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Blog
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Blog
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March 5, 2010
Question: Do you always put a cast on the nose following rhinoplasty or revision rhinoplasty?
Answer: The answer is – no. I will only place a cast on the nose if I have performed osteotomies (breaking the nose) during the rhinoplasty procedure. The cast, like for a broken arm, is intended to keep the bones in position during the early healing process. Unlike with your arm, however, we take the cast off within the first week. Dr. Hilinski.
Question: Is it normal to have my ear look like it is overcorrected after having an otoplasty?
Answer: The answer to this is – yes. It is entirely normal and even expected that the ear(s) looks much closer to the surface of the head early on after otoplasty, or ear reshaping. The cartilage of the ear has what is termed ‘memory’ that gives it a tendency to go back to its original position. This is what accounts for the ears ‘relaxing’ weeks to months after otoplasty. In order to compensate for this relaxation, the otoplasty procedure is done with a certain amount of overcorrection. That is precisely why your ears might look too close to your head in the early recovery period after otoplasty. Just give it some time and they will relax. Best regards, Dr. Hilinski
Question: Why do some plastic surgeons only show the lateral or profile view of the nose following rhinoplasty or revision rhinoplasty?
Answer: This is a great question. In my opinion, plastic surgeons should provide at least two views of the nose in their before and after photos. Nasal reshaping is such a 3-dimensional process that I don’t a single lateral view can represent an accurate outcome of the surgery. Plastic surgeons should always try to provide before and after rhinoplasty photos of at least two views – preferably a frontal and side view. Sometimes the oblique or 45 degree angle view also helps in demonstrating an accurate change. Many plastic surgeons will post only the lateral view of the nose showing how, for instance, a hump has been removed or how the tip was elevated. That is great to see this view but the real question is how does that nose look from the front? Getting the frontal view symmetric and refined is the real challenge in rhinoplasty and revision rhinoplasty. Without the frontal postoperative photo, I personally don’t think that one can accurately judge how good of a rhinoplasty was performed. My humble opinion. Dr. Hilinski
One of the more frequently asked questions is what will my eyes look like after an upper blepharoplasty, or eyelid lift, procedure? Or what can I expect at one week out from my eyelid lift? Within the first 72-96 hours your eyes will swell and might even bruise. We always recommend ice compresses (or Karo syrup bags) to the eyes during this period to minimize swelling and discoloration. Within 5-6 days, I will see you in our office to remove the sutures. The sutures are fine threads placed along the upper eyelid crease to bring the skin edges together very carefully. There are some additional sutures along the outside of the eyelid in some cases where the patient has ‘hooding’ of the skin to the side. You may still look puffy that day when the sutures come out but within a few days to weeks will begin to look more and more presentable in the public. One of our San Diego rhinoplasty patients who had an upper eyelid blepharoplasty is shown in the attached photo 5 days out from surgery on the left showing what the average patient looks like at this point. Notice the fine blue sutures along the upper eyelid. On the right is the same patient within a few weeks. Happy healing. Dr. Hilinski
I often times get asked what type of facelift technique do I prefer to do on my patients. The answer to this is – it depends on the type of facial anatomy that I am presented with and the desired change. Essentially any facelift procedure done today involves some type of lifting of the SMAS layer (also known as the superficial musculo-aponeurotic sytem). This is the thicker fibrous layer of tissue that sits below the skin and above the muscles of the face. In order to effectively lift the face and get a long-term esthetic improvement, one has to involve the SMAS layer in one or another. The main differences between the various facelift techniques mostly relate to if and how far below your surgeon dissects the SMAS to lift the face. Some facial plastic surgeons go quite deep, therefore, the term deep plane facelift. Others go a short distance under the SMAS and some don’t even lift the SMAS at all. Instead, they tighten the SMAS layer with permanent sutures to get a similar result. The MACS facelift technique has gained increasing popularity recently and is a variation of the SMAS suture tightening technique. The MACS lift (which stands for minimal access cranial suspension) involves placing a series of suture loops anchored to the deep fibrous tissue above the ear. By strategically placing these suture loops, the surgeon can effectively lift the lower face and upper neck to achieve a nice cosmetic improvement. All of these facelift techniques have been used by surgeons to achieve great cosmetic outcomes over the years. In many cases, patients aren’t even aware of what technique was used in their particular case. Not that it really matters as long as your surgeon is comfortable with their chosen technique and has enjoyed safe, successful outcomes over time. Dr. Hilinski.
March 4, 2010
I just completed an interview today with an independent journalist here in San Diego who was researching the topic of injectable filler use for the nose. This idea has actually been around for many years but has been gaining increasing media attention. It has been called among other things the non-surgical nose job as well as injection rhinoplasty and lunchtime rhinoplasty. These names and labels all refer to the technique of injecting a dermal filler (like Restylane, Perlane and Juvederm) into the nose to reshape and contour. It is not a bad option in those patients who want to bridge the gap and buy time before they ultimately undergo an actual rhinoplasty or revision rhinoplasty. We have had many rhinoplasty patients over the years here in San Diego opt for this procedure and then end up having their rhinoplasty performed after the filler has gone way (6-9 months typically for the temporary fillers mentioned).
Many patients inquire about septoplasty for nasal obstruction, or difficulty breathing through the nose, and ask whether I perform suture technique to straighten the septum. The answer to this is ‘no’ in terms of my primary surgical technique for septoplasty. The reason for this is that the cartilage of the septum has what we call ‘memory’, which means that it has a tendency to go back to its original shape if given the opportunity. Conservative methods of straightening the septum like just suturing the cartilage are highly prone to failure because the cartilage memory overrides the suture tension. The end result is that the cartilage bends back to its original crooked shape. In order to effectively straighten a deviated septum, the surgeon normally has to cut the cartilage at the very least to permanently reshape it. By cutting the septum in strategic locations one can completely erase the memory issue and provide a long-term improvement.
Question: If I just want to narrow my nose by reducing the width of the base, do I have to undergo an anesthetic?
Answer: The answer to this is ‘no’ if that is all you want done in terms of a limited rhinoplasty or revision rhinoplasty. We have several patients every year that only want to narrow the base of the nose where the nostrils attach to the cheek and lip. There are a variety of methods used for base narrowing of the nose and essentially all of these can be done in the office under local anesthesia and sometimes an oral sedative medication. In most cases, this simple limited type of nasal reshaping can make a significant improvement in the appearance of the nose.
March 3, 2010
Question: What is Asian rhinoplasty and how is it different from standard rhinoplasty?
Answer: Asian rhinoplasty is quite different than the average rhinoplasty procedure. The reasons for this are multiple but primarily involve the desired endpoint in terms of esthetic outcome and the unique underlying anatomy. With regard to the desired esthetic outcome, any experienced rhinoplasty surgeon is going to agree that you cannot reshape an Asian (or any ethnic nose) the same as you would in a Caucasian rhinoplasty. Although the bridge is typically augmented and the tip is made more defined in Asian and ethnic rhinoplasty, the end result has to remain in balance with the rest of the facial features. Since there are such distinct differences in Asian and ethnic faces, your rhinoplasty surgeon must respect these unique characteristics and avoid performing ‘westernization rhinoplasty’ in this population. Only rarely do I have Asian rhinoplasty patients who truly desire to move away from their ethnic look. With regard to the anatomy of an Asian nose, there are very clear anatomic variances that warrant a different technical approach to the nose. For instance, the combination of thicker skin and weaker underlying cartilage in the Asian rhinoplasty patient means that your rhinoplasty surgeon has to alter their surgical technique to compensate for these variables. For these reasons and more, you need to make sure that your chosen rhinoplasty surgeon is experienced and versed in performing Asian rhinoplasty on a regular basis. Sincerely, Dr. Hilinski.
March 2, 2010
One of my San Diego revision rhinoplasty patients was just in and asked what many patients ask regarding nasal exercises. Is it normal to have pain with the exercises? The answer is absolutely. In fact, if you are not pushing hard enough on your nose to elicit some degree of pain, you are likely not pushing hard enough! In order to effectively move the nasal bone after we perform an osteotomy (fracture or break the bone) you have to push to the point where pain is felt. Many rhinoplasty patients worry about over correcting the bone, but this is essentially unheard of when performing nasal exercises. Happy healing. Dr. Hilinski.
February 27, 2010
Artefill, made by Suneva Medical in San Diego, is the only FDA approved permanent injectable filler on the market. Artefill is a fantastic injectable filler product that is a great alternative to Restylane, Perlane, Juvederm, Radiesse and Sculptra. It is used very much like the other fillers for smoothing out unwanted facial lines, creases and wrinkles. The one exception is the lip where Artefill should not be used. You do have to get skin tested before getting Artefill but it is highly unusual that patients respond to the skin test. If you are thinking of having a permanent dermal filler for soft tissue augmentation of your face, just give us a call. Let my staff know you are interested in Artefill. Look forward to seeing you. Dr. Hilinski
Question: What are steroid injections and why are they used for rhinoplasty and revision rhinoplasty patients?
Answer: Steroid injections refer to an injectable corticosteroid (called steroid for short) solution that is used to decrease swelling and dissolve unwanted scar tissue. I use steroids quite commonly to help during the healing process following rhinoplasty and revision rhinoplasty. If taping the nose does not address the issue sufficiently and/or quickly enough, I might recommend a steroid injection to reduce an unwanted contour or prominence. Contrary to popular belief, steroid injections can be used even very late in the rhinoplasty healing process (like 6-12 months out).
The short answer to this question is – yes, if you have symptoms of nasal blockage that are not improved with medications. If you are found to have evidence of a deviated septum, or crooked septum, on examination by a facial plastic surgery or otolaryngology specialist, they will likely recommend surgical repair. In order for your insurance company to cover these services, your surgeon will submit paperwork documenting their opinion and recommending septoplasty surgery. If preauthorized (meaning the insurance company offers preliminary approval), then most patients proceed with the septoplasty and have the expenses covered by their insurance company. Of course, as the patient, you should be well aware of any and all restrictions and responsibilities related to your healthcare policy. Hope this helps. Dr. Hilinski.
This is a frequent question that I get asked from potential rhinoplasty and revision rhinoplasty patients. Normally most rhinoplasty patients will look ’supermarket’ presentable in about 10-14 days. I will remove the sutures, tape and cast (if placed) 5-6 days following your surgery. The nose looks swollen that day but, in general, rhinoplasty patients can appreciate the changes that were made even at that point in time. A significant improvement will be seen between that day and the 10-14 day mark to the point that most patients feel comfortable in the public eye. To visually see what I am talking about, the following link is provided so you can see one of our San Diego rhinoplasty patients at 5-6 days out from his rhinoplasty procedure. http://www.drhilinski.com/videos.htm
Question: I had an ear graft done as part of a complex revision rhinoplasty. Is it normal for my ear to hurt more than my nose?
Answer: Thank you for your inquiry. The answer is yes. It is quite normal to have more attention drawn to the ear as a result of discomfort and pain. The ear is quite sensitive being innervated by many sensory nerves. Therefore, it is expected to hurt more than the nose does following rhinoplasty. In most cases of rhinoplasty and revision rhinoplasty when there is no ear grafting, pain is actually very mild and usually requires only a few days of low dose Vicodin or equivalent. Best regards, Dr. Hilinski.
November 16, 2009
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.
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!
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).
November 11, 2009
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.
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
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Dr. Hilinski's office in San Diego, CA is conveniently located near the following:
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