My Second Way to Look Younger without Plastic Surgery: Reduce Facial Folds

As we age our skin becomes thinner because of a natural reduction in our collagen layer.  With this thinness comes a hollowing of the cheeks and a loss of skin elasticity. The tell-tale signs of loss of facial volume and a decrease of skin elasticity are:

  • A fall of the cheek tissues from the cheek bone (malar eminence) resulting in a downward dropping of the corner of the mouth and a deepening of the fold from the side of the nose to the corner of the mouth (nasolabial fold)
  • A fall of the eyebrow secondary to a loss of the elasticity of the forehead skin
  • An uneven jawline because of the fall of the cheek
  • A deepening of the marionette line (corner of mouth to chin)
  • Folds beneath the eye

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So the aim is to restore our lost facial volume and secondarily reduce the unsightly facial folds. Over a 30 year history, I have come to realize that the best non-invasive method to restore facial volume is with the use of dermal fillers.

Dermal Fillers have been drastically improved over the past 10 years. In the earlier years, fillers were primarily used for lip augmentation only. Now we have fillers for facial lifting, fillers for the treatment of folds and fillers specifically designed for treating the areas around the eyes. One of the most common mistakes that I have seen with the use of fillers is an overzealous injection beneath facial folds which can often produce a “done” and unnatural appearance. Fillers if employed properly should be used to lift as well as a method for fold reduction and volume replacement. When putting this all together I try to approach each patient with a detailed evaluation of the facial volume loss and then employ a systematic plan to restore volume and reduce folds to produce a younger, natural, and more rested appearance.

So let’s paint the picture and use our fillers as the different available colors on our volume replacement palette.

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Deep Nasolabial and Jawline Folds                                  Dermal Filler: Nasolabial Folds, Jawline

Subtle changes with dermal fillers can  produce a more even facial contour and project a more youthful appearance. My next post will be on the third way to attain a more youthful appearance without surgery (Smoothing the Facial Skin Envelope). Feel free to click on the “Follow” button on the right to be alerted when it is posted.

Joseph W. Rucker Jr. M.D. F.A.C.S





5 Proactive Ways to Look Younger without Plastic Surgery

I recently gave a seminar on the above topic.  The subject was well received because there are many people that desire to look younger but either don’t have the budget, do not like the idea of undergoing an operation, or don’t like the idea of being off work because of an extended recovery. After 30 years of performing many cosmetic facial procedures, I can truly say that I know the skin both inside and out.  During this time I have become obsessed with the concept of ways to control facing aging by employing less-invasive effective methods to obtain this goal.  I firmly believe that the most important factor in obtaining younger appearing skin is to embrace a proactive approach.  Over the next month I will provide 5 blog posts describing the proactive techniques that I have employed to obtain this goal.  The first method is to blend in and control irregular pigment.

 Irregular Pigmentation is one of the most noticeable features of an aging appearance.  As we age, the pigment-producing cells in our skin called melanocytes become victim to excess sun exposure, inflammation, and in the female population, hormonal changes.  These factors trigger these cells to overproduce the dark pigment melanin, resulting in an uneven pigment distribution in the upper skin layer.  The outward appearance of hyperpigmentation and dark spots soon follows, with some of the most common sites being the face, arms, back, and hands.

Over a period of 20 years, we have employed the following methods to obtain pigment control:

If these methods are used properly, the areas of irregular pigmentation can be blended in and the results can be rather astounding.

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I have taken this concept one step further and have provided an intense advanced training program to our already highly trained aesthetician, Melissa Bowe.  She is by far the most knowledgeable and well trained individual in the field of pigment control in our region.  With the introduction of our Forever Young Skin Treatment Plan, that only she has been trained in, we are now able to take the management of the this difficult problem to the next level. For more information on pigment control, feel free to contact us at: or by contacting Melissa directly at 1-715-832-1774.

Our second proactive approach to obtain a more youthful appearance without surgery will be posted soon. For an email alert, please consider following us by signing in on the right.

Cosmetic Surgeon vs. Plastic Surgeon: What is the difference?

The term Plastic Surgery can be confusing for most people.  One must understand that the word Plastic is derived from the Greek word Plastikos.  The term is actually a verb which means to mold or shape. Plastic Surgery is a field that is composed of two main sub-specialties including reconstructive plastic surgery, which involves the restoration of body function that has been damaged by trauma, disease or birth defect, and aesthetic (cosmetic) surgery, which is a reshaping of the body to improve appearance only.  Therefore reconstructive Plastic Surgery is often covered by insurance and cosmetic plastic surgery is not.

Training: Now in order to fully understand the difference between a Cosmetic Surgeon and a Board Certified Plastic Surgeon we should look at the training required for each. A physician referring to themselves as a cosmetic surgeon might belong to any medical specialty including dermatology, gynecology or a family practice and they then decide that they would like to perform cosmetic procedures.  The training can be anywhere from a one year of training to a series of short weekend courses.  

The training for a board-certified plastic surgeon is much more extensive.  Following a completion of medical school, a board-certified plastic surgeon serves first a surgical residency for at least 3 years and sometimes five years.  During this residency they are trained in all aspects of surgery followed by a 3 year residency which is focused on plastic surgery training. This process can take 6 to 9 years and many further their training in fellowships including hand, micro-vascular pediatric and cosmetic surgery. Therefore the amount of and the wide scope of training is the key differentiator between a Plastic Surgeon and a cosmetic surgeon.

Board certification is another major difference between a cosmetic surgeon and a Plastic Surgeon. 
Cosmetic surgeons who claim to be board-certified may have received their certificate from the American Board of Cosmetic Surgery, this board is not recognized by the American Board of Medical Specialties. Alternatively, they may be certified by their specialty board which may not even be a surgical specialty, such as internal medicine. Cosmetic surgeons referring to themselves as board-certified can be misleading if you don’t know the right questions to ask.

It is always important to confirm that a plastic surgeon has been certified by the American Board of Plastic Surgery (ABPS) – the only Board recognized by the American Board of Medical Specialties (ABMS) to certify doctors in the specialty of Plastic Surgery. Only ABPS diplomates can call themselves a Plastic Surgeon. In Canada, a patient should look for certification by the Royal College of Physicians and Surgeons of Canada (RCSC). International plastic surgeons should be board-certified in their country of origin.

In conclusion, if you are considering any type of aesthetic/cosmetic procedure, it is prudent to be aware of the education and training of the surgeon you’re considering for your procedure. You can verify the credentials of a doctor by checking with your state medical board or verify you are seeing a board-certified plastic surgeon whose practice focuses on aesthetic surgery by visiting  to select a Surgeon. Choose Well.

Joseph W. Rucker M.D. 


3 Ways to Keep Cosmetic Surgery Fees Low without Going to Mexico

  1. Select a Board Certified P.S. When considering cosmetic surgery, probably the most important factor would be to select a surgeon that is board certified and a member of the American Society of Plastic Surgery. It ensures that he or she has been intensively trained in performing these cosmetic procedures and is able to manage any complications that may occur. This is important because there may be a higher complication rate with non-board certified surgeons which can ultimately lead to higher costs and the possibility of a more difficult recovery period.
  2. Having Multiple Procedures at the same time: I strongly advise my patients that are interested in having more than one cosmetic procedure to have them done at the same time for several reasons:
    1. Most surgeons routinely decrease the second procedure by at least 30%
    2. Having the procedures at the same time also produces one recovery episode and one time off work resulting in a significant savings in fees.
  3. Does Your Surgeon have an In-Office Operating Room?: A great many cosmetic surgery procedures are done in a hospital setting and this can lead to increased fees. First there is the cost for the hospital room, then the anesthetic cost is also included. If the surgeon has an accredited operating room in his or her office, the overall cost can be significantly reduced by avoiding these additional hospital and anesthesia charges.

BOTOX: A New Treatment for Depression?

Getting a wrinkle-free look is enough cause for enjoyment, but Botox® cosmetic may be going deeper.

A study conducted by Georgetown University seems to have found a fix for depression. In an analysis of 74 people, all who had been diagnosed with depression, Botox® was administered to half (while the other half received a placebo) over a span of six weeks. With the injections given between their brows, each of the participants was asked how they felt post-administration. Those who received Botox® reported a better mood by 50%.

What is it about a Botox® injection that can lighten the mood or damper negative thoughts? Let’s take a look:

How Botox® can affect you:

  1. Stops the contraction of muscles that cause wrinkles
    1. When Botox® is injected, muscles that normally form those worry lines, crow’s feet, and frown lines are relaxed. Brain stimulation from these muscles is consequently relaxed.
  2. Reduces fine lines for 3-6 months after administration
    1. Not only will you have a significant wrinkle reduction for this period of time, but you will also notice your facial expressions have changed – less frowning leads to more happiness.
  3. May cause light bruising that will go away in a matter of hours
    1. There’s extremely minimal downtime with Botox®. If you’re heading back to work, to a big event, or social gathering, there’s no need to worry about your appearance.
  4. Brightens your face by combating lines around the eyes, mouth, and forehead
    1. With wrinkles and fine lines diminished, you’ll appear younger, more vibrant, and happier.

With all of this, essentially, if you aren’t able to see your frown lines, you are happier. Less visible wrinkles, little risk, and a brighter complexion for up to half a year can really contribute to a more positive demeanor.  Even with this positive finding, we must understand that this is a preliminary study and it may well not prove helpful for all forms of depression.  Stay Well

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The Causes and Treatment of Breast Asymmetry (Uneven Breasts)

The condition of breast asymmetry or uneven breasts is much more common than most people think.  As a Plastic and Reconstructive breast surgeon in Wisconsin, I would guess that approximately 65% of the women that I have examined have some form of breast asymmetry.  Breast asymmetry is defined as a difference of form, position or volume of the breast and in most cases the difference between the breasts is about ½ cup but occasionally may be a 1 to 2 cup size difference.  It is also interesting to note that this condition can cause some rather significant psychological problems, as noted in a recent study by the American Society of Plastic Surgeons.  The causes are unknown but I feel the four main reasons that we see this condition are:

  • First, would be a hereditary cause, where this is passed down from generation to generation.
  • Second breast feeding on one breast more than the other can cause differences in size.
  • Third and thankfully less common is the presence of a breast mass.
  • Fourth, a deformity of the Chest wall may also contribute to displacement of the breast leading to the perception of asymmetry

The treatment for uneven breasts is dependent upon the severity of the condition.  Listed below are the three most common conditions and their recommended treatment.

  • Mild Asymmetry with no evidence of breast sagging …. A small augmentation (breast implant) of the smaller breast would usually be sufficient.
  • Larger breasts with some evidence of breast sagging on the larger side….. A breast lift of the larger breast.
  • Much larger breasted female with a significant asymmetry…. A breast reduction on the larger side.

The procedure for the treatment of breast asymmetry is:

  • Usually done under a general anesthetic in our office
  • The surgery takes about 2 hours to perform
  • A return to normal activity takes about 2 weeks, depending on the type of procedure done
  • This is usually considered as a cosmetic procedure and is therefore not covered by insurance.

Patient presented with significant breast asymmetry. Underwent

Bilateral Breast Lift.. Post-operative photograph at 4 months


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6 Steps to Speed Insurance Coverage for Breast Reduction

The process of seeking prior authorization for Breast Reduction can be very frustrating because many insurance carriers have developed more rigid guidelines prior to approval.  I have performed over 2,300 breast reduction cases, and my staff and I have developed a protocol that we have found very helpful in 1. Reducing the time for approval and 2. Increasing the percentage of those patients that have received approval for Breast Reduction. Below is our step-by-step approach to seeking prior insurance authorization:

  1. Seek your consultation with a surgeon that is board-certified by the American Society of Plastic Surgeons who has performed a high volume of breast reduction cases and is familiar with the process of insurance authorization.
  2. Have all of your documentation including: your insurance information, all of your symptoms, any input from you primary care physician regarding your symptoms, any conservative measures that you have employed to reduce your symptoms, and, if you are older than 40, the results of your most recent mammogram, forwarded to your Plastic Surgeon prior to your consultation.
  3. Document your symptoms well. The most common findings  associated with enlarged breasts are:
    1. Bra strap irritation
    2. Upper and lower back problems
    3. Neck strain
    4. Chest wall heaviness
    5. Rashes beneath the breasts
    6. A decrease in overall activity levels because of the above
    7. Overall difficulties during your employment because of your breast size
  4. Provide a complete list of the conservative measures that you have employed over the past year to improve your symptoms:
    1. Physical therapy: massage, heat treatments for the back
    2. Chiropractic care
    3. Medication for back soreness: Tylenol, muscle relaxers
    4. Special support garments employed
    5. Documentation from your primary care physician regarding your symptoms
  5. Match a reasonable weight relative to your height 
  6. During your consultation your physician will review all of your documentation, perform a detailed examination, and forward a letter including your photographs to your insurance carrier.

If the above guidelines have been met, we see coverage within 2-6 weeks.  If there has been inadequate documentation provided, the approval process may require 4 to 8 weeks.   Depending on the insurance carrier and the physical examination findings, our approval rate over a 30 year period has been 70 to 85%. For more information on the breast reduction procedure, the recovery, and before and after photographs, please visit us at

Good luck!