Neck Sculpture, Conservative Rhinoplasty and Chin Implant

We frequently receive inquiries from budget conscience but appearance-minded readers about having neck liposuction.

Long story short: most patients, even including thin patients, are usually disappointed with the results of liposuction only on a naturally aging neck.

In virtually all cases, the platysma, (PLA-tis-muh) a long muscle that runs from the shoulders up to the chin, has stretched and is sagging.

The key to a more youthful and rested look is shortening that muscle to remove its:

• Laxity
• Sagging
• “Turkey gobbler” look

A neck sculpture also includes some liposuction and can be done alone or in connection with a face lift. (Read more about the neck lift procedure.)

First the liposuction: the cosmetic surgeon makes an incision under your chin so the scar can’t be seen later. Then, the shallow layer of fat in the neck is liposuctioned away except for a naturally occurring section of fat found deeper in the neck that does not respond to liposuction. That fatty area is removed with surgical tools.

After that, the cosmetic plastic surgeon turns his attention to that long platysma muscle which has been making you look older than you feel. The platysma is also a very broad muscle so it is heavy.

(You can feel your platysma stiffen if you forcefully draw down the corners of your mouth. The platysma also creates expressions of sadness or fright.)

Using surgical tools designed for the procedure, the surgeon shaves the excess from the platysma and then stitches the two edges together to form what is basically a sling or corset of muscle. That internal tightening is the key to a long-lasting result that gives you a more natural looking, smooth neck.

Plastic surgeons also have a great eye for balance; so if you have a receding chin, your facial profile will be out of balance as was the woma’s below. This would be the opportune time to have a chin augmentation (with a chin implant) to bring out the best in your features.

A neck sculpture procedure is more involved than liposuction alone but it does much more. We frequently see patients who only had neck liposuction but were very disappointed with the result.

What’s more, neck sculpture may even be good for you!

According to a recent article in Science Daily, researchers found that removing a portion of the platysma muscle may ease symptoms of chronic neck stiffness and a few other maladies.

(Read more about medical benefits of neck sculpture.)

Before and After Chin Augmentation

Filling a Nasolabial Fold

So much is being written about fat transfer, (a cosmetic plastic surgery procedure that takes fat from where you don’t want it and applies it to where you do want it) that many are asking facial plastic surgeons:

• Can fat injection be used to fill in grooves, folds and deep facial wrinkles?

The procedure is also known as fat grafting and fat transplantation.

Mostly, patients want the following filled:

• The nasolabial lines, running from the corners of the nose to the corners of the mouth

• The sardonically named “drool lines” that run from the outer edges of the lower lip down the chin

Also responsible for normal facial aging – and open to fat grafting — are sunken cheeks and hollow, under eye areas.

Fat transfer is extremely time-consuming: the surgeon must liposuction a donor area – usually the tummy or the buttocks – then filter and prepare the fat for injection.

The plastic surgeon then painstakingly places dozens, if not hundreds, of fat droplets through layers of tissue and muscle.

The key to lasting fat transfer is finding a blood supply. Top practitioners say droplets of fat no larger than a small pearl stand the best chance of surviving.

Long story short?  Sometimes fat transfer works as intended. At other times, transferred fat is absorbed into the body.

Cosmetic Surgery Times, recently interviewed two top cosmetic surgeons, one of whom is very pro-fat transfer while the second is decidedly not.

Observed the more skeptical cosmetic surgeon, Val Lambros, MD, about another rarely mentioned consideration: “Injected fat can also grow.”

Will that become a problem over time?

Meanwhile, the fat grafting advocate, J. William Little, MD, says that rejection does not take place because the transferred fat is your own natural tissue.

However, transferred fat can’t be removed. What happens if injected fat on one side of your face grows while the fat on the opposite side stays as is?

(Read more about the virtues and vices of facial fat grafting.)

Meanwhile, cosmetic plastic surgeons offer a handful of facial fillers that are proven to be reliable, predictable and, not least, wildly popular with consumers. Those fillers include:

• Juvederm
• Radiesse
• Sculptra
• Restylane

With the exception of Artefill, the fillers are absorbed into the body, but you know what you’re getting.

Sculptra can last up to five years in some cases although it requires several months for results to appear.

Getting a little long in the tooth but think you would like a surgical rejuvenation to make you look as young as feel? (Nose job re-dos are often done by a revision rhinoplasty specialist.)

Plastic surgery researchers at the famed Cleveland Clinic also wondered how face lifts would go in over 65ers.

Due to a dragging economy, many seniors are still in the workplace and do not want to look like they are tired, angry or fierce; those are emotions typically read in the face of a person’s facial flesh that is wrinkled and sagging a bit more than a couple of decades ago.

The key to studying seniors’ facelifts was looking closely at those who had been properly screened and then had surgical procedures.

While only a complete personal exam by your own internist or family practitioner can clear you for rejuvenation surgery, generally those patients must be:

• In good health with the medical tests to prove it
• Non-smokers
• Wanting plastic surgery for the right reasons (for work reasons, reentering the dating scene, and other personal reasons)

The list can be long but wanting cosmetic plastic surgery for the wrong reasons incudes having:

• An odd ailment known as Body Dysmorphic Disorder in which no aesthetic result is ever good enough
• Surgery to please somebody else like a husband who wants you to have breast augmentation for extra-large breasts
• “Revenge” cosmetic surgery (Some get plastic surgery only to look better than their divorced mates)

Cleveland Clinic researchers followed 216 women 65 and over for three years after each had a face lift. They then compared the health and rate of post-surgical complications of 68 women (whose average age was 70) with another group of 148 younger women who also had facelifts.

Results: no additional risks for the oldsters.

Said the lead researcher, James Zins, chairman of plastic surgery at Cleveland Clinic: “Facelift surgery in the elderly has always been seen as carrying more post-operative risks. But according to our study, over age 65 patients had no statistically significant increase in complications.”

Until now, many cosmetic plastic surgeons ruled out surgery for people 65 and over.

(Read more about the cosmetic surgery study.)

 Recently, a press release from one of the plastic surgery trade organizations reported that there was an increase in activity in the plastic surgery community.  That was said to be harbinger of better economic times to come. 

Frankly, I am not so sure of that.  The growth in cosmetic procedures is not in the surgical arena.  It is in the non-surgical office treatment arena.  So, as I see it, the increase in the “ plastic surgery business” is not in the plastic surgery but in the syringe and needle department.

Botox Cosmetic, Dysport, Restylane, Juvederm, Sculptra, and Radiesse, Artifill and medical-grade liquid silicone are all good and valuable treatments that patients are flocking to. 

We cosmetic surgeons are glad to have these excellent products available to us, but the reality is, alone, they cannot do the job.

Today’s patients, watching their budgets, are apt to opt for the non-surgical treatments before the more major treatments, such as face and neck lift, neck sculpture, upper and lower eyelid surgery, brow lift, chemical skin peel, or laser skin treatments.  It is understandable. Office treatments require no time off, are virtually painless, and are far less expensive. 

It may be that we never reach the numbers of surgical procedures that were done before the current Great Recession.  While the cutting and sewing procedures are available for patients, the utilization may be less because of economics, primarily.  Understanding that, many practices are offering reasonable discounts to aid people who might otherwise not be able to afford the procedures.

When consulting with doctors, be sure to ask about all treatments available, both surgical and non-surgical. And, ask how you can shave some dollars from the cost without sacrificing quality.

I have some hints on that for you on a future blog post.

Recently, one of our patients, a registered nurse having a face and neck lift, commented that the anesthesia experience was “So terrific.  I found it astonishing.”  This veteran nurse practiced in a previous era where, frankly, the practice of anesthesia did not deliver the same level of patient comfort and safety.  All this has to do, really, with the drugs that are available, but most importantly, the technique and bedside manner of the anesthesiologist.

The anesthesiologist for this procedure was Barry Friedberg, MD, faculty member at UC-Irvine, and author of  Getting Over Going Under.  Dr. Friedberg is the world’s leading authority on a particular anesthesia technique which is extremely appropriate for face and neck lifting.  It is known as “PK Anesthesia” – “P” for propofol and “K” for ketamine.  This is essentially a very sophisticated sedation formulation accompanied by brainwave monitoring by the anesthesiologist.  Brainwave monitoring is the key to the proper level of medications being given to the patient. Not too much and not too little is the key.

One of the great virtues of this technique is that there is no tube placed into the windpipe; therefore, there is no throat irritation.  There is almost no chance of postoperative nausea and vomiting.  The patient wakes up quickly and comfortably without any bizarre dreams.  There is no evidence that this technique leads to any brain cell damage, which other techniques are now being linked to.  So, there should not be either  loss of memory nor any other intellectual faculties. 

What I like about the procedure is that it is simple, predictable, and with only two drugs being used, not much can go wrong.  Knowing that Dr. Friedberg is reading the brainwave monitor is as comforting to me as knowing that a cardiologist is reading my patient’s EKG. 

Anesthesiologists are “the second doctor in the operating room.”  While patients rarely develop as deep and long a relationship with them as they do with their surgeon, thoughtful surgeons recognize that the experience the surgeon brings to the patient, in terms of comfort and safety, is dependent upon the anesthesiologist. Great value there.

Today, anesthesia is safer than ever.  The reason is giant strides towards patient safety and comfort achieved by the specialty of anesthesiology. 

Several patients have asked me whether it is necessary to have an anesthesia specialist.  They ask, “Is it not possible to do the procedure under local anesthesia, without an anesthesiologist?”  I think this question is being posed because there are some marketing companies that promote “lunchtime” or “one-hour” or “quick” facelifts, whose patients do not have the benefit of an anesthesiologist. 

Not having that “second doctor” in the operating room is one of the most foolish decisions a patient can  make. For cosmetic surgery–or any surgery.  Why wouldn’t you have a specialist whose entire work is devoted to patient comfort and safety?  Is anything more important than either for you?  Today’s anesthesia is so safe that, in fact, you’re safer in a certified outpatient surgery center or hospital, with a doctor anesthesiologist at your side, than you are on the freeway or road you took to get to the surgery center! 

Finally, if people are attracted to a program that does not include an anesthesiologist within the package of services, consider that the anesthesiologist’s fee typically is no more than 10% of the total outlay for all services, including the surgeon’s fee, outpatient surgery center or hospital, postoperative medications, and postoperative recovery facility. 

It’s a false bargain to try to save money when your very life is on the line. 

The Mid-Face Lift Revisited

For the last 10 years or so, there was a lot of attention to the “mid-face lift”.  This was an operation that was expected to pull up the cheeks and help flatten the deep nasolabial creases which run between the base of the nose and the corner of the lower lip.  Frankly, I never saw the value of the operation. 

It is very difficult to improve that nasolabial crease by trying to reposition or pull the skin or other tissue through incisions in the hairline or in front of the ear. Typically, the face just looks “pulled”, and that is difficult to correct.  In my opinion, there have been better ways to deal with the nasolabial crease, including filling injections.  For some people, it is even improved with a deep chemical skin peel when the skin is extremely wrinkled and has lost its elasticity.  Sometimes laser treatments can be successful also.

The recognition is that the mid-face lift has not been successful enough to be considered a first-line treatment, and this parallels the rise in popularity of fillers, because fillers are doing a good job in the nasolabial creases. Some of the newer filling agents will continue to extend our talents in this direction.

The most thoughtful surgeons know when surgery is best but also when a non-surgical treatment will do the job. 

Computer Imaging and Hollywood

There is something magical about computer imaging.  The uniqueness is that the prospective patient can see their predicted result on a computer screen and immediately understand “what it is all about.”

The discussion of cosmetic procedures is often very abstract without some visuals.  The most powerful graphic they can have would be a computerized prediction of the outcome of whatever procedure they are considering, whether it is rhinoplasty, blepharoplasty, face and neck lift, chemical skin peel or neck sculpturing with or without chin augmentation. 

Previously all we had available to demonstrate to patients would be a magic marker to “erase” the bump on the nose.  We have used computer imaging in our practice since 1989.  Today’s technology, of course, is far advanced over those rudimentary computer systems we had and patients very much appreciate the chance to have that as an important part of their consultation.

In Hollywood, the home of the stars, we sometimes kid our patients who come from out of state to see us that “Welcome to Hollywood, now we will show your transformation to a Hollywood star!”