Category Archives: Los Angeles

Revision Nasal Surgery

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Discussion of Revision Nasal Surgery

Nasal surgery is an art based on a science, but it is not magic.  As a surgeon, I can only work with what I have been given with respect to tissue characteristics following previous surgery.  The aim is often to improve both appearance and function, and; therefore, there is a challenge introduced when the operation is not the first visit to the tissue.

I want to urge a sense of realism on the part of what the expectations could be.  We always attempt to yield the very best result possible with respect to both breathing and appearance.  So, while maximum improvement is always the surgical goal, and is, indeed, very often attainable, improvement is not the same as perfection.  The reasonable aim is to deliver a nose that is natural in appearance and functions well.

Please understand that in contrast with both primary nasal surgery, or original nasal surgery, the final result takes a bit longer to present itself.  Not that you will look terrible.  It is just that the swelling, although not necessarily highly visible to anyone, just takes a bit longer to subside.  Some noses look very good in 3-4 weeks, and others need more time for maturation.  As one patient said, “I guess it’s sort of like fine wine.  It takes a little time to get to its best.” That is true. 

After Surgery

After the surgical session, it may be important to undergo minor improvements at the postoperative office visits.  We have long experience in the use of medications that can be used to “smooth out” any irregularities or imperfections.  Another class of medication is used to help reduce internal scar tissue and unwelcomed thickening of the skin.  These are the medications that are called “shrinkers.” 

You and I make the decisions, jointly, before committing to any of these treatments.

For more information, please consult our website dedicated to revision nasal surgery at http://www.revisionrhinoplastydoctor.com/.

Middle Eastern Rhinoplasty

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Noses are different within the varied ethnic groups that populate the planet.   An Asian nose has certain features which distinguishes it from the Northern or Central European nose which is different than the Middle Eastern nose which is different than the Central American nose.  One’s color which is a reflection of racial ancestry has an influence also irrespective of the geographic location.  For example, Asian patients regardless of where they dwell in the world, typically have a broad nose with a low bridge and wide nostrils with thick nostril walls.  These are racial characteristics.  Due to intermarriage, often certain features are improved or worsened depending on the genetic match.

Rhinoplasty or cosmetic nasal surgery for Middle Eastern patients must take into account the following typical features of the nose:  There is usually a bump or hump.  The nose tends to be long and somewhat curled down.  When smiling, the tip of the nose drops down even further.  The nose may be wide with very broad lower cartilages causing large nostrils.

The management of such noses has to be very judicious.  It is important to remove the bump without causing a scooped-out appearance.  The nose should be narrowed but never pinched.  The tip needs to be raised up such that the nose no longer seems like it is going to touch the lip when smiling.  And, speaking of smiling, the little muscle that causes the tip to depress with smile generally has to be severed.

The ideal result would be a nose that has not been made too small, is not turned up too much and, as noted earlier, does not have a scooped bridge or a pinched tip. Improvement with preservation of ethnic identity is the key to success. 

Fractional Laser

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Fractional Laser – How Good Is It?  

I’ve written before about laser treatments to improve skin quality.  The aim is to make the skin smoother, less wrinkled, and free of age spots, brown spots, and even some tiny spider veins, all of which contribute to an aged look.

We’ve had our ups and downs with the laser treatments since they were first introduced in the mid-90s.   The full-strength CO2 laser was difficult to manage and too many people had complications from over-treatment.  Other variations of laser technology followed. 

We’ve been carefully watching the fractionated laser.  It had some good common sense and science behind it.  Instead of the entire skin surface being treated by the invisible beam of energy, which essentially destroys the outer skin layers and promotes regrowth of new skin, the fractionated laser’s computerized handpiece lays down a series of dots in a grid-like manner.  Each dot represents an area of skin treatment.  Between the dots, the skin is untreated.  What that allows is a certain level of safety and rapid healing.  Now it is not likely one treatment can do the job.  It may take several, separated by many months, but I think we’re on the right track because the most important thing is avoiding complications. 

The question that many of us have is whether or not such fractionated lasers can make a difference in skin tightness, because it’s in the neck where our greatest challenges have been.  The neck takes the punishment from aging and the sun even more than the face because the neck skin is thinner, and it provides a riskier environment for rejuvenation because of that differential thickness. 

We’re watching very carefully to see how much rejuvenation these techniques can accomplish.  So far I’m happy with the results of the fractionated CO2 laser with respect to lightening the skin and flushing out all the pigmentary changes.  The skin is smoother also.  But how much actual tightening we can get, we’re not yet certain of.  However, we must plod along slowly so that we don’t regret our over-zealous desires to achieve perfection. 

Appropriate Age For Cosmetic Surgery

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Cosmetic Surgery For An 11-Year-Old?

Recently on the Fox News channel was one of their occasional investigative reporting series entitled “From the Fox Files.”  This project was called “Operation Teen.”

The reporter and producer called the office of a non-board certified plastic surgeon in a large metropolitan city in the south and made an appointment ostensibly for their 11-year-old child.  All this was somewhat of a ruse:  the point of the consultation was to determine what the doctor’s attitude and disposition would be with respect to the requested cosmetic surgery for an 11-year old.

The 11-year-old patient said that she wanted a chin augmentation, nasal cosmetic surgery and lip enhancement. 

With hidden cameras, the child and ostensibly the mother (in reality, the segment producer), came to the office and first visited with the doctor’s wife who is the “consultant”.  The consultant spent much more time with the patient than the doctor would subsequently.  The consultant recommended that indeed the patient have a chin implant and nose surgery and lip augmentation and said that she would “take care of everything”. 

Then, the “patient” and “mother” were escorted in to see the doctor.  His examination took 52 seconds, according to the voiceover.  He said, “Yes,” and noted that she would be scheduled for surgery the next day.  Interestingly, the program did not raise this issue but I was shocked that there were no provisions made for this patient to have a pre-operative history and physical and appropriate laboratory testing. 

The doctor’s wife had given patient and mother the quotation and all was seemingly well. 

The next day, the “patient” and “mother” plus the segment’s reporter presented themselves at the appointed time for surgery and then revealed to the doctor who they were and asked how and why he could possibly make these recommendations for an 11-year-old. Frankly, it was one of the saddest and poorest commentaries on professional conduct I have ever seen as the doctor tried to weasel out of having blessed the surgical undertaking the day before.  On this visit under tough questioning, he attempted to back pedal in saying something to the effect of “. . . well, we really make the final decision right before surgery.”

What a poor quality professional this doctor was. 

I thought it important to share this with you because, unfortunately, particularly because of the changes in the health care delivery system, many doctors are migrating into cosmetic surgery who neither have the training and background nor the proper ethics.  I am not happy about this; the medical profession at large is not happy with this but we have no control over how an individual doctor conducts his practice and how he may or may not breach the high standards we would like to see in force.

Mid Facelift

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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. 

Cosmetic Surgery Anesthesiologist

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The Last Thing To Bargain About Should Be The Services of a Doctor Anesthesiologist

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 a cosmetic surgery 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. 

Neck Sculpture Versus Neck Liposuction

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Liposuction first arrived in 1985 and very quickly we learned to adapt the techniques to help remove excess fat from the neck.  It was done with a tiny incision where the chin meets the upper neck.  That’s a perfect place because it is hidden.  And we would use a cannula or narrow suction tip to evacuate the fat that sat between the platysma muscle and the skin. 

However, we observed that the results were not as good as we wanted them to be.  We asked ourselves why this was the case.

The answer came with cadaver dissections and further anatomic studies which convinced us that the key to success was doing more, that liposuction alone was inadequate.  We needed to address the sagging of that platysma neck muscle and that even direct ourselves to the next layer of fat below that muscle which would not be accessed by routine liposuction.

When these two additional components were added, the removal of fat beneath the platysma and then actually trimming the redundant or extra edges of the platysma, and then tying them together with sutures to form an internal sling or corset, the results became quite impressive.   That is what a neck sculpture procedure is.  It is liposuction with two other steps in the operation that allow the best possible definition between the jaw line and the neck.

Understand that this operation – since it removes quite a bit of tissue – relies on the skin’s elasticity to contract to envelope a smaller neck.  If the skin is sun damaged, stretched out, very wrinkled, thin and parchment-like, it is predictable that the skin does not have the ability to snap back like a tight rubber band or like a brand new balloon and that the skin, therefore, cannot drape evenly.  If the skin cannot drape evenly, the result will not look good. Patients with such skin are not candidates.

In order to assess one’s candidacy for the procedure, it is necessary to evaluate the skin’s quality, particularly its elasticity and redundancy.  Typically, men can have the procedure up to the late 60s because men’s skin is thicker and tends to remain more elastic.  But few women older than 45 or 50 qualify because typically the women’s skin by that age perhaps due to decline in hormones, is thin, less elastic, no longer that nice tight rubber band and would not be up to the task of contracting evenly and giving a nice smooth skin contour. 

 

 

 

 

 

 

How Patients Teach Cosmetic Surgeons

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“Patients Are Our Teaches, Guides, And The Inspiration For All We Do”

That reminder came from one of the speakers at a weekend seminar I attended at Cedars-Sinai Medical Center.  The presentation was about the face transplant done at the Cleveland Clinic last year.  It was quite an impressive presentation, and frankly all in the audience were wowed by the success of that operation.  And that was a tribute to the doctors who spent years planning and thinking about how significant portions of the face, when injured or destroyed, could be replaced by a transplant from a corpse. 

When doctors take on a highly experimental and perhaps unpredictable procedure, fraught with all kinds of risks and hazards, including rejection of the facial tissue by the recipient, they must do so with the strong support and will of the patient.

In reality, patients are, in such circumstances, our teachers. They are inspiring us to do what they themselves cannot do.  Remember, only a physician can do the surgery and preside over the healing.  The patient gives up certain autonomy when asking a physician to help them.

We physicians must never forget the great and unique trust that is placed in our hearts and our hands by our patients. 

Cosmetic Plastic Surgery Patients

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“Sometimes We Need To Protect Patients From Themselves” 

I heard that comment made recently at a seminar at the Cedars-Sinai Hospital here in the Beverly Hills area. 

There is a lot of wisdom there.   Patients today, while empowered and enlightened by the Internet, often cannot have appreciation of all the issues that have to be considered when decisions for cosmetic surgery are made.   Often patients cannot understand that some things  cannot be done or if done will have a low success rate.  And low success rates are not what patients – nor their cosmetic plastic surgeons – want.   It is wiser to not operate if there is significant doubt about the prospects for a happy patient and a gratified surgeon. 

When we tell patients we do not think it is a good idea to operate, it is not to insult them or to brush them off, it’s just that we have their best interests at heart.  Is it fair to do an operation that the surgeon does not believe in?  No, it isn’t. 

Medical ethics and common courtesy dictate that if the surgeon feels there is an unfavorable risk/reward ratio, he should not agree to operate.  A wise patient will accept the doctor’s reservations and respect his professionalism and regard for the welfare of the patient. 

Asian Rhinoplasty

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Noses are different within the varied ethnic groups that populate the planet.   An Asian nose has certain features which distinguishes it from the Northern or Central European nose which is different than the Middle Eastern nose which is different than the Central American nose.  One’s color which is a reflection of racial ancestry has an influence also irrespective of the geographic location.  For example, Asian patients regardless of where they dwell in the world, typically have a broad nose with a low bridge and wide nostrils with thick nostril walls.  These are racial characteristics.  Due to intermarriage, often certain features are improved or worsened depending on the genetic match.

For Asian rhinoplasties, typically, nostril narrowing may be necessary.  Now, the decision to do nostril narrowing has to be done after considerable thought and deliberation.  First, not all Asian nostrils are amenable to nostril narrowing.  The ideal candidate for nostril narrowing is a patient that has wide, oblong nostrils primarily due to a very wide sill or floor of the nostril.  That is the part that is easiest to narrow. The surgical procedure that does that is aptly called “nostril narrowing” or is also known by its eponym, the Weir’s procedure, named after the surgeon who devised it.

Nostril narrowing is done as an independent procedure or as part of a rhinoplasty or cosmetic nasal surgery.   It can be done also at the same time that functional nasal surgery is done, e.g., nasal septoplasty and turbinate reduction.  The surgeon seeks to excise a wedge-shaped portion of that sill or floor of the nostril.  Two connecting incisions are fashioned.  One is placed in the crease between the ala or nostril wall in the floor of the nose and extends into that groove between the ala and the cheek.  The second incision is made at a location which will determine how much of the skin is removed.  That is made typically in about the midportion of the widened nostril sill and, thus, the tissue between the two markings is removed.  After the blood vessels are sealed, two layers of stitches are used to close the incision such that the end resulting scar would be very fine and hidden within that crease between the nostril wall and the upper lip and cheek.

There is a very small chance that the incisions will show.  Unfortunately, people of Asian ancestry do have more of a tendency to develop thickened scars or keloid-like hypertrophic or heavy scars but these can be managed by injections of cortisone.  Rarely is it necessary to do any revisional surgery.

Here, as in all aspects of rhinoplasty, the art form and skill of the surgeon will be the determiner of the outcome.