Procedures
Facelift
Facelifts when properly done, will yield wonderful results without a tight or pulled look. This surgery will allow the plastic surgeon to lift and re-contour the face and neck in order to eliminate many of the tell-tale signs of aging.
A facelift requires lifting both the skin and deeper tissues of the face and neck, which will result in softening of the facial wrinkles and folds and correction of laxity and banding in the anterior neck. All patients, in my experience, appear significantly younger, although no one can accurately predict exactly how much younger the patient may look.
In my opinion, a skin-only facelift will not give an optimal result. This will frequently appear as a pulled, unnatural, stepped-into-a-wind-tunnel look. The skin was never meant to be used to tighten the facial skin laxity. A SMAS flap, which is a flap created from tissue deep to the skin, allows for a strong, even, lift to the face and neck which will last for many years. When the SMAS flap is used to do the lifting, the skin can then be re-draped in a soft natural fashion without appearing tight or pulled. However, not every surgeon does a full SMAS lift, as this flap is immediately adjacent to the facial nerves, which control the facial muscles.
Also, special fat grafting can be done to give the softer, fuller contours of a young face. The facial skin droops with age, but the face also looses fat and becomes thinner and more gaunt. The correction of this problem is achieved by use of specially harvested fat which is then used to create the proper facial contours with fat grafting. These grafts are placed deeply, using a special small cannula which creates micro-droplet placement of the fat grafts. These grafts work well and are usually permanent.
The very best way to know the quality of the surgeon’s facelifts is to ask to see a number of before and after photos and even ask to speak to one or two of his recent facelift patients.
Short Scar Facelift
Short scar facelift, S incision facelifts, laser facelifts, or week-end facelifts all sound great because they suggest minimal surgery for the patient with a quick recovery. Also they convey the idea of the newest and best techniques, or they take advantage of some great new technology.
But if one pauses and examines the actual reality, things may be very different. A surgeon can do something very simple, or something very wonderful, but they are rarely the same thing. Just consider, if simple procedures gave great results, then none of the highly trained and skilled plastic surgeons would ever use the more difficult full-facelift procedures. Obviously, plastic surgeons wish to have great results, so they will use whatever technique works the best. The only reason that plastic surgeons do a face and neck lift with a SMAS, is that it will give a far superior and longer-lasting result.
Necklift
Many patients wish to have just a neck-lift, as this is the area of greatest concern for them. Often patients are told that this is a straight-forward procedure and can be done with minimal incisions, located below the jaw line and behind the ear.
In my experience, it is impossible to achieve any worthwhile or lasting correction of an undesirable neck appearance using only those types of incisions. With the correct incisions and the proper procedure, the skin laxity, excess fat, and anterior neck folds can all be addressed and corrected. However, a well-done necklift requires both superior and posterior lifting. This requires an incision just in front of the ear in order to work out the excess skin. This is the only way to get a truly effective and long-lasting result. This scar will be very minimal and will allow for an excellent and extremely natural result to the neck and submental area.
Blepharoplasty / Eyelid Surgery
Eyelid surgery allows for the removal of excess skin and fat from the upper and lower eyelids. The upper eyelids can have redundant skin, which can result in the lid skin drooping. Excess fat gives a puffiness to either the upper or lower eyelids. Lower eyelids may have excess skin, significant wrinkles, puffiness or all three.
Lid surgery involves the removal of the excess skin and fat. The scars are very minimal and fall within the natural fold of the upper lid, or immediately below the eyelashes in the lower lid. When eyelid surgery is done properly, the results are very natural and soft in appearance with very minimal scars. The surgery usually may involve mild bruising, but no real pain, and a rapid recovery.
Browlift / Endoscopic Browlift
Eyebrows tend to droop with age. If the eyebrows droop excessively, repositioning the eyebrows to the proper level will give a much more youthful and pleasant appearance. Over-elevation of the brow can give an unnatural, surprised look. Not all surgeons realize the importance of this need for correct positioning and may over elevate the eyebrow. This will result in a surprised or unpleasant appearance.
A browlift can be done, either as an endoscopic procedure, or with a coronal browlift. Endoscopic brow surgery is more widely used, but both types of browlifts have advantages. The endoscopic browlift utilizes several small incisions in the hair, through which the browlift is done with endoscopic instruments.
The coronal browlift works well when a full facelift is being done at the same time and allows precise positioning of the eyebrows. While the incision is longer, the scar is usually very well hidden by the hair.
These patients may also appear tired or angry due to furrows between the eyebrows. The browlift does an excellent job in correcting this problem. The results of a well done browlift appear both refreshed and natural.
Rhinoplasty / Nasal Surgery
Rhinoplasty is the medical term used to describe the surgery performed to reshape the nose or to reduce the nose in size. It may also be done to improve the nasal airway if necessary.
This is done by trimming nasal cartilage and filing down nasal bones. This may require in fracturing the nasal bones, which means cutting or breaking the nasal bones in a very careful manner and moving them in. This will correct a nose that is overly broad. The nasal tip can be refined and slightly elevated if necessary. However, it is a very poor idea to create a pinched or over-elevated tip, as this will result in a very unnatural or unpleasant, “done” appearance.
Most plastic surgeons will agree that rhinoplasties are among the most challenging and aesthetically demanding cosmetic procedures that we perform. Perhaps more than any other procedure, patients should ask to see a number of before and after photos of rhinoplasties. Each of these should be an individualized result appropriate for that particular patient.
Revision Rhinoplasty
Revision rhinoplasties, which are more often called secondary rhinoplasties, are performed when the initial or primary rhinoplasty was unsuccessful or did not fully achieve the goals that the patient desired. These problems may be small and very limited, or there may be major problems.
Each secondary rhinoplasty represents a unique problem and must be carefully evaluated by a very experienced surgeon in a well thought-out and individual manner. Rebuilding the nose with the patients own cartilage may be necessary when too much support of the nose has been removed. This loss of support results in partial nasal collapse, frequently with decreased ability to breathe through the nose. With reconstruction, there can be a marked improvement in the appearance and shape of the nose.
This is a very challenging surgery with only a limited number of surgeons that do this well. This happens to be one of my favorite surgeries, and I have performed a number of these surgeries in my many years in practice.
Ear Shaping / Otoplasty
This surgery is done for ears which are prominent or stand-out. The patient is frequently very self-conscious in regards to this. Ears are almost fully grown within the first six years, so the surgery can be done anytime after that age. It works well on both boys and girls, but girls are especially likely to have this surgery, as prominent ears may prevent them from wearing their hair up or behind their ears. This surgery should be quite successful and able to be done with no visible scars.
The incision is made on the back of the ear. Both the concha (the shell portion of the ear next to the ear canal) and a special fold called the antihelical fold are responsible for the prominence and they are both corrected. This should result in a very natural, non-surgical appearance when done correctly.
Breast Augmentation
Breast augmentation involves placement of a silicone gel or saline implant under the breast tissue or under the pectoralis muscle, to enlarge the breasts or help with breasts which droop due to loss of breast volume. This frequently occurs after one or more pregnancies.
In my experience, placement of the implants under the muscle, allows for the most natural appearance without the “stuck on the chest” look. It also allows for better mammography and has a reduced incidence of capsular contraction (the breasts becoming firm post-operatively). The incision at the inferior portion of the areola, which is at the junction of the areola (the pigmented skin) and the skin, gives a scar that blends in beautifully and is usually very difficult to see. Generally, the silicone gel implants are lighter, softer, and feel and move much more like normal breast tissue than the saline implants.
Obviously, it is important to achieve the size that the patient is envisioning. Bra cup size is extremely inaccurate, so it’s much better to work from photographs of semi-nude models, and ask the patient some very specific questions regarding their goals in relationship to the photograph. This allows the surgeon to give the patient the breast size that they are seeking.
The key to a beautiful augmentation is a smooth and even breast pocket on the chest wall and the placement of the optimal implants to meet the patient’s goals. The results should be pretty and very natural in appearance.
Breast Lift & Breast Reduction
Breasts are usually not symmetrical. They may be different in size or shape. Patients with drooping (ptotic) breasts can have their breasts lifted and re-shaped. This is frequently combined with a breast augmentation, with the lift and augmentation being done in the same surgical sitting.
There are multiple types of breast lifts. Which procedure works best depends on the extent of the drooping, the shape of the breast, the position of the nipple on the breast mound, and the patient’s goals. Therefore, each patient is different, and each problem needs to be evaluated on an individual basis.
In some patients, the breasts are large, heavy, and pendulous. This can cause upper back pain, cutting of the shoulder from bra straps, rashes under the breasts, and difficultly in physical activity. These patients require a reduction in the size and weight of their breasts. They are extremely grateful when their breasts are able to be reduced to the size that they wish them to be.
The incisions resulting from breast reduction surgery are similar to that of a full mastopexy (breast lift). As in the mastopexy, the breasts are both lifted as well as being reduced in size. The correct positioning of the nipple (which is still attached to the breast tissue), the symmetry of the breasts, and the careful closure of the incisions, (which are related to the quality of the final scars), are all details that are very important in determining the quality of the final results.
Liposuction/ Liposculpture
Liposuction, also known as lipoplasty or liposculpture, is the technique for removing fat by use of a cannula (steel tube with small holes at the end) and a liposuction machine. Regardless of the name attached to this procedure, the real skill and art of this surgery is the removal of the correct amount of fat from these precise areas of concern. With liposuction, care must be taken so that the proper amount of fat, no more, and no less is removed. This should result in a post-operative appearance in which the areas that are liposuctioned have uniform and even contours. Every attempt should be made so that these areas have little or no depressions or irregularities.
There are several techniques which are necessary for optimal results. Of these, the most important is that of tumescent infiltration prior to surgery. This means infusing the area to be liposuctioned with a special solution containing a low concentration of adrenalin and an anesthetic agent. This allows liposuction to be done with minimal blood loss and decreased post-operative pain. Also, the use of smaller cannulas allows better control, more even results, and less bruising and pain post-operatively.
Patients who are significantly obese, who have a large abdominal overhang of skin and fat (panniculus), or that are gaining weight, are generally not good candidates for this procedure.
This is a great surgery for many patients, but again the results are highly variable depending on the surgeon’s skill and experience.
Abdominoplasty/ Tummy Tuck
Abdominoplasty, or tummy tuck, is an excellent surgery which allows for the removal of a large amount of skin and fat from the lower abdomen, in which exercise and diet alone cannot remove. This surgery is usually done for women who have had one or more pregnancies or have lost a large amount of weight. Post-operatively, this will result in a much firmer, flatter abdomen with removal of the lax or excess skin. It will also result in a smaller waist, as well as a more generally youthful appearance to the abdomen.
The surgery involves making a low incision in the bikini area, and then separating the skin and fat from the underlying muscle. But the umbilicus (belly button) is left attached. The umbilicus is reshaped and tightened (an innie) during the closure. The separation of the muscles is carefully repaired. The excess skin and fat is removed and the incision is carefully closed.
Two important additions to this surgery have made a significant difference for the patients. One is a small pump that allows a tiny volume of local anesthesia to run over the abdominal wall. This reduces post-operative pain by a remarkable amount. The second is an intra-operative fibrin spray (a completely natural material which our own body makes) that helps seal the overlying skin and fat to the abdominal wall. This dramatically reduces the likelihood of a seroma (a collection of serum or fluid).
When there is a lesser degree of laxity involving the skin and/or muscle, then a limited abdominoplasty can be performed. This procedure has a much shorter incision and allows for a shorter surgical time and a quicker recovery.
LIP AUGMENTATION
Lip augmentation can create fuller and more youthful appearing lips. There are a number of ways to create fuller lips, but some techniques have potential drawbacks. Some of the most commonly used fillers can be used to “plump” the lips, but most of these fillers are temporary and they last anywhere from four to eight months. Some of the fillers are made of material that’s the building block of bones and can be granular or irregularly firm in the lips. Silicone injections can be used, but this is not approved by the FDA and may lead to problems later.
There are a number of fillers that generally work well, depending on the patients’ goals and the degree of augmentation. In our practice, the best permanent treatment involves the use of micro-droplets of one’s own fat using special equipment.
Regardless, this is a good and frequently requested procedure that when done properly, works very well.