointment, we offer them the option of receiving from me either by surface mail or in downloadable format a package containing forms to be filled out and then sent back to me,” Miller explains. “These forms include medical history, HIPAA privacy rights, a check-off sheet about the procedures of interest, and an assignment agreement form. Also included are instructions to photograph areas of the body that are of concern; the patient—or a relative or friend—takes these pictures.”

After the completed forms and accompanying photos reach Miller’s office, his staff contacts senders to schedule a “virtual consultation” with Miller. The virtual consultation is conducted by telephone, and Miller uses the occasion to discuss the information and photos with the patient.

“I address all details of the patient’s specific situation, plus all of his or her questions and concerns,” he says. “This opens the lines of communication and keeps patients actively in the loop during the wait, rather than leaving them feeling disconnected and causing them to search for a less busy, less experienced plastic surgeon.”

Lots of Takers
Another advantage of Miller’s virtual-consultation model is that it expedites matters for Miller as well, enabling him to be more productive. “Because the patient fills out the paperwork at home and we’re able to make a considerable amount of case headway by phone, I’m able to be a lot more efficient when the day of our first face-to-face visit finally arrives,” he says. “I go into that first in-person encounter with an already-developed sense of the patient’s wants and needs, so the time we spend together can be exceptionally productive.”

Miller started conducting virtual consultations about 3 years ago. His first few were very informal and were meant to make things somewhat more convenient for out-of-town prospective patients. “The idea was to save them one trip to the office,” he says.

However, over time, many patients living near and even in San Diego have turned to using it. “Right now, about a fifth of my patients go through the virtual-consultation process,” says Miller, who thinks its popularity could improve to the extent that as many as half of his patients opt for it eventually. “One of the lessons I’ve learned over the years is that some of the biggest successes begin surprisingly small.”

A potential problem inherent to the virtual-consultation process is its reliance on the patient to produce at least some of the documenting and planning photographs, images that normally would be shot in the office under carefully controlled conditions. Miller addresses this by supplying the patient with detailed, yet easy to follow instructions for taking photos.

“We give them examples of the kind of photographs we need, and they use those as templates to give us the photos just how we like to see them,” he says. “We recommend they use a digital camera so they can immediately see whether what they’ve shot matches up to the examples provided, and, if not, then to reshoot as much as necessary in order to get them right.”

Not infrequently, patients who take their own photos will zero in on a body section or feature that is especially displeasing to them. Miller appreciates that, because it helps him to better and more quickly determine the patient’s greatest source of anxiety or unhappiness.

“Because of the patient-centric nature of this exercise, it gives me an immediate clue as to whether the patient is concerned about an area or problem that is even amenable to surgery or that offers the possibility that my work will yield a pleasing result—and a happy patient.”

Room at the Inn
Patients who come from outside the San Diego area often ask Miller to suggest a place they can stay for a time after surgery before making the trek back home. There are several hotels and resorts he recommends; one in particular is a medically oriented inn that specializes in the postoperative pampering of plastic surgery patients. Miller is not an owner of that facility, just someone impressed enough by it to include it on his referral list.

“I’ve never had a desire to invest in a venture like that, either as a partner or as a sole owner,” he says. “I know my limitations. I’ve got a great practice supported by a terrific, dedicated, incredibly hard-working staff, and that’s where my focus is. If I were to start getting myself into various ancillary enterprises, it would take me off my clinical focus.

“Besides, there is already a myriad of providers of services and products related to plastic surgery aftercare here in town that my patients can and do benefit from. I’m more comfortable going out, doing the legwork, and locating the best of these for my patients, and then directing them to those providers.”

Miller reveals that there is occasional extra legwork to be done once an aftercare resource is identified and added to the list. “We establish a relationship with these providers, but sometimes there are internal changes that result in a reduction in the quality or availability of the service. For example, there might be a big turnover of the provider’s staff and a lot of the best people there are suddenly gone,” he says.

“So we may then have to look around for a substitute provider of that particular service. And getting out, meeting with the candidates, meeting with their staffs, making sure we’re all on the same page when it comes to philosophy about quality and service, that all takes a surprising amount of time and effort. But it’s a necessary investment and entirely worthwhile because of the satisfaction it delivers to the patients.

“The patient’s best interest is my top priority. I always advise the patient as I would a family member by weighing the trade-offs and various alternatives. I identify patient needs with a focus on solving problems and let that guide the practice’s future. I believe in thinking outside the box, not just copying what has been done before. In a marketing world, I believe my practice has proved that you can grow and thrive by focusing on quality.”

Rich Smith is a contributing writer for Plastic Surgery Products.