INTRODUCTION

Eyelid surgery, or blepharoplasty is a very common outpatient surgical procedure, which aims to rejuvenate one or both eyelids.

 INDICATIONS

Blepharoplasty may be an option if you have:

• You may undergo blepharoplasty at the same time as another procedure, such as a brow lift, face-lift or skin resurfacing.
• Bags under your eyes
• Baggy or droopy upper eyelids
• Excess skin on the lower eyelids
• Excess skin of the upper eyelids that interferes with your peripheral vision

 Options to Enhance the Procedure

Some patients choose to have laser resurfacing or a chemical peel in addition to the blepharoplasty. This may minimize fine wrinkles near the eye. A forehead lift may correct sagging or abnormally positioned eyebrows.

CONSULTATION

During your initial consultation, you should expect to:

• Provide a complete medical history. Include information about any previous surgical procedures; past and present medical conditions; and all medications or herbal supplements you are taking.
• Be sure to inform your surgeon about symptoms of dry eyes and eyeglass or contact wear.
• Have your surgeon conduct a complete physical examination.
• Discuss possible risks and complications.

PREPARING FOR SURGERY

We will give you pre-operative information that explains everything you should do and know before your procedure.

You should arrange for someone to drive you home after your surgery. You also may want to make arrangements for someone to help you out for a day or two while you heal.

LOCATION

Your procedure will take place in state-of-the-art surgical suites and recovery areas. Most procedures are outpatient.

ANESTHESIA

We use either local anesthesia with intravenous sedation or general anesthetic.

THE SURGERY

A.  Blepharoplasty For Upper Eyelids

Plastic surgeons place incisions a certain distance above the eyelid margin (the line where your eyelashes are.) This may differ depending on:

• Your facial structure.
• The prominence of your eyes
• If you are a man or woman.
• Your ethnicity (the Caucasian and Asian eyelids have different shapes and anatomy)

Often, the best place to hide an upper blepharoplasty incision is the natural crease formed by the upper eyelid.

Because it is in the fold of the eyelid, the scar will appears as a very thin line – a natural part of the face hidden when your eyes are open.

B.   Lower Eyelid Blepharoplasty

There are two types of incisions that are used for lower eyelid surgery

A transconjuntival incision takes place on the inside of the eyelid. It’s an ideal location for hiding scars since it’s never visible to anyone. This approach to blepharoplasty is best for people who want to address puffiness or tired-looking eyes but who do not have a lot of excess skin that needs to be removed.

The transconjuctival incision (inside the lower eyelid) is used when only fat needs to be removed

A subciliary incision, which takes place just below the lower eyelid lash line, is another commonly used incision. The resulting scar is very difficult to see once it has healed.

This type of blepharoplasty can help patients get rid of loose skin around the eye that may be causing their face to look prematurely aged. It can also be used for removing or repositioning fat (the “lower eyelid bags”).

 

In most cases of lower eyelid blepharoplasty and in some cases of upper eyelid blepharoplasty the fat compartments of the eyelids need to be removed

In almost all cases of upper eyelid blepharoplasty and in most cases of lower eyelid blepharoplasty a portion of skin needs to be removed (grey area)

If your upper eyelid droops close to your pupil, your surgeon may do blepharoplasty with a procedure called BLEPHAROPTOSIS REPAIR that provides additional support to the eyebrow muscle.

If the lower eyelid is too loose (the surgeon will assess that during the consultation with the so called “snap-test”), then he will also perform tightening procedures of the lower eyelid called CANTOPEXY and CANTHOPLASTY.

RECOVERY

After surgery you spend time in a recovery room, where you are monitored for complications. You can leave later that day to recuperate at home. After surgery you may temporarily experience:

• Blurred vision from the lubricating ointment applied to your eyes
• Watering eyes
• Light sensitivity
• Double vision
• Puffy, numb eyelids
• Swelling and bruising similar to having black eyes
• Pain or discomfort

Your doctor will likely suggest you take the following steps after surgery:

• Use ice packs on your eyes for 10 minutes every hour the night after surgery. The following day, use ice packs on your eyes four to five times throughout the day.
• Gently clean your eyelids and use prescribed eyedrops or ointments.
• Avoid straining, heavy lifting and swimming for a week.
• Avoid strenuous activities, such as aerobics and jogging, for a week.
• Avoid smoking.
• Avoid spending too much time in front of a computer screen.
• Sleep with a couple of pillows so the head is raised higher than your chest for a few days to help the swelling disappear faster
• Use ARNICA crème or oil.
• Avoid rubbing your eyes.
• If you use contact lenses, don’t put them in for about two weeks after surgery.
• Wear darkly tinted sunglasses to protect the skin of your eyelids from sun and wind.
• Apply cool chamomile compresses to reduce swelling.
• After a few days, return to the doctor’s office to have stitches removed, if needed.
• For about a week, avoid aspirin, ibuprofen, naproxen and other medications or herbal supplements that may increase bleeding. If needed, use acetaminophen to control pain.

In general most of the swelling and bruising will disappear in a week.

RISKS

• Infection and bleeding
• Dry, irritated eyes
• Difficulty closing your eyes or other eyelid problems
• Noticeable scarring
• Injury to eye muscles
• Skin discoloration
• The need for a follow-up surgery
• Temporarily blurred vision or, rarely, loss of eyesight
• Hollow eyes and ectropion (eversion of the lower eyelid)
• Risks associated with surgery in general, including reaction to anesthesia and blood clots

RESULTS

The results are long lasting. Very rare a patient undergoes a blepharoplasty for a second time. Blepharoplasty is a high satisfaction rate cosmetic operation.

Upper and lower blepharoplsty on a 55 year old lady. Left: before surgery, Right: one month after surgery

Lower blepharoplasty with transconjuctival incision (inside the eyelid, no external scar) on a 36 year old lady. Left: before surgery, Right: one month after surgery. No more”bags” in the lower eyelid

Lower blepharoplasty with external subciliary skin incision and removal of skin and fat on a 52 year old lady. Left: before surgery, Right: one month after surgery. No more”bags” in the lower eyelid

Upper and lower blepharoplsty on a 51 year old lady, with skin excision, fat excision and canthopexy. Left: before surgery, Right: two months after surgery. No scars are visible

 

Upper and lower blepharoplsty on a 46 year old lady, with skin excision and fat excision. Left: before surgery, Right: two months after surgery. No scars are visible

 

Lower blepharoplasty on 53 year old male. Subciliary (external incision), fat removal. No canthopexy. Left: before,  Right: two months later, no visible scars

INTRODUCTION

Blepharoptosis (droopy eueylids), is defined as an abnormal low-lying upper eyelid margin with the eye in primary gaze. The normal adult upper lid lies 1.5 mm below the superior corneal limbus and is highest just nasal to the pupil. 

TYPES OF BLEPHAROPTOSIS

Blepharoptosis if it is based on age can be classified as

• Congenital (from the first day of life)
• Acquired (developed during the lifetime)

A more comprehensive classification is based on etiology and includes:

• Myogenic – the muscle that lift the eyelid does not function
• Aponeurotic – the tendon of the levator muscle is loose
• Neurogenic – the nerve to the muscle does not work
• Traumatic – usually after a facial fracture
• Pseudoptotic – Pseudoptosis can result from
• Dermatochalasis (loose sagging skin)
• Microphthalmos (small eye)
• Enophthalmos (the eyeball lies inwards)

INDICATIONS FOR SURGERY

Patients usually complain of a bedroom-eye appearance, always appearing sleepy or tired, and constriction of their visual fields. Most common reasons to seek help for surgery include:

• Blockage of the visual axis in the severely ptotic eyelid.
• Congenital cases can obstruct vision and lead toamblyopia.
• In adults difficulty with the upper gaze (constriction of the superior visual fields).
• Patients may complain that they tire easily when reading and experience frontal headaches as they lift their eyebrows in an effort to keep the eyelids open.
• Patients may be dissatisfied with their appearance.

CONSULTATION

Every patient is different, and your surgeon will choose the surgical technique and treatment plan that is right for you.

The doctor will obtain a thorough medical and ophthalmic history. More specifically, the onset of ptosis, alleviating or aggravating factors, family history of ptosis, and history of trauma or ocular surgery are important clues to the etiology.

If the patient has not been under the care of an ophthalmologist, a complete ocular examination is required.

Quantification and qualification of the blepharoptosis is needed for proper diagnosis and treatment. All quantitative eyelid and eyebrow measurements should be taken before the use of dilating drops.

The presence of proptosis, lagophthalmos, tear dysfunction, absence of a Bell response, and lower eyelid laxity or scleral show may affect the amount of ptosis repair.

Other specialties involved

If a specific etiology of blepharoptosis is identified and has related systemic manifestations, consultation with other specialists is necessary.

• If myasthenia gravis or multiple sclerosis is diagnosed, appropriate follow-up care with a neurologist is warranted.
• If dysthyroid orbitopathy is found, an endocrinologist should be consulted to address the thyroidopathy.
• Patients with Kearns-Sayre disease can have cardiac conduction abnormalities that should be managed by an internist or a cardiologist.

DIAGNOSTIC TESTS

If blepharoptosis is present with other neurologic deficits, imaging of the brain, orbits, or cerebrovascular system should be performed.

An emergent CT angiography of the brain is necessary when ptosis is accompanied by signs of a third nerve palsy.

MRI of the brain is the imaging modality of choice to exclude tumors of the brain or the orbit and multiple sclerosis.

CT scanning of the head can be used to exclude dysthyroid orbitopathy

In acquired Horner syndrome, MRI or CT scan of the brain, MRA of neck, CT scan or X-ray of the spine, and CT scan or X-ray of the chest (especially of the apex of the lung) are needed. 

PREPARATION FOR SURGERY

After your consultation and decision about surgery, we will give you pre-operative information that explains everything you should do and know before your procedure. You should arrange for someone to drive you home after your surgery. You also may want to make arrangements for someone to help you out for a day or two while you heal. 

LOCATION

Your procedure will take place in state-of-the-art surgical suites and recovery areas. Most procedures are outpatient.

ANESTHESIA 

We use general anesthetic so that you will sleep and remain comfortable throughout the procedure. Local anesthesia with intravenous sedation is also an option for some patients.

SURGERY

1. External Approach

External approach, or levator advancement, is the most commonly performed surgery to treat ptosis. It is recommended for people with ptosis who have strong levator muscle function.

In an external approach, the oculoplastic surgeon makes an incision in the skin of the eyelid. The surgeon then repositions the attachment of the levator muscle by stitching it to the tarsus, which is connective tissue in the eyelid.

2. Internal Approach (Fassanella – Servat proscedure)

Your doctor may choose to perform ptosis surgery using an internal approach. This is also recommended for people with strong levator muscle function.

In this procedure, the surgeon turns the eyelid inside out and shortens the eyelid muscles from the inside of the eyelid. Either the levator muscle or Mueller’s muscle—which also plays a role in lifting the lid—is shortened.

3. Frontalis Sling Fixation

If you have ptosis and poor muscle function, your eye surgeon may choose to perform frontalis sling fixation. In this procedure the surgeon attaches the upper eyelid to the frontalis muscle—the muscle just above the eyebrows—typically with the use of a small silicone rod that is passed through the eyelid, underneath the skin. Connecting the eyelid to the frontalis muscle with this rod allows the forehead muscles to elevate the eyelid.

RECOVERY

It’s likely your surgeon will tell you not to drive for at last 24 hours after your procedure, so have a friend or family member lined up to bring you home or plan to use a car service.

You also should plan to take some time off from work—at the very least the day of your surgery and the day after.  

Your doctor also may advise you to use cold compresses on your eyes the day of your blepharoplasty as well as the day after to help reduce swelling.

In addition, he or she may instruct you to do any or all of the following:

• Use prescription eye drops or ointments as directed.
• Be very gentle when cleaning the area around your eyelids.
• If you wear contacts, use your glasses instead.
• Wear dark tinted sunglasses and/or sunscreen when outside to protect your eyes from sun and the wind.
• Don’t smoke.
• Don’t lift anything heavy or take part in strenuous activities or exercise for at least 10 days to a week.
• Don’t swim.
• Don’t rub your eyes.
• Sleep on several pillows so that your head is elevated above your torso.
• Don’t take blood-thinning medications. 

RISKS

Typical side effects may include:

• Bruising for at least a couple of weeks.
• Swelling. The swelling may increase during the first 48 hours after your surgery but should subside gradually after that.  
• Undercorrection
• Overcorrection
• Blurred vision (caused by the ointment you’ll likely need to apply to your eyes after the procedure)
• Double vision
• Watery eyes or sticky, dry eyes
• Sensitivity to light
• Puffiness
• Pain

About a week after surgery, your stitches can be removed. 

RESULTS

Example of unilateral posttraumatic left sided ptosis. Left photo before correction and right photo 2 months after surgery  

Example of  bilateral involutional ptosis. Left photo before correction and right photo 2 months after surgery 

INTRODUCTION

A brow lift, also known as a forehead lift or forehead rejuvenation, is a cosmetic surgical procedure to improve the appearance of the forehead, the brow and the area around the eyes.

INDICATIONS

You might consider a brow lift if you have:

• Creases across your forehead or high on the bridge of your nose, between your eyes
• Vertical creases between your eyebrows
• A low or sagging brow that’s contributing to sagging upper eyelids

CONSULTATION

During your first visit, your plastic surgeon will likely:

• Review your medical history.Be prepared to answer questions about current and past medical conditions. Talk about any medications you’re taking or have taken recently, as well as any surgeries you’ve had.
• Do a physical exam. To determine your treatment options, the doctor will examine and measure different parts of your face with your eyes open and closed.
• Discuss your expectations.

PREPARATION FOR THE PROCEDURE

• Stop or reduce smoking.Smoking decreases blood flow in the skin and can slow the healing process. In addition, smoking increases the risk of tissue damage.
• Avoid certain medications.You’ll likely need to avoid taking aspirin, anti-inflammatory drugs and herbal supplements, which can increase bleeding.
• Arrange for help during recovery

LOCATION

A brow lift is done in a hospital or an outpatient surgical facility.

ANESTHESIA

We use general anesthetic so that you will sleep and remain comfortable throughout the procedure.

SURGERY

• Endoscopic brow lift.Your surgeon will make several small incisions behind your hairline. He or she will then insert a long thin tube with a light and a tiny camera mounted on its end (endoscope) through one of the incisions to view your underlying muscles and tissues. Using an instrument inserted through another incision, your surgeon will lift your forehead tissues and anchor them in place with sutures, small screws or another technique. Your incisions are then closed with stitches or small clips.
• Coronal brow lift.Your surgeon will make an incision behind your hairline across the top of your head, from ear to ear or primarily on the top of your head. He or she will lift your forehead into its new position, with the scalp in front of the incision overlapping the scalp behind it. The overlapping scalp is then removed and the remaining scalp is sewn together. This technique is not typically done in people who have high hairlines, thin hair or who are likely to lose their hair.
• Hairline brow lift.Your surgeon will make an incision between the top of your forehead and the beginning of your hairline. He or she will remove a small amount of skin and tissue from the top of your forehead, rather than your scalp. As a result, your hairline won’t be pulled back. The technique can yield dramatic improvements in horizontal creases. A hairline brow lift is often used if someone has a high receding hairline. However, depending upon healing, a scar might be visible along the hairline.

RECOVERY

After a brow lift, your forehead might be taped and your head might be loosely wrapped to minimize swelling. A small tube might be placed along the incision site to drain any excess blood or fluid.

In the first few days after a brow lift:

• Rest with your head elevated and take pain medication as recommended by your doctor
• Apply cold compresses to relieve swelling
• Avoid exposing your incisions to excessive pressure or motion

As your incisions heal, you might experience itching and numbness, which will likely diminish over time. Sutures typically will be removed within seven to 10 days of surgery.

Ask your doctor when it’s OK to resume daily activities, such as washing and drying your hair and bathing. Keep in mind that swelling might last several weeks. Incision lines will fade over time. You might use makeup to conceal any prolonged bruising.

RISKS

• Changes in skin sensation.
• Asymmetry in the position of the brows. A brow lift can result in asymmetry, with one or both of the eyebrows appearing too high. However, asymmetry typically evens out during the healing process.
• Hair problems.A brow lift can cause an elevated hairline or hair loss at the incision site.
• Like any other type of major surgery, a brow lift poses a risk of bleeding, infection and an adverse reaction to anesthesia.

INTRODUCTION

Ectropion is a condition that usually occurs as our eyelids age. The term Ectropion refers to the outward turning of the lower eyelid. This leaves the inner eyelid surface exposed and prone to irritation. Ectropion is more common in older adults, and it generally affects only the lower eyelid.

CAUSES

Ectropion can be caused by:

• Muscle weakness – Involutional ectropion.As you age, the muscles under your eyes tend to weaken, and tendons stretch out. These muscles and tendons hold your eyelid taut against your eye. When they weaken, your eyelid can begin to droop.
• Facial paralysis.Certain conditions, such as Bell’s palsy, and certain types of tumors can paralyze facial nerves and muscles. Facial paralysis that affects eyelid muscles can lead to ectropion.
• Scars or previous surgeries.Skin that has been damaged by burns or trauma can affect the way that your eyelid rests against your eye. Previous eyelid surgery (blepharoplasty) can cause ectropion, particularly if a considerable amount of skin was removed from the eyelid at the time of surgery.
• Eyelid growths.Benign or cancerous growths on your eyelid can cause the lid to turn outward.
• Genetic disorders.Rarely, ectropion is present at birth (congenital), when it is usually associated with genetic disorders, such as Down syndrome.
• Trauma to the eye, such as burns, blunt force injuries and paralysis from tumors and other medical conditions.
• Ongoing inflammation in the eye area, including damage caused by wearing certain types of contact lenses.

SYMPTOMS

Normally when you blink, your eyelids distribute tears evenly across your eyes, keeping the surfaces of the eyes lubricated. These tears drain into small openings on the inner part of your eyelids (puncta).

If you have ectropion, your lower lid pulls away from your eye and tears don’t drain properly into the puncta. The resulting signs and symptoms can include:

• Watery eyes (excessive tearing).
• Excessive dryness.
• Sensitivity to light

INDICATIONS FOR SURGERY

• Rapidly increasing redness in your eyes
• Sensitivity to light
• Decreasing vision

CONSULTATION

Your surgeon will discuss your overall health and what may be needed before and after surgery to achieve optimum results and healing. You and your Surgeon can discuss your expectations about what can actually be achieved through corrective eyelid surgery such as a Canthoplasty or other type of Eyelid Surgery. Find out if you’re a good candidate for these procedures and what’s involved.

LOCATION

Your procedure will take place in state-of-the-art surgical suites and recovery areas. Most procedures are outpatient.

ANESTHESIA

We use general anesthetic so that you will sleep and remain comfortable throughout the procedure. Local anesthesia with intravenous sedation is also an option for some patients.

SURGERY

Tarsorrhaphy 
Tarsorrhaphy is a reasonable option to consider when preventing and treating corneal exposure. A principle disadvantage of the procedure is the poor cosmetic appearance and compromised peripheral vision. The advantages of a tarsorrhaphy include its multiple surgical technical variations allowing customization of the procedure to the individual patient (i.e. medial or lateral tarsorrhaphy), a swift and simple surgical technique and relative ease of reversing the procedure.

Canthoplasty

A Canthoplasty refers to any or all of the several procedures that can be used to change the configuration (or position) of the lateral canthus, which means the corner of your eyes where your upper eyelids meet your bottom eye lids.

The procedure involves cutting the insertion of the lateral canthus form the bone (top figure), pulling the canthus towards the corner of the eye in order to tighten and suspend the droopy lower eyelid and fixing it with sutures to the bone (bottom figure). 

Suspension of the lower eyelid with tendon graft

During this procedure a 4-6 cm long tendon graft (which is obtained from the palmaris longus tendon a useless muscle from the wrist area) is placed in the lower eyelid and tightened to the inner canthus (the native tendon of the lower eyelid)(left figure) and to the bone of the eye, in the same way as in the cantoplasty surgery (right figure).

 RECOVERY

This is a relatively short recovery as the surgery is often performed using just a local anesthetic. Full recovery from a Canthoplasty will vary for each patient, but you can expect roughly 2-4 weeks.

RISKS

The possible risks or complications that may arise after the surgery are:

• Excessive bleeding – Hematoma
• Accidental injury to neighboring tissue or cornea
• Infection in the surgical wound
• Wound dehiscence (rupture of wound around the sutures)
• Improper placing of the eyelid
• Assymmetry

RESULTS

The results are usually permanent and vary rarely a corrective surgery may be needed

72 year old patient with paralytic ectropion and excessive tearing of the left eye, underwent canthoplasty. Left before the surgery, right 1 month after the surgery

INTRODUCTION

A face lift, or rhytidectomy, surgically removes wrinkles, sagging skin, or fatty deposits on the face and neck for a more youthful appearance.

INDICATIONS

Activities such as smoking, sunbathing, outdoor activities, and stress can alter the appearance of the face. In addition, as we age, deep creases may form between the nose and mouth, the jawline may grow slack and sag, and folds and fat deposits may appear around the neck. If you are interested in having a firmer, fresher appearance, a face lift may be right for you.

Typically, we perform face lifts on patients who are between 40 to 60 years old. The procedure can produce good results for people from 60 to 80 as well.

If you have strong, well-defined bone structure and some skin elasticity, you are most likely to have good results from a face lift.

If your face exhibits a loss of skin elasticity, wrinkles and folds, you may be a good candidate for a facelift.

A facelift can address conditions such as:

• Deep nasolabial folds
• Excess skin
• Fat deposits or folds around neck
• Sagging face and/or neck

CONSULTATION

During your initial consultation, you should expect to:

• Provide a complete medical history. Include information about any previous surgical procedures; past and present medical conditions; and all medications or herbal supplements you are taking.
• Have your surgeon to conduct a complete physical examination.
• Discuss possible risks and complications.

PREPARING FOR SURGERY

We will give you pre-operative information that explains everything you should do and know before your procedure. Your surgical team will instruct you on how to prepare. You should arrange for someone to drive you home after your surgery. You may also want to make arrangements for someone to help you for a day or two while you heal. Stoping or reducing smoking will help you heal faster. Most patients one week prior to surgery take ARNICA pills to reduce swelling and bruising.

 Location

Your procedure will take place in state-of-the-art surgical suites and recovery areas. Most face lifts are outpatient.

 Anesthesia
In most cases, we use general anesthetic so that you will sleep throughout the procedure.

THE PROCEDURE

During this surgical procedure, the surgeon removes excess face and neck skin and tightens the tissues under the skin.

Usually, our surgeons make an incision in the hair near the temple and continue to the front of the ear, around the ear lobe, behind the ear and into the hair. The surgeon then tightens muscles and sagging tissue, removes excess skin and repositions the remaining skin to create a more youthful look. The surgeon then closes the incision with sutures or with metal clips on the scalp. The surgeon may make a small incision under the chin if a neck lift is needed.

The type and size of face lift you will have will depend on the location and extent of your skin laxity. Plastic surgeries range from “mini” to “standard.”

Types of Facelift

The Deep Plane Lift – SMAS flaps

The deep plane lift is considered the gold standard. It involves lifting, releasing and repositioning the superficial musculoaponeurotic system (SMAS). In short, the SMAS layer is located underneath the skin and surrounds the muscles of facial expression; that is, the muscles used for smiling, frowning, and other facial expressions. The deep plane lift has been shown through peer-reviewed studies to offer longer-lasting results with fewer revisions.

During the deep plane lift, the plastic surgeon separates the skin from the SMAS layer, and then enters the “deep plane” by going underneath the SMAS layer to release attachments. It is the release of these attachments that allows the surgeon to reposition the SMAS layer, and accompanying skin, in a more youthful, natural, and tension-free position. After the SMAS is repositioned, excess and loose skin is removed, and the edges are sutured.

The results of deep plane lifts are dramatic, especially in the mid-face area (the cheeks, nasolabial folds, jawline and chin). The effects last about 10 years.

Deep Plane Lift – Elevating the SMAS flap (tissues under the skin involving muscle, fat, connective tissue and nerves) tightens the whole face

The SMAS MACS Lift and the SMAS plication lift

The SMAS lift affects the superficial top layers of skin and the deeper tissues of the face and neck. These tissues tend to grow lax and sag with use and advancing age.

To perform a SMAS lift, your facial plastic surgeon creates an incision at the temple, above your hairline. From there the incision is extended downward, following your skin’s natural crease in front of or at the edge of the ear, below the ear lobe and behind your ear. The SMAS is then tightened using sutures, any excess or redundant skin is removed and the remaining skin is stitched up.

The SMAS lift works well for individuals with mild laxity, some jowls and mid-face sagging. There are several popular SMAS lift techniques, some more reliable than others. The most commonly used are the classic SMAS plication lift and the most advanced and reliable SMAS MACS lift.

Position of sutures in the MACS lift

 The Midface or Cheek Lift  (Subperiosteal facelift)

These lifts target the middle third of your face. The incisions are placed in the inside of your mouth, the hairline around the temporal area and the inside of the lower eyelid. Your surgeon then lifts and repositions the natural fatty layer over your cheekbones.

Midface lifts improve nose-to-mouth lines and lift sagging cheeks. This area can also be treated with an SMAS or deep plane lift. An isolated mid-facelift can be done through the lower lid along with eyelid surgery (blepharoplasty). This lift provides a subtle freshening-up with minimal risk and downtime.

Incisions for Subperiosteal Midface Lift. Left: Hairline incision, Right: Intraoral (mouth ) incision

Short Scar Lifts

The short scar facelift is an umbrella term for several facelifts that involve abbreviated scars. One such lift involves an S-shaped incision at the temple or in front of the ear.

Unlike with other types of facelifts, the short scar lift incision does not extend behind the ear. Your surgeon can still re-suspend the tissues that support your smile lines and jowls and tighten a moderate amount of your loose skin.

Another example of a short scar lift is the minimal access cranial suspension lift (MACS). With this technique, your incision stops right at your ear lobe.

Short scar lifts, whether the S-shaped or the MACS, may be options for people in their 40s and 50s with minimal to moderate excess skin. This procedure is also ideal if a shorter scar is a priority, or if you have no visible signs of aging on your neck.

Endoscopic Facelift _- Midface lift

During endoscopic facelift procedures, your surgeon uses a pencil-shaped probe with a tiny camera attached to it (an endoscope) to transmit video images of your internal facial structures to a TV screen in the operating room. The endoscope is inserted via three or more small incisions that are often less than one inch long and can be easily hidden.

Endoscopic facelifts are usually done on an outpatient basis using local or intravenous anesthesia. The smaller incisions may result in a lower risk of nerve damage. The tradeoff is that this type of lift is effective only for cheek sagging. These types of facelifts are falling out of favor because the results do not compare to those seen with other facelifts.

With aging the midface soft tissues (skin, fat, muscle) are drooping downwards and inwards (left). With a midface lift the goal is to lift the sagging midface upwards and outwards in order to achieve a youthful look (right)

A face lift may be performed alone or in conjunction with a forehead lift and/or eye lift (blepharoplasty) or nose surgery (rhinoplasty).

To improve the texture of your facial skin, we may recommend laser resurfacing or chemical peeling. View our other plastic surgeries.

RECOVERY
It’s very important that you follow your surgeon’s instructions. This will promote healing and improve progress towards your new physical appearance.

Recovery from face lift surgery is expected to last between two and three weeks.

• Keep your head elevated at this time and get plenty of rest.
• Activity should be limited.
• You can shower the very next day of the procedure.
• Do not lift heavy weights for two weeks.
• Ideally do not sleep on the side for a week.
• Sutures are removed in a week during your first follow-up appointment.
• Numbness, bruising are common postoperative symptoms, as is swelling.
• Be sure to wear the loose bandage wrapping per our surgeon’s instructions in order to minimize these symptoms.
• Your scars are hidden within the hairline and natural facial contours, and will fade gradually as you heal.
• Avoid taking Aspiring or homeopathic medications as they can produce hematomas (bleeding).

Arnica crème or oil can be applied to help the bruising and swelling will disappear faster.

RISKS

Facelift risks include:

• Anesthesia risks
• Bleeding
• Infection
• Poor wound healing and skin loss
• Facial nerve injury with weakness
• Temporary or permanent hair loss at the incisions
• Fluid accumulation
• Numbness or other changes in skin sensation
• Persistent pain
• Unfavorable scarring
• Prolonged swelling
• Skin irregularities and discoloration
• Sutures may spontaneously surface through the skin, become visible or produce irritation that require removal
• Unsatisfactory results may include: asymmetry, unsatisfactory surgical scar location and unacceptable visible deformities at the ends of the incisions. (It may be necessary to perform an additional surgery to improve your results)
• Deep vein thrombosis, cardiac and pulmonary complications

RESULTS

Usually a facelift will last about 8-10 years and eventually the effects of the facelift will fade away, as if you had no surgery.

Regardless of the specific procedure you undergo, there are some simple universal facelift recovery tips you can follow to ensure the results of your procedure last as long as possible.

1. Protect Your Skin From the Sun

Unfortunately, you can’t do anything about sun damage that occurred prior to your cosmetic surgery. You can, however, prevent further damage and prolong the positive results of that surgery. Use sunscreen every day. Depending on your needs, you might even get clinical grade sunscreen from your doctor. Otherwise, look for something that is at least SPF 30 and contains zinc oxide.

2. Eat Healthy

A healthy diet, complete with greens, bright fruits and vegetables, complex carbs, and meat can actually help your skin look younger by keeping it nourished and improving its elasticity.

• Vitamin C in particular has rejuvenating qualities, encouraging collagen production which in turn improves skin strength and structure. In doing so, it reduces wrinkles and makes your skin feel smoother. Try to get your Vitamin C from oranges, red peppers, kale, and other direct, natural sources.
• Vitamin E is another major player when it comes to skin health. It works to smooth over scars and rough skin, helping skin heal more effectively. Eat nuts and spinach to up your Vitamin E intake.
• Vitamin A helps skin heal itself and stay smooth and moist. You can find vitamin A in everything from sweet potatoes and squash to fish and fresh fruits.
• Finally, all of the B vitamins, known collectively as Vitamin B Complex, aid the production of new skin cells. Turn to brightly colored fruits and vegetables for these nutrients.

Of course, eating right is only part of the battle. For a truly skin friendly diet, you need to make sure you drink enough water. Well hydrated skin is stronger, smoother, and younger.

3. Don’t Smoke

Nicotine dries your skin out, making it age more rapidly. Nicotine also interferes with the healing process, making smoking particularly harmful just after surgery.

In fact, many facial plastic surgeons ask that if you are intent on continuing the habit, you stop during your recovery time in order to ensure proper healing. They note that nicotine could not only delay the healing process but also cause tissue death.

However, if you’re fully healed and thinking of picking your smoking habit back up, remember that nicotine reduces Vitamin A and carbon monoxide affects Vitamin C levels, negating all that healthy eating and shortening the lifespan of your youthful new look.

4. Medical Grade Skin Care

Ordinary skin care products work on the epidermis, or outer layer, of the skin. Medical grade skin care products work on the middle layer, where collagen and elastin are located, and the deepest layer, where new skin cell growth occurs. While this definitely makes them more effective, it also means that they are heavy duty. Deeper facial tissues are more sensitive, and overuse of these products can result in negative reactions that could actually damage the skin.

5. Non-Surgical Boosters

Liquid and laser facelifts in particular can help increase moisture and skin elasticity, keeping you looking younger for longer.

57 year old lady, underwent full facelift and neck liposuction. Top row: before, Bottom row: 4 months after

INTRODUCTION

Facial implants are sculpted pieces of silicone or other substances that are placed in the chin, cheeks or jaw to enhance the contours of the face

INDICATIONS

Facial implants may be used to help strengthen a jaw line or to balance the chin or cheekbones with the rest of the face.

Implants may help fill out a face that appears “sunken” or tired. For example, jaw implants can help strengthen the jaw line, improving the proportions of the face. Chin implants can add proportion or balance to a face. An implant placed over the cheekbones may help restore a more youthful appearance in some patients.

IDEAL CANDIDATES

Plastic surgeons will frequently use facial implants to balance the features of a younger patient, or in conjunction with another cosmetic procedure in a more mature patient.

In general, the best facial implant candidates have naturally weak facial bones around the eyes, cheeks, midface, or chin and jawline. The use of synthetic injectable fillers can be used as a trial method to see if a more permanent implant option is right for you.

CONSULTATION

During your initial consultation, you should expect to:

• Provide a complete medical history. Include information about: any previous surgical procedures; past and present medical conditions; and all medications or herbal supplements you are taking.
• Have your surgeon to conduct a complete examination of your face, including the skin and underlying bone.
• Discuss possible risks and complications.

PREPARATION FOR SURGERY

Your surgical team will instruct you on how to prepare for surgery. You should arrange for someone to drive you home after your surgery, whether your surgery is outpatient or inpatient. You also may want to make arrangements for someone to help you for a day or two while you heal.

LOCATION

Your procedure will take place in the hospital in state of the art surgical suites. Most facial implants are outpatient procedures.

ANESTHESIA

We use general anesthetic so that you will sleep and remain comfortable throughout the procedure. Local anesthesia with intravenous sedation is also an option for some patients.

THE PROCEDURE

 Most facial implant cases are done on an outpatient basis, but more extensive facial augmentation procedures may require an overnight stay.

There are several implants available. Implants may be manufactured from a variety of materials, including silicone or other substances. There is no evidence to suspect that silicone implants cause any disease. Your surgeon will consult with you and discuss recommendations for the type of implant to use.

LEGEND: Different types of facial implants

The most common facial implants are chin, jaw, cheek, nose, orbital (around the eye) and temporal (sides of the skull) implants. Sometimes more than one type of implant is needed. Your doctor can help make this determination during your consultation.

• Cheek Implants

Cheek implants are available in many different styles to augment the cheekbone (malar) and/or the area on its underside (submalar). Different effects can be created using the various implant styles. Cheek implants are placed via small incisions made high under the upper lip. In some cases, they may even be placed through eyelid incisions if eyelid surgery is being done simultaneously. They can be placed on the front part of the cheekbone or further back along the tail depending on implant style and the desired effect. The procedure takes approximately 60 minutes to perform on its own.

• Chin Implants

Chin implants come in many different styles that provide horizontal, vertical and square width that extends back along the jawline. A chin implant can be placed through an incision under your chin or inside your lower lip depending on size and preference. The chin implant is inserted and secured to the bone by sutures or small screws. The procedure takes roughly 30 to 45 minutes if performed on its own.

• Jaw Implants

Jaw-angle implants augment the back part of the jaw. They are available in different styles including a widening jaw-angle implant and a vertically lengthening jaw-angle implant to help create a stronger and more defined jaw. They are placed inside the mouth via incisions made behind the molars and under the large jaw muscle.

Jaw implants usually need to be secured in place with small screws to prevent displacement.

The procedure takes 60 to 90 minutes to perform. During a jaw implant procedure, the surgeon makes incisions for the implant on either side of the lower lip.

• Nose Implants

Nasal implants can help elevate the bridge or dorsal line, and/or improve tip projection. They can be done alone, but more often are done as part of an overall nose reshaping surgery. They are usually placed via an incision crafted inside the mouth below the upper lip. It can also be placed with an incision inside the nose during rhinoplasty.

 RECOVERY

Recovery from facial implant surgery is primarily related to how much swelling occurs and how long it lasts. Fifty percent of the swelling is typically gone within 10 days of surgery.

• You will experience some tenderness. Post-operative discomfort can be controlled with prescribed medications.

• Chewing will probably be limited immediately after chin surgery, and a liquid and soft food diet may be required for a few days after surgery. Most patients feel a stretched, tight sensation after the surgery, but this usually subsides in a week.
• After approximately six weeks, most swelling will be gone, and you can enjoy the results of your procedure. Rigorous activity may be prohibited for the first few weeks after surgery. Normal activity can be resumed after approximately ten days.

RISKS

The risks of surgery include

• Pain for which you will be given painkillers afterwards
• Bleeding
• Swelling
• Antibiotics are prescribed to minimize that risk. In rare cases that the implant gets infected then it may have to be removed
• Numbness to the lower lip and chin and sometimes the front teeth because the nerve that supplies those areas can be stretched during the surgery. Usually it recovers completely but there’s a small chance of permanent altered sensation.
• Slight asymmetry which may have to be corrected with second surgery
• Malposition of the implant

RESULTS

The results of any facial implant plastic surgery aren’t fully visible until two to three months after surgery when most of the swelling has subsided.

The results of facial implants are permanent

INTRODUCTION

The terms Fat Transfer, Fat Injections, Autologous Fat Transfer, and Fat Grafting all refer to the process of taking fat from an unwanted area of your body and re-injecting purified adipose fat tissues into another area of your body.

INDICATIONS

Fat transferred from other areas of your body to your face will not only give some lifting to the general facial structure, but also improve the look of your skin. Patients seeking a fat transfer for facial rejuvenation often present these symptoms:

• fine lines and wrinkles
• crows feet
• under eye bags or dark circles
• worry and/or frown lines
• ‘sunken’ cheeks
• tired look

ADVANTAGES OF FAT TRANSFER

• Autologous fat (from your own body), as opposed to dermal fillers, replaces “like with like,” reducing the chance of allergic reactions to foreign substances.
• Fat transfer results are natural, long lasting and safe.
• Fat transfer is a noninvasive method for achieving facial rejuvenation.
• In addition to filling out wrinkles in the face, highly purified fat injections also enhance the blood circulation in the tissues. This is because there is a population ofadipose stem cells in the fat cells that are re-injected. Even with only minimal manipulation, such as centrifugation, a small plug of Adipose Stem Cells (ASC’s) are collected in high density fat grafting. Thus, a small number of regenerative type cells are reinjected into your face with high density fat processing techniques!

DISADVANTAGES OF FAT TRANSFER

• It is time consuming to prepare fat tissue before transferring it, compared to dermal fillers, which are prepackaged.
• Though longer lasting than dermal fillers, fat transfer costs more.
• For augmentation, you may require multiple sessions to achieve your desired breast or buttock size.

CONSULTATION

During your consultation, we’ll discuss the liposuction areas as well as fat injection areas to determine the best surgical plan to achieve your goals. Be sure to listen to all of the pre-op instructions and get answers to any concerns you may have. Pre-op instructions will depend heavily on whether you elect to have the procedure under local or IV anesthesia.

PREPARATION FOR THE SURGERY

• Your surgeon may take pre-procedure photos.
• Regardless of the type of surgery to be performed, hydration is very important before and after surgery for safe recovery and the best outcomes.

In advance of your procedure, your surgeon will ask you to:

• Stop smoking at least six weeks before the procedure to avoid poor wound healing and scarring.
• Avoid taking aspirin, nonsteroidal anti-inflammatory medications (NSAIDs: Advil, Motrin, Aleve) and vitamins/homeopathic regimens that can increase bleeding.
• Regardless of the type of procedure to be performed, hydration is very important before and after for safe recovery.
• Arrange for someone to drive you home after surgery and stay with you for at least the first twenty-four hours unless you and your surgeon have decided on other postoperative recovery options.

LOCATION

Your procedure will take place in the hospital in state of the art surgical suites. Most facial fat transfers are outpatient procedures.

ANESTHESIA

Fat injections can be done under local or IV sedation anesthesia.

THE PROCEDURE

The 3 components of Fat Transfer are:

1. Harvesting of fat withliposuction
2. Processing and centrifugation of fat
3. Re-injection of fat

Harvesting with liposuction: You and your surgeon will select a site for fat removal and will inject it with a local anesthetic. Your surgeon will then create a small incision in the area for fat removal and, using a sterile technique, insert a cannula connected to a syringe to carefully extract fat (liposuction). Using thin cannulas, fat is harvested safely usually from the hip, inner or outer thigh, lower back, or lower abdomen. These areas are called the ‘donor sites‘.

Processing – Purification and Centrifugation: Once enough fat is obtained from the donor area, your surgeon will process it to prepare the fat cells for transfer to small syringes that will be used for fat injection. Purification may require the use of a centrifuge to spin the fat or a filtration process to remove impurities.

Re-injection and Placement: The area designated to receive the graft will then be prepared. Your surgeon will insert a needle or cannula into the incision point of the site being augmented. The injection needle is usually passed in and out of the areas to be augmented multiple times. This process is repeated until the desired correction has been achieved, creating a grid of grafted fat.

RECOVERY

You will likely have some discomfort as well as some swelling during the immediate post op period. For a fat graft to be as successful as possible you’ll need to avoid stressing the fat injection area(s) for three weeks. It takes up to 4 days for the blood vessels to grow ito the fat grafts and another 2 or 3 days for the blood vessels to strengthen. It takes 2 to 3 weeks for the extracellular matrix surrounding the fat graft to reach enough strength to withstand minor stresses.

Post op instructions for facial fat grafting include the following:

• wear surgical tape on facial areas for 5 days
• sleep on back with head elevated for the first week
• no rubbing of the face for 2 weeks (only soft washing)
• post op office visit at day 5
• return to work after 1 week
• exercise as tolerated after 2 weeks
• follow up office visits at month 1 , month 4

RISKS

• swelling
• irregular contours or uneven results from liposuction
• hematoma
• seroma
• skin necrosis
• fat necrosis
• less than expected results
• asymmetry

RESULTS

Some patients think that fat injections “do not last.” However, this is not the case. When a fat transfer is performed properly, a large percentage of the injected fat cells do indeed survive and are permanent. However, since some fat cells are lost in the immediate post op period, we tend to ‘over-correct,’ or inject more than we need to. After the majority of the swelling is gone, approximately two weeks later, you will have a very good idea of what the final result will be.

INTRODUCTION

A well defined chin helps give balance to the face and creates a major part of one’s profile. Mentoplasty, or chin augmentation, is used to enhance the profile and/or facial contours and balance.

INDICATIONS – IDEAL CANDIDATES

The goal of chin surgery is to bring balance to the face as described above. Chin surgery/genioplasty corrects receding chins, chin misalignment or chin excess.

A chin that seems too small in proportion to other facial features can make the nose appear overly long. Plastic surgeons frequently use chin implants to balance the features of a younger patient or may use genioplasty in conjunction with another cosmetic procedure in a more mature patient.

A sliding Genioplasty is reserved for more complex chin deformities, such as those caused by genetics, trauma, or disease. This procedure can resolve problems related with chin deformities, such as airway obstruction. Since this is a sliding surgery, no bone grafting procedure is required.

CONSULTATION

Important factors to discuss with your surgeon include:

• Skin type
• Ethnic background
• Individual healing rate
• Age

Your surgeon can also provide information on new medical techniques for chin surgery and offer recommendations for supplementary surgery that can ensure the greatest improvement.

During the preliminary consultation the Plastic Surgeon will:

• Take a thorough medical history, as well as assess the patient’s mental and emotional attitudes toward the surgery. Because a realistic attitude is crucial to the success of the surgery, the surgical procedure and realistic expectations will be discussed.
• Take photographs so he can study your facial features and chin.
• Discuss individual risks, especially those related to medical situations such as high blood pressure, a tendency to scar, smoking, and any deficiency in blood clotting.
• A Panoramic X-ray or a CT scan of the facial bones may be necessary to determine the proper procedure for you.

PREPARATION FOR THE SURGERY

Your surgical team will instruct you on how to prepare. You should arrange for someone to drive you home after your surgery. You may also want to make arrangements for someone to help you for a day or two while you heal. In advance of your procedure, your surgeon will ask you to:

• Stop smoking at least six weeks before undergoing surgery to promote better healing
• Avoid taking aspirin, certain anti-inflammatory drugs, and some herbal medications that can cause increased bleeding
• Regardless of the type of surgery to be performed, hydration is very important before and after surgery for safe recovery.

LOCATION

A Genioplasty is done in a hospital or an outpatient surgical facility.

ANESTHESIA

In most cases, we use general anesthetic so that you will sleep throughout the procedure. Local anesthesia with intravenous sedation is also an option for some patients.

THE PROCEDURE

1. AUGMENTATION GENIOPLASTY WITH IMPLANTS

• To augment the chin, the surgeon begins by making an incision either in the natural crease line just under the chin or inside the mouth, where gum and lower lip meet.
• By gently stretching this tissue, the surgeon creates a space where an implant can be inserted. This implant, made of synthetic material that feels much like natural tissue normally found in the chin, is available in a wide variety of sizes and shapes. This allows custom fitting of the implant to the configurations of the patient’s face.

Many types of implants are available, manufactured from a variety of materials, including silicone or other substances. There is no available evidence to suspect that silicone implants cause any disease. Your surgeon will consult with you and discuss recommendations for the type of implant to use.

• After implantation, the surgeon uses fine sutures to close the incision. When the incision is inside the mouth, no scarring is visible. If the incision is under the chin, the scar is usually imperceptible.

1. AUGMENTATION GENIOPLASTY WITH SLIDING OSTEOTOMY

• A sliding genioplasty is the most well known of all the facial osteotomies and also the most commonly performed. It is done for various chin augmentation and reshaping purposes.
• The incisions are usually made in the inside of the mouth

• The advantage of a sliding genioplasty is that it is very versatile in terms of dimensional changes of the chin. The bone cuts can be devised to bring the chin forward, make it vertically longer, widen or narrow it or almost any combination thereof.

• With the use of today’s plate and screw designs, the genioplasty no longer just as to ‘slide’ forward to make for a stable dimensional change to the chin.

 

1. CHIN REDUCTION SURGERY

• In chin reduction surgery, incisions are made either in the mouth or under the chin. The surgeon sculpts the bone to a more pleasing size.
• For this surgery, the surgeon will make an incision inside the mouth and reposition the facial bones. The procedure, depending on the extent of the work, takes from less than an hour to approximately three hours.
• He may use plates and screws to achieve that.

 

1. OTHER PROCEDURES TO ENGANCE THE RESULT

 

Submental liposuction in which excess fatty tissue is removed to redefine the chin or neckline

Performing a facelift and neck lift, with tightening of the muscles of the neck.

When there is a contributing problem of dental malocclusion, or birth defects in the structure of the jaw itself, surgery of the jaw can improve the form and function of the lower face and greatly enhance appearance.

The plastic surgeon may also recommend chin augmentation in conjunction with rhinoplasty, as when the nose is changed the entire balance of the face changes as well. 

RECOVERY

• Immediately after surgery, the surgeon usually applies a dressing that will remain in place for two to three days. You will experience some tenderness. Post-operative discomfort can be controlled with prescribed medications.
• Chewing will probably be limited immediately after chin surgery, and a liquid and soft food diet may be required for a few days after surgery. Most patients feel a stretched, tight sensation after the surgery, but this usually subsides in a week.
• After approximately six weeks, most swelling will be gone, and you can enjoy the results of your procedure. Rigorous activity may be prohibited for the first few weeks after surgery. Normal activity can be resumed after approximately ten days.

RISKS

• Pain for which you will be given painkillers afterwards
• Bleeding
• Swelling
• Antibiotics are prescribed to minimize that risk. In rare cases that the implant gets infected then it may have to be removed
• Numbness to the lower lip and chin and sometimes the front teeth because the nerve that supplies those areas can be stretched during the surgery. Usually it recovers completely but there’s a small chance of permanent altered sensation.

RESULTS

The results of a genioplasty are permanent.

43 year old lady with small chin. Correction with silicone implant  

45 year old male with small chin. Correction with horizontal sliding osteotomy

INTRODUCTION

A neck lift, also known as a submental lipectomy, is a surgical procedure that removes localized fat deposits under the chin, corrects muscle laxity, tightens sagging skin or enhances a receding chin.

INDICATIONS – IDEAL CANDIDATES

The goal of a neck lift is to tighten the excess skin from the neck to diminish wrinkling and sagging. Some fat may be removed and underlying muscles and connective tissue are tightened. This area is routinely addressed with a facelift.

A neck lift cannot stop aging, nor can it turn back the clock. What it can do is help your face look its best and give you a healthy look and a more youthful appearance. A side benefit is that many patients experience increased self-confidence.

CONSULTATION

Important factors to be discussed with your surgeon include:

• Skin type
• Your bone structure – the jaw as well as the structures below the jaw, in the neck
• Your medical history
• Ethnic background
• Degree of skin elasticity
• Individual healing rate
• In order to undergo a neck lift, you must be in a good general health, both physically and mentally.
• Be frank with your surgeon about what you want to be altered in your neck. Make sure you get the results you want.
• During your consultation, your surgeon will instruct you on what medications to avoid prior to your surgery.
• If you are a smoker, you must quit at least two weeks before the surgery and two weeks after, to ensure proper healing.
• Make sure you wear loose, comfortable clothing on the day of the surgery.

PREPARATION FOR THE SURGERY

Your surgeon will provide thorough preoperative instructions, answer any questions you may have, take a detailed medical history, and perform a physical exam to determine your fitness for surgery.

In advance of your procedure, your surgeon will ask you to:

• Stop smoking at least six weeks before undergoing surgery to promote better healing
• Avoid taking aspirin, certain anti-inflammatory drugs, and some herbal medications that can cause increased bleeding
• Regardless of the type of surgery to be performed, hydration is very important before and after surgery for safe recovery.

LOCATION

A neck lift is done in a hospital or an outpatient surgical facility.

ANESTHESIA

We use general anesthetic so that you will sleep and remain comfortable throughout the procedure.

THE PROCEDURE

The surgery takes two or three hours. The time will vary according to what kind of surgery you will be going through.

The exact procedure will depend on your surgeon’s assessment of your anatomy and your desired results. In general, your surgeon will make a small incision underneath the chin. Your surgeon will suction or directly excise the fat in this region, will tighten muscles and may remove a small amount of skin.

The most common problems are:

• Turkey wattle-weakened or loose neck muscles

If you have weakened or loose muscle, this may cause the turkey wattle or appearance of neck “bands”.

Your surgeon may recommend Platysmaplasty surgery to correct this. The surgeon makes incisions under your chin and/or before your ears to access the platysma and manipulate it accordingly. The surgeon may also use permanent sutures to hold the tissue in place.

The surgeon may also decide to use a less invasive procedure by making a smaller incision and use an endoscope (small camera attached to a think tube) to do the surgery. You can ask your surgeon to use either local or general anesthesia depending how you feel.

LEGEND: Incision and tightening of the platysma (medial platysmaplasty)

• Excess fat:

During liposuction the surgeon will make a small incision below the chin and remove the excess fat. This procedure will take an hour. Your incisions will be stitched and bandaged.

LEGEND: Liposuction of the neck

• Too much skin:

Surgeon will make sure similar incisions for a Cervicoplasty, trimming parts of the skin and lifting it into place.

It will be secured with tissue glue or stitches. The Cervicoplasty can be completed in about two or four hours, depending on the complexity of your procedure. Again your anesthesia will depend on your own comfort level.

The bandage will have to be worn for a week. Unless instructed otherwise.

OPTIONS TO ENHANCE THE RESULT

We often perform this procedure in conjunction with a standard face lift or a rhinoplasty in order to achieve balanced facial proportions. We may also perform a Chin Surgery (Genioplasty) to alter the basic shape and balance of the face. A submental lipectomy can reshape the jaw line and may be especially useful for enhancing the profile of a patient with a receding chin.

RECOVERY

• Even though most patients experience very little pain after surgery, the surgeon will still prescribe medication.
• Some degree of swelling and bruising is unavoidable, and your surgeon may instruct you to use cold compresses to keep swelling to a minimum.
• If a dressing has been applied, it will be removed within one to two days.
• The surgeon will also instruct you to keep your head elevated when lying down, to avoid as much activity as possible, and to report any undue discomfort.
• In some cases, a drainage tube may have been inserted during surgery. This will be removed on the first or second day after surgery.
• All sutures and staples are usually removed within five to 10 days following surgery.
• Recovery takes time. Most people return to their normal routine after 10-14 days. You need to wait for at least three weeks before you become physically active.
• Your surgeon will discuss how long it will be before you can return to your normal level of activity and work.

RISKS

• In the first few weeks after the surgery you will have swelling and bruising that can last for several days.
• You may feel tightness or tingling and different sensations including burning or pulling.
• You may also experience numbness
• There is a risk of infection
• Hematoma (blood collection
• Thick scarring
• Skin loss
• Open wounds
• If you are running temperature then contact your doctor.

RESULTS

Under normal circumstances, the results of your neck lift surgery will be long-lasting. An average neck lift lasts for about 8 to 10 years.

58 year old lady with skin and plastysma muscle laxity, underwent neck lift with medial and lateral platysmaplasty. Left: before, Right: after 3 months

64 year old lady with skin and muscle laxity and a fatty neck, underwent neck lift with liposuction, medial and lateral platysmaplasty. Left: before, Right: after 3 months

INTRODUCTION

Rhinoplasty is a surgical procedure that is performed to improve the aesthetic appearance of the nose. The goal is to generate a cosmetic result that is in harmony with the remainder of the face.

IDEAL AGE

Studies suggest a minimal age of 17 years  is preferred to perform rhinoplasty as the bony structures of the face near completion at this age and the shape of the bony skeleton of the face will not change much after this age.

INDICATIONS

You may be an appropriate candidate for a rhinoplasty for one of the following reasons:

• you have been thinking for a while about improving the appearance of your nose
• trauma or infection has changed the shape of your nose more than 12 months ago
• a congenital defect like cleft lip was corrected at a young age, you are now at least  17 years of age and you would like the nasal deformity corrected.
• the effects of aging have changed the shape of your nose; you may feel the tip of your nose is hanging and droopy.
• breathing through your nose is obstructed and medical treatment (nasal sprays) do not provide lasting alleviation
• you can improve the obstruction of your nasal airway by pushing the nasal tip up or by pulling the cheek tissues to the side

CONSULTATION

Your surgeon will take a detailed history. This includes your complaints related to nasal breathing and your wishes regarding the external shape of the nose. You will also be asked about your past medical history, medications, allergies, smoking habits, previous surgery and more.

Your surgeon will then perform a clinical examination. This may include inspection of the inside of the nose with an endoscope, often before and after application of a nasal decongesting spray. This tells your surgeon about the condition of the midline partition of the nose (the nasal septum) and about the mucosa on the side of the nasal air passage (the turbinates). Your surgeon may also gently spread the nostrils apart with an instrument to observe if the inside of the nostril (the so-called nasal valve) causes obstruction.

Photographs of the nose will be taken prior to surgery in different planes and you may discuss your wishes and expectations with the surgeon with the help of these photographs.

Some surgeons utilize computer simulation in order to show you better how the nose may look like after surgery. Of course, simulated images can never perfectly predict the final result, but some surgeons and patients feel it is a helpful instrument for the pre-surgical discussion.            

Your surgeon will also talk to you about the risks, benefits and possible complications of rhinoplasty procedures. The discussion includes the type of anesthesia you will undergo. General anesthesia is more frequently performed; local anesthesia with sedation may also be utilized.

If you have previously undergone rhinoplasty or your surgeon feels that the cartilage obtainable from your nose will not be sufficient for shaping and reconstructing your nose, your surgeon may need to harvest cartilage either from your ear or your rib cartilage. The operation may be performed as an outpatient procedure or you may be admitted to the hospital for observation and dressing changes.

 PREPARATION FOR SURGERY

Your surgical team will instruct you on how to prepare. You should arrange for someone to drive you home after your surgery. You may also want to make arrangements for someone to help you for a day or two while you heal.

 LOCATION

Your procedure will take place in state-of-the-art surgical suites and recovery areas.

 ANESTHESIA

In most cases, we use general anesthetic so that you will sleep throughout the procedure.

THE PROCEDURE

There are two major techniques in rhinoplasty surgery:

• The closed rhinoplasty technique:

No incision is placed on the skin and the structures of the nose are approached through incisions on the inside of the nostrils. When the corrections of the cartilaginous and bony structures of the nose are completed, the incisions are closed with sutures.

• The open rhinoplasty technique:

A small incision is placed across the columella. The columella  is the strip of skin between your nostrils. This incision is combined with incisions on the inside of the nostrils. The skin of the nasal tip is then carefully lifted up and the cartilages and bones of the nose are surgically corrected. At the end of the procedure the skin is redraped and the incisions are closed with fine sutures. The small scar on the skin between the nostrils typically heals well and is barely perceptible in most cases.

• Preserving architectural integrity – cartilage grafts

In the patient lacking natural architectural integrity of the nose, we add it by borrowing cartilage from the septum, a rib, or possibly from the ear.

A spreader graft is often performed to maintain the dorsal lines of the nose. It maintains support for breathing in the midvault, gives an aesthetically pleasing contour line, and prevents a pinched look in the middle portion of the nose.

We’ll add strut grafts to the columella to maintain support of the tip and to give and maintain tip projection. Plus, we use various small cartilage grafts within the tip of the nose to give contour.

• Making the tip of the nose look smaller

Traditionally, making the tip smaller involved removing a portion of the tip cartilage. Today, a large number of tips are made smaller by removing very little of the tip cartilage — sometimes none. Instead, you resculpt, reshape, and reposition the tip cartilage.

• Reducing the hump

 In most cases the so called “hump” of the nose is made of cartilage and in a few cases from bone. This hump need to be removed in order to make a straight nose with a nice slope

• Skin is not removed

The skin of the nose contracts to conform to the bone and cartilage underneath. Removing skin has no place in routine cosmetic rhinoplasty.

• Breaking the bones of the nose

It’s necessary in probably 90% of rhinoplasties. When you lower the profile, you usually need to reduce the width of the base of the nose. Oteotomies can lead to bruising, but are much less traumatic than they were years ago.

• Breathing better after a rhinoplasty – Septoplasty

Repair of a deviated septum is common. If patients present with compromised valves, spreader grafts are used to maintain the internal valves of the nose. Sometimes internal valves could become compromised as part of the reduction rhinoplasty, but spreader grafts keep them open.

If the major cause of the breathing problems and snoring is a deviated (crooked) septum, then the central part of the cartilaginous septum (almost 90%) needs to be removed, leaving an L-shaped septum (diaphragm) behind to maintain support of the nose

RECOVERY

You can typically get up and walk around the evening of the surgery. You will have a splint on your nose. Many surgeons also place packing in the nostrils to avoid bleeding for one or two nights. When no packing is used, you may have some bleeding from the nostrils. This typically subsides on its own or with nasal sprays.

During the first week after surgery breathing through the nose may be difficult or impossible.  You should be prepared for moderate swelling and some bruising of the skin. The degree of swelling differs from patient to patient. A cold mask may be placed over your eyes and above the splint to decrease swelling and bruising. Generally speaking most of the swelling and bruising will subside in 7-14 days although some swelling can persist for up to 2 months. You should expect to see the final appearance of your nose at the end of 6 to nine months.

If you have undergone an open rhinoplasty, sutures have been placed the skin between your nostrils. If these are permanent sutures, they will be removed 5-10 days after surgery. If absorbable sutures are used, they do not have to be removed. The incisions inside of the nose are closed with  absorbable material and do not need to be removed.

After the cast on your nose has been removed some surgeons permit the use of glasses immediately whereas some may ask you to refrain from using glasses for a period between 2-6 months.

You should refrain from exercise prior to removal of the cast and splints. After these have been removed, your surgeon will give you specific instructions when you may resume sports and at which intensity. Contact sports are typically avoided for at least one year.

After surgery pain is mild to moderate for 1 to 3 days  and is usually well managed with pain pills. Severe pain is not expected and if you are experiencing this then you should visit your doctor as soon as possible.

RISKS

The most frequent untoward effect of nose surgery is an unsatisfactory cosmetic (appearance) or functional (breathing) result. A secondary or touch up surgery may be required to obtain the intended result. Secondary procedures may be minor, some may be performed under local anaesthesia and / or as an outpatient procedure. The need for a secondary procedure does not signify poor quality of the initial surgery.

Other complications occur infrequently. These include:

• Bleeding
• Infection
• Hypertrophic scars
• Discoloration
• Numbness of the nose
• Revision surgery

RESULTS

The results of a rhinoplasty last forever. Very rare a patient undergoes a rhinoplasty for a second time. Rhinoplasty in general is a high satisfaction rate cosmetic operation.

CASE 1

   

29 year old female, underwent external rhinoplasty, in order to reduce the hump of the nose to create a smooth slope, reduce the size of the tip of the nose (which was boxy) and rotate the tip of the nose upwards. Top row: before, Bottom row: 3 months after.

CASE 2

26 year old female underwent external rhinoplasty to reduce the hump of the nose. Left: before, Right: 3 months after.

CASE 3

28 year old female underwent external rhinoplasty to reduce the severe hump of the nose, to reduce the bulbous nose tip and also the width of the upper part of the nose by breaking the bones (osteotomies). Top row: before, Top right photo: immediate after the operation, Bottom row: 3 months after.

CASE 4

19 year old male underwent external Rhinoplasty, to reduce the hump of the nose, to reduce the bulbous boxy nose tip with cartilage remodeling, to reduce the width of the upper part of the nose by breaking the bones (osteotomies) and to improve breathing by Septoplasty (removing the crooked septum) and by using spreader grafts. Top row: before, Middle photo: immediate after the operation, Bottom row: 3 months after

 CASE 5

16 year old female underwent external Rhinoplasty to correct severe deformity of the nose caused by a congenital deformity – CLEFT LIP. The cleft surgery was performed at 6 months of age. The surgery include osteotomies (nasal bones breaking), hump reduction, cartilage rearrangement and use of cartilage grafts. Left photo just before the surgery and Right photo just after completion of the surgery.