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Question of the Day

Facial Surgery

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Q. I have a large nose; can I get a non-surgical rhinoplasty?

A rhinoplasty procedure is necessary to reduce a large nose so it is proportional to the surrounding facial features. A so called “non-surgical rhinoplasty” typically involves the use of fillers. This is appropriate for improving irregularities and refining contours but injecting fillers will not actually reduce the size of the nose.

Q. Are implants the best way to improve facial projection and contours?

There are many options to improve facial contours and definition including fillers, fat injections and implants. There are advantages and disadvantages of each technique depending on the needs of the individual patient. Filler injections are the easiest for a patient, fat injections typically last a lot longer, and implants provide a permanent result. The most common requests include cheek augmentation, chin augmentation and improving jaw line definition. Patients frequently request chin reduction procedures but that is a topic for another time. Consult with a surgeon that is experienced with all of these techniques so you can make an educated decision about what is best for you.

Q. Can I change part of my nose without doing a full rhinoplasty?

Every rhinoplasty procedure should be individualized based on the undesirable anatomy, nasal function and goals of the patient and surgeon. Sometimes a limited rhinoplasty is appropriate but it is important that a balanced, natural nose be created. A good experienced surgeon who specializes in rhinoplasty surgery will carefully describe the exact changes that will be made so the patient clearly understands the goals of their procedure.

Q. What can I accomplish with facelift surgery?

A facelift operation is a rejuvenation procedure which is done to lift sagging muscles, remove excess skin and restore normal youthful fat distribution which has changed as part of the aging process. There are many, many different facelift procedures and individual variations depending on your surgeon. The best advice I give patients is to ask what physical signs of aging will be reversed or reduced, what are reasonable expectations for the duration of improvement, and see results of other patients who looked like them before surgery.

Q. I have thick nasal skin. Will rhinoplasty improve the appearance of my nose?

In a patient with thick skin, it is sometimes difficult to get ideal definition in the lower part of the nose. However the tip can be narrowed and reduced using specific rhinoplasty techniques so that significant improvement can be achieved. Although the ideal refined result is not possible, I encourage these patients to consider rhinoplasty after establishing realistic expectations so they can achieve more balanced facial features. I’d also recommend that they establish an appropriate skin care regimen which will not only improve facial skin quality but also the rhinoplasty result.

Eyes

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Q: Is it better to do an upper eyelid blepharoplasty or a browlift?

A: While eyelids are frequently the first to show the signs of aging, brow position is always evaluated when considering surgery to correct the tired appearance caused by excess skin and fat of the upper lids. Removal of the excess skin and fat from the upper eyelid can be accomplished through an incision in the upper eyelid crease. However, if the brows are low or there is significant hooding and heaviness below the brows a browlift is the best approach to give the patient a more alert, rested appearance. Sometimes the browlift will eliminate all of the excess upper lid skin but an upper blepharoplasty can also be performed.

Q: How can I tell if a browlift or upper eyelid blepharoplasty is the best approach?

A: Obviously, the ideal way to determine what procedure is best to correct the tired appearance is to consult with an experienced surgeon. However, a patient can also stand in front of a mirror and lift their brows; if they like that look a browlift is probably the best approach for them.

Q: How can I reduce the deep grooves in my lower eyelids?

A: There are several choices depending on the appearance of the lower lids. If there are bags adjacent to the depressions a blepharoplasty can be done, the bags removed and some of that fat repositioned to fill the depressions at the eyelid margin. In other patients where the grooves are the only problem they can be filled and the lower eyelid contour improved with a filler such as Restylane or the patient’s own fat. If fat is injected the patient should carefully select a surgeon who is experienced in this technique because problems such as surface irregularities are difficult to correct.

Q: Where are the incision placed for a browlift?

A: There are multiple choices for incision placement in browlift surgery with advantages and disadvantages of each. I avoid incisions at the brow or in the forehead where there is a risk of visible, unfavorable scaring. Incisions are hidden within the hair using the coronal incision across the top of the scalp or multiple small incisions with the endoscopic approach but these techniques will both elevate the hairline. If a patient wants to maintain or lower their hairline position I recommend the Irregular Trichophytic Hairline Incision technique that we described many years ago. With this approach hair will grow through and in front of the hairline incision so it is not visible.

Q: When can I resume my exercise routine after facial cosmetic surgery?

A: While recovery is different with every patient and after every procedure I usually instruct my patients to avoid strenuous activities for 10 – 14 days after surgery. By “strenuous” I mean any activity that increases the blood pressure, pulse, or breathing rate. I also advise them to avoid any activity where there is a risk of facial contact or trauma for about 6 weeks.

Q: What is the minimal age a young person can have rhinoplasty surgery?

A: We advise patients to physically mature before considering rhinoplasty surgery. For ladies, that is usually 14 – 16 years old and for boys, it is 17 – 18 years old. I have occasionally done this surgery on younger individuals who had severe nasal functional problems or significant abnormal psychological and social issues because of their nasal appearance.

Nose Surgery

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Q: What is an open rhinoplasty?

A: The location of the nasal incision determines whether the rhinoplasty is open or closed. With the closed technique, which has been used for over 125 years in the United States, all incisions are made within the nose. In open rhinoplasty an additional incision is made in the columella (the strip between the nostrils). In some noses there is a distinct advantage to this approach because it provides better exposure of the underlying structures and therefore more predictable results. I use the open technique in noses that require cartilage and soft tissue grafting, in most revision noses originally done by other surgeons, in patients who need extensive nasal tip work, in patients with inherited or congenital nasal deformities such as cleft lips, and in patients with crooked noses.

Q: What type of anesthesia is used in rhinoplasty surgery?

A: Local anesthetics are always used to numb the nasal tissues and minimize bleeding during the surgery. In full rhinoplasty cases a topical anesthetic is also placed on the internal lining of the nose. In most procedures some form of general anesthesia, whether it be intravenous medication (sedation) or inhaled gases are provided by an anesthesiologist (MD) or a certified registered nurse (CRNA).

Q: Solid silicone or cartilage grafts in nasal surgery?

A: Solid silicone grafts are frequently used to augment the nose but I avoid their use because of the increased risk of movement, extrusion, and infection, sometimes years after placement. Cadaver cartilage can be used but in my hands I don’t feel survival of these grafts is optimal. I prefer using the patients own cartilage, preferably harvested from the nasal septum or the ears. I personally feel that it is rarely necessary to harvest rib cartilage, which is more difficult for the patient and the surgeon but this is available if necessary.

Q: Is a rhinoplasty revision more difficult than the original procedure?

A: Rhinoplasty surgery is one of the most challenging operations that we do and a revision is usually more difficult than the original procedure because frequently the normal anatomy and function has been compromised if the results are not satisfactory. For this reason, a patient should always consult with an experienced surgeon who specializes in revision rhinoplasty.

Q: How long after my original rhinoplasty should I wait for a revision?

A: Generally I advise a patient to wait about one year because some parts of the nose, such as the tip, will continue to improve as healing progresses. Although some of these changes are minor it is best to wait because the patient’s ultimate goal is to achieve the best possible result.