Facial Procedures

Blepharoplasty

Eyelid rejuvenation surgery, like rhinoplasty, is an operation that produces a permanent change holding up extremely well to the ravages of time. In the world of facial rejuvenation, and perhaps aesthetic surgery in general, blepharoplasty is definitely the biggest 'bang for the buck.'

Most people, as they get older, develop a redundancy of eyelid skin that may produce hooding in the upper lids and wrinkles in the lower. In addition, the fat that normally surrounds and cushions the eyeball can bulge as the retaining tissues become lax, producing 'fat pads' in both the upper and lower eyelids. The effect is that the individual begins to look older and somewhat tired, even when fully awake.

The pattern is not the same for everyone and in addition there are other problems that frequently co-exist. For instance, the patient may have ptosis where the upper lid hangs lower than it should. This is commonly the result of the eye-opening muscle becoming stretched. Ptosis may interfere with vision when the upper lid cannot be elevated above the pupil. Here the individual looks half asleep, though is often said to have 'bedroom eyes.' The basic blepharoplasty will not correct this: it must be combined with a specific ptosis operation.

Other problems include dry eye, lax lower lid, ectropion where the lower eyelid turns out - hanging away from the eyeball; and entropion, where it turns inwards rubbing the eyelashes uncomfortably against it. These problems, too, must be considered and addressed at the time of surgery.

The permutations and solutions are complex and serve to underline the fact that the surgical plan must be tailored to the needs of the individual patient. Like most plastic surgery procedures, there is no such thing as one operation fitting all.

At your initial consultation, I will take a detailed history and perform a thorough examination with the object of diagnosing your specific problems, determining what combination of procedures would best address them and ensuring that any pre-existing medical conditions may be appropriately managed to minimize risk at the time of surgery. You will have ample time to ask questions and discuss your options in a professional yet friendly environment. Blepharoplasty is usually carried out with the patient awake, but under sedation so that he or she can co-operate with eyelid positioning. No bandages are worn after the same-day surgery and the sutures are removed in a week. Bruising has usually cleared by two.

Endoscopic Brow Lift

Many people come to my office requesting a blepharoplasty to correct an excess of skin in the upper eyelids when the real problem lies in the brow. In such patients, the brow itself has fallen and has resulted in bunching of upper eyelid skin. Aggressive removal of skin during a blepharoplasty will tend to pull the eyebrow down even further, exacerbating the problem and giving the individual a tired and weary appearance.

A brow lift sets the eyebrows at a higher level and stretches out the upper eyelid skin. Often none needs to be removed; but if it does, I prefer to trim it later once the new brow position has been firmly established, so that the two operations are not working against each other and eye closure does not become a problem. With the eyebrows set higher, patients stop wrinkling their brows since there in no longer any need for conscious elevation.

A brow lift also gives the surgeon access to the corrugator muscles between the eyebrows. These muscles are responsible for frowning and their removal decreases those angry looking vertical lines with which we are all familiar. It is a sad fact that some people have prominent frown lines and appear angry even when they are not.

Traditional brow lifts involve a coronal incision passing from ear to ear over the top of the head. With the introduction of the endoscopic brow lift things have changed. The operation is performed through five small incisions just behind the hairline using a telescope and specialized instruments. The surgeon visualizes the operative field on a high definition monitor. At first, I thought that this was just an expensive gimmick, but now it is the only way I perform brow lifts. The HD monitor magnifies and displays the surgical field in ways the human eye just cannot see. There is less cutting and sewing and the nerves supplying sensation to the scalp are not divided - as they are in a conventional brow lift. Furthermore, I feel I can get a better release and lift than I could ever get with the older method.

As mentioned, I prefer to delay the upper lid blepharoplasty if one is needed: it can be performed in the office under local anesthesia three months later. However, the lower lid blepharoplasty, if indicated, may safely be performed at the same time as the endoscopic brow lift.

At your initial consultation, I shall take a detailed history and perform a thorough examination with the object of analyzing the aesthetic problem, establishing goals, and ensuring that any pre-existing medical conditions may be appropriately managed to minimize risk at the time of surgery. You will have ample time to ask questions and discuss your options in a professional yet friendly setting. The surgery itself will be carried out in a safe environment (a hospital or an accredited ambulatory surgery center) and you will have a board certified anesthesiologist giving the anesthetic. You should be able to return to work in about a two weeks or even sooner if you can tolerate visible bruising.

Facelift

The most comprehensive method of facial rejuvenation is the facelift. However, blepharoplasty is definitely a 'bigger bang for the buck' and should be considered either prior to, or together with, a facelift when aesthetic surgery of the face is being contemplated.

Having said that, it is important to understand what exactly a facelift is. It is an operation in which the facial skin is dissected off the underlying structures via an incision that is concealed around and behind the ear, and then drawn back under some tension. Excess skin is excised, the facial tissues tightened and the wound closed leaving an inconspicuous scar. It does not involve the brow or the eyelids, although it is certainly possible to perform a brow lift and/or blepharoplasty at the same time. A facelift is aimed primarily at the cheek, jowls and neck.

The most effective outcome of a facelift is seen in the jowls and in the neck. Its benefits in the mid face are less predictable but may be augmented by ancillary procedures such as fat injection. Facelifts that simply serve to tighten the skin are rarely effective. To be beneficial, it is necessary to tighten the underlying superficial musculo aponeurotic system (SMAS), a layer which is intimately connected to the muscles of facial expression. There are various methods of doing this but the superiority of one over another has not yet been established.

In younger patients, where a large skin excision is not required, a 'MACS' lift may be contemplated. Here the lift is performed through an incision that extends down the front of the ear, ending at the lobe. Undermining of the facial skin is limited and skin excision is minimal. However SMAS work is performed using non-absorbable sutures to plicate (tighten) the SMAS in the cheek and neck. This is not suitable for patients with a large redundancy of skin.

Beware of practitioners touting 'thread lifts,' 'week-end face lifts' 'mini face lifts' and the like. Getting a long-lasting result from a facelift takes a lot of hard work. The beneficial effects of such procedures barely outlast the postoperative swelling. Surgeons can perform several of these in a day, but the patient merely ends up with a keepsake scar, no benefit and empty pockets.

A facelift is usually performed under either general anesthesia or local anesthesia with intravenous sedation. Although a pure facelift is comfortably carried out on a day surgery basis under sedation, the addition of other procedures would lead me to recommend a general anesthetic and an overnight stay.

At your initial consultation, I shall take a detailed history and perform a thorough examination with the object of defining the esthetic problem, establishing your goals, formulating a treatment plan and ensuring that any pre-existing medical conditions may be appropriately managed to minimize risk at the time of surgery. You will have ample time to ask questions and discuss your options in a professional yet friendly setting. The surgery itself will be carried out in a safe environment (a hospital or an accredited ambulatory surgery center) and you will have a board certified anesthesiologist giving the anesthetic. You should be able to return to work in about a two weeks or even sooner if you can tolerate visible bruising.

Rhinoplasty

Surgery to change the shape of the nose for esthetic reasons has been performed routinely for almost 100 years. Presently it is one of the most popular aesthetic surgery procedures in the United States. Although most of the patients are young, there are no contraindications based on age. Unlike many aesthetic procedures, rhinoplasty is not performed for rejuvenation, but to fundamentally change appearance. Modern techniques have made the operation safer and more predictable, but revisions are not uncommon. The modern trend is to avoid extensive surgery and keep changes to a minimum. By these means secondary problems can be minimized.

Most patients undergoing rhinoplasty will receive a general anesthetic and go home the same day. Broadly there are two types of rhinoplasty: open and closed. Many surgeons favor one over the other, while others, like me, perform both - the decision resting on the indications. I find that the open approach is excellent for secondary rhinoplasties, the twisted nose and in those cases where tip work is potentially complicated.

The operation is performed through the nostril and takes place in the layers between the skin and lining of the nose. The bone and the cartilage are trimmed and reshaped, with the expectation that the skin will redrape to the new form. Often this means 'breaking' the nasal bones, but this is done in a controlled way using very fine chisels. Judicious trimming of the cartilage and tiny cartilage grafts are also employed. If there is a breathing problem further work will be required, often on the nasal septum. The patient will generally wear a splint for a week and retain nasal packs for 24 hours.

At your initial consultation, I shall take a detailed history and perform a thorough examination with the object of defining the esthetic problem, establishing your goals, formulating a treatment plan and ensuring that any pre-existing medical conditions may be appropriately managed to minimize risk at the time of surgery. It is important to determine whether you have an associated breathing problem and to plan for its correction. You will have ample time to ask questions and discuss your options in a professional yet friendly setting. The surgery itself will be carried out in a safe environment (a hospital or an accredited ambulatory surgery center) and you will have a board certified anesthesiologist giving the anesthetic. You should be able to return to work in about two weeks or even sooner if you can tolerate visible bruising around the eyes.

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