Posted on November 16, 2009 in Facial Plastic Surgery
We have been quite busy around the office lately, consulting with many of you about a wide variety of facial plastic/cosmetic surgery procedures. As my staff has likely already explained to many of you, we are embarking on a very busy time of year when it comes to facial plastic surgery. Traditionally, this time of year is very popular for plastic surgery since many patients take advantage of holiday vacation time to assist in their recovery. For this reason, I personally take very limited time off between now and the first of the year. So please be patient with us if we cannot immediately honor your scheduling requests – my staff have been instructed to make every effort to accommodate everyone’s needs. On behalf of the staff at San Diego Face and Neck Specialties, I would like to wish you a great upcoming holiday season. We look forward to being part of a bigger and better new year’s celebration with you!
Posted on in Facial Plastic Surgery, Revision Rhinoplasty, Rhinoplasty
All patients undergoing rhinoplasty or revision rhinoplasty by my office are counseled on how to minimize chances of bruising following surgery. The onset and severity of bruising after cosmetic rhinoplasty is dependent on multiple factors, which can usually be accounted for by careful planning. All patients are instructed to review our list of restricted of medications that is handed out to you and is always on our website for reference. I prefer my patients avoid these potential blood thinners at least 10-14 days prior to their rhinoplasty procedure. I also highly recommend that my patients begin taking Arnica Montana starting two days before and continuing for one week after surgery (see photo below of the exact kit we carry in our office). Arnica is an herbal supplement that can significantly reduce chances of bruising from many plastic surgery procedures. Although scientific evidence of this effect is scant, I can tell you anecdotally that Arnica unequivocally aids in healing from nearly all plastic surgery procedures, including rhinoplasty and revision rhinoplasty. Patients who undergo osteotomies (breaking the bone) as part of their rhinoplasty procedure tend to have more bruising than those undergoing only cartilage and soft tissue reshaping of the nose. When performing osteotomies, rest assured I take extreme caution in my technique to help minimize unwanted bruising. This includes use of a specially formulated solution that I inject in your nose to chemically constrict the blood vessels. Elevating your head following surgery is another helpful step that works by counteracting gravity to decrease blood flow and, therefore, pooling of blood around the nasal bones. I am not a big fan of ice compresses applied directly over the nose as this can sometimes cause unwanted shifting of the cast and underlying bones. Instead, I prefer if patients apply a small packet of frozen peas or similar lightweight cold compress over each eye in a symmetric fashion. In doing so you can minimize chances of shifting the newly positioned bones and maximize control of bruising. Finally, limiting physical activity during the first 1-2 weeks following rhinoplasty further minimizes chances of bruising.
Posted on in Facial Plastic Surgery, Revision Rhinoplasty, Rhinoplasty
In many cases where patients are undergoing reshaping of the dorsum (bridge) I will recommend that we place spreader grafts at the time of the surgery. Spreader grafts are long, rectangular-shaped pieces of cartilage that are placed in parallel with the bridge in between the septum and the upper lateral cartilage. They are what we term ‘hidden’ grafts in that they are placed within a precise pocket without contacting the skin directly. This is in comparison to other grafts we use in rhinoplasty and revision rhinoplasty, such as tip and dorsal onlay grafts, that directly contact the skin and alter shape of the nose. Spreader grafts, in contrast, push or spread the upper lateral cartilage outward, thereby widening the middle one-third of the bridge indirectly. For this reason, the most common indication for spreader graft placement in cosmetic rhinoplasty is a pinched middle vault (another term for the middle one-third of the bridge). This can be a congenital finding in some patients who have never had rhinoplasty but also frequently occurs as a result of having had a prior nose job where this area of the nose was overlooked. In the latter instance, many of these revision rhinoplasty candidates present with what is called an inverted V deformity where the upper lateral cartilage has collapse inward creating unwanted shadowing in this particular shape. Other candidates for spreader graft placement are those with functional problems and difficulty breathing through the nose. These patients have narrowing of their breathing passage as a result of the upper lateral cartilage collapsing inward. When this occurs, a critical area inside termed the internal nasal valve becomes excessively narrowed causing a subjective feeling of difficulty breathing through the nose. In this case, spreader grafts are used to reopen the valve area and restore more optimal nasal breathing. It is for this reason that many patients who undergo spreader graft placement for cosmetic rhinoplasty also enjoy a moderate to significant improvement in their breathing as a passive side effect. To learn more about spreader grafts, you can read my online book chapter “Rhinoplasty, Spreader Grafts” on Emedicine.com (http://emedicine.medscape.com/article/1292527-overview).
Posted on November 11, 2009 in Revision Rhinoplasty, Rhinoplasty
Many patients who are scheduled to undergo revision rhinoplasty require ear cartilage grafting (also known as auricular cartilage grafting) as part of their surgery. This is commonly done when we need to add structural support and/or additional contour to the nose following prior rhinoplasty where too much cartilage or bone was removed. Patients often wonder what the ear is going to look like after the cartilage has been removed from their ear. As I tell any of my patients having this type of procedure, the ear should look essentially the same as it did before I took the cartilage. I use a hidden incision made entirely behind the ear and leave behind a sufficient amount of ear cartilage to maintain a normal shape. The ear tends to hurt a little more than the nose does, but this is managed with low dose pain medication during the first week. I have attached a photo below of one of my San Diego revision rhinoplasty patients who had ear grafting to the nose just one week prior. You will notice that her ear looks almost entirely normal without any obvious evidence that we were there.
Appearance of Ear One Week After Surgery
Posted on in Dermal Fillers, Facial Plastic Surgery
We have had a lot of inquiries lately about the return of the only FDA-approved permanent dermal filler on the market in the United States – Artefill. I am excited to report that Artefill is officially back as of several months ago. Artefill was previously manufactured and distributed by Artes Medical before they went bankrupt. Many patients were concerned about this development and mistakingly thought it may be due to something about the actual Artefill product. Fortunately, this is definitely not the case. Artes Medical, unfortunately, made a series of poor business decisions that contributed to the demise of the company. This had essentially nothing to do with the merits of the Artefill product and, in fact, some say occurred despite having one of the most promising dermal fillers on the market.
Artefill has now reemerged and is being manufactured and distributed by Suneva Medical out of San Diego, CA, with a whole new business model and phenomenal leadership at the helm. Because my practice is located in proximity to Suneva, I have been fortunate enough to see all the latest Artefill developments first hand. In fact, last month I joined several facial plastic surgery colleagues of mine from Beverly Hills down to San Diego for an exclusive visit to the company. We toured the manufacturing facilities and had an in depth group discussion about using Artefill for a variety of cosmetic uses in the face. This product, which contains finely engineered polymethylmethacrylate (PMMA) beads, is the only non-absorbable dermal/soft tissue filler that has undergone the scrutiny of the FDA and received approval for this particular use. It is currently FDA approved for use in the smile line region (nasolabial fold augmentation) but has had great success in other areas of the face like the cheek and prejowl regions (off label uses). Patients do require a skin test 7-14 days before injection to make sure they do not react to the collagen paste contained in the syringe (which only acts as a carrier for the permanent PMMA).
If you are a current Juvederm or Restylane patient or even someone who has never had a filler but desire a more permanent dermal filler option, I would strongly recommend you consider Artefill.
Posted on November 5, 2009 in Revision Rhinoplasty, Rhinoplasty
Many times I will ask that my patients begin taping their nose following rhinoplasty. This is recommended to encourage your nose skin to adhere down to the underlying cartilage and bone that was just reshaped. In rhinoplasty patients with thin skin, this is usually not necessary. In rhinoplasty patients with thick skin, however, taping for several weeks to months following surgery can be of significant benefit. I will direct you if and when to start doing this as needed. I recommend that my patients use 1/2″ x 3″ steri-strips manufactured by 3M since these seem to provide the best quality tape for our purpose. In the past I have referred most patients to the 3M website since most pharmacies do not carry this specific brand. For my San Diego rhinoplasty patients, we have now discovered a local pharmacy close by in La Jolla that carries these same steri-strips. It is Burns Drugs at 7824 Girard Avenue and their website is burnsdrugs.com. Thanks to one of my revision rhinoplasty patients in La Jolla, Julie, for the updated information!
Posted on November 3, 2009 in Blepharoplasty
Eyelid swelling following blepharoplasty, or an eyelid lift, is quite common within the first 72 hours of the recovery period. The eyelid skin is rather thin and, therefore, even a small amount of inflammation will contribute to moderate swelling of the region. Because of this I recommend that all patients apply a cold/ice compress to the eyelids during the first three days of recovery. One handy trick that was recommended to me by one of my patients (thank you Dee Ann!) this past year involved using regular old Karo syrup! Karo is corn syrup that is commonly found in many kitchen cupboards. If placed into a ziplock sandwich bag and then the freezer, it becomes a nearly ideal cold compress for the eyes! The syrup will typically not freeze but does get sufficiently cold for our purpose. Unlike ice and even frozen peas, the cold liquid then conforms very nicely to the contour of the eye and surrounding cheek bone. The Karo syrup maintains a nice cold temperature for quite a while before having to place it back in the freezer. Most patients will keep two bags in the freezer while using one on each eye and rotating them accordingly. What a novel and effective way to keep your eyelid swelling to a minimum following blepharoplasty.
Posted on November 1, 2009 in Chin Implant, Rhinoplasty
The answer to this question is – quite commonly. I would say that nearly 20% of our patients seeking primary rhinoplasty (1st time rhinoplasty) also consider chin augmentation with an implant. One of the main goals of rhinoplasty is to achieve improved harmony with the rest of the face. In cases where the nose is disproportionately large compared to the rest of the face, the aim would be to make it smaller. Most of these cases involve noses that are projected too far out from the face and/or have an excessively high bridge. This usually is more pronounced when looking at the profile view (side view). Unfortunately, there is a limit to how much smaller the nose can be made, particularly if one has thicker than average skin. In cases like this where even more balance is necessary, one must consider the shape and size of the chin to help compensate. These patients have a chin that is quite weak or underdeveloped, which makes a large nose appear even larger (since the lower one-third of the face looks comparatively too small). By augmenting the chin and jawline with an implant, the lower face is brought into better balance with the remainder of the face. When doing this in combination with rhinoplasty to make the nose smaller, the results can be rather dramatic. In fact, in many cases this is often a multiplicative effect and not just additive (like 1+1=3!).
Posted on in Otoplasty
In essentially all cases of routine otoplasty for prominent ears the incisions (skin cuts) are hidden completely behind the ear. Although some plastic surgeons still make incisions in front of the ear, I have been quite successful with keeping our incisions behind the ear. My otoplasty technique involves an incision made in parallel with the attachment of the ear to the scalp. This type of approach provides me sufficient exposure to reshape the entire ear without having to make an incisions on the front. Therefore, there are no scars or visible signs of otoplasty having been performed.