Non-surgical

Body

Breast

Face

Face
- Facelift | Necklift
- Blepharoplasty
- Rhinoplasty
- Buccal Fat Pad Resection
- Neck Liposuction

This surgery is performed in an operating room under general anesthesia. You will go home after surgery and need a responsible adult to drive you home and stay with you for the first 24 hours. On the day of the procedure, wear loose-fitting clothing, and avoid any aspirin, ibuprofen, or other blood-thinning products for at least one week. Make sure you have absolutely no exposure to tobacco, marijuana, or any products (hookah, nicotine gum, or any other agents) for at least 30 days before and after surgery. Please keep in mind that second-hand exposure can be just as damaging as direct use of these products, so please avoid any exposure at all for at least 30 days before and after the procedure.

On the night of surgery, you will have some bandages that are applied at the time of surgery. There is usually a Velcro attachment, and if the bandage is too tight, you can loosen the Velcro and release it by one to two inches so that you are more comfortable. Sleep on two to three pillows, and you can apply ice to the sides of the face and neck during the night. If you have drains, empty the drains twice a day, or more frequently if they are ½ full. Try to minimize activity outside of going to the restroom.

The day following surgery, you can remove the dressings and shower gently. If you prefer not to remove the dressings, you can keep them on until your follow up appointment. However, it is completely safe to remove the cotton and gauze dressings, discard them, and shower with soap and water.

For the first week following surgery, minimize strenuous activity that would raise your blood pressure. In addition, you will find tightness in your neck and in opening and closing your mouth; be gentle with your movements and eat softer foods like soup or rice that do not require strenuous biting and chewing. It is best to maintain these gentle movements for the first one week, and then slowly increasing activity over the next three weeks.

In your postoperative visits, the sutures will be removed, the drains removed, and you will be evaluated on several criteria. There are four main issues to be examined with each visit, fortunately each of which is very rare: hematoma (bleeding), ischemia (poor blood flow), neuropraxia (weakness), and infection. Most patients do extremely well, and in fact even if one of these concerns does arise, they can often be resolved in a straightforward manner.

Instructions before & after surgery:

Facelift/Necklift is one of the most effective techniques at improving the contour and appearance of the face and neck. While these are technically two separate procedures, they are accessed through similar incisions and are often done together and are sometimes just referred to as facelift. In other words, “facelift” often refers to a lift of the lower face and neck. There are several variations of this operation although the basic technique and principles have persisted over the past few decades.

The ultimate goals of a facelift are to reduce jowling to create a more linear, defined jawline, improve the contour of the neck to create a well-defined neck crease, and to a degree, to raise the skin of the mid-face to soften the nasolabial folds. This operation can be combined with other procedures that address the eyelids (blepharoplasty), forehead (forehead lift), and central face skin (chemical peel).

The incisions for a facelift are around the ear and in the crease below the chin. The incision often begins in the hair, comes down to the skin just in front of the ear, rounds backwards around the ear, and then continues down in the hairline. Sometimes there is an extension in the sideburn. There is a separate incision that is often made in the crease just below the chin, to access the neck. Once these incisions have been made, the skin is gently lifted off the underlying tissue, and the strong muscle fascia, called the “SMAS”, is then contoured. The SMAS can be pulled, plicated, or folded over to give the desired effect. In the neck, the muscles in the midline are often sutured together to give a more pleasing neck crease. The skin is then gently rewrapped, trimmed, and sutured. Frequently, small drains are placed so that any fluid can egress, and these drains are usually removed in the first two to four days.

External sutures in a facelift are usually removed in the first five to ten days; there are many deeper absorbable sutures that dissolve in the first few weeks. Most patients find that within one week, much of their pain and discomfort is improved, and within two weeks they can resume most normal activities. Usually, it is best to wait eight weeks before engaging in strenuous activity.

It is common for facelift patients to have a TCA peel a few months following their surgery, as the peel can accentuate the results of a lift. While it is not mandatory, the peel can significantly enhance the improvement as it tightens and smoothens the lifted skin.

Facelift | Neck Lift

Wear loose-fitting clothing on the day of the procedure, and avoid any aspirin, ibuprofen, or other blood-thinning products for at least one week. The procedure usually takes about two hours.

Following surgery, sutures will be in the eyelid, and swelling will increase over the first day. You will be prescribed antibiotic ointment which you can place both in your eyes and on the incision line; ideally place three to four times a day for the first three days. Following the first three days, you can leave the incision alone, or place a bland ointment on it such as Aquaphor if it is dry. It is helpful to sleep on two pillows, and you can shower the day after surgery. Do not perform any strenuous activity for at least one week, and ideally for two weeks. Your sutures will be removed in the office, after which the wound will continue to heal for several weeks. By two to three months, the result will become apparent, and you will have your result in about six months.

Instructions before & after surgery:

The skin of the upper and lower eyelids, along with some of the underlying fat, can increase with age, and its removal can be remarkably effective in creating a more youthful, refreshed appearance.

Upper eyelid blepharoplasty is one of the most common cosmetic procedures performed, and can be performed in the office under local anesthetic. An ellipse of skin is removed, as well as some of the underlying fat on the inner part of the upper eyelid. The skin is sutured closed, and the sutures are removed about one week afterwards. Recovery can take one to two weeks and can vary from one person to the next; for many patients, they can return to the public eye in about ten days. Although the area looks a lot better after one to two weeks, the scar continues to improve for up to six months; while the scar is always present, in many circumstances it can be quite difficult to see.

There are several variants of the upper eyelid blepharoplasty that affect skin removal on the inner and outer parts of the eyelid. On the inner part of the eyelid, there is a risk of skin stretching which would cause webbing, and for that reason modifications exist to allow extra skin to lay down in the concavity of the upper inner eyelid. I prefer to place a “W-plasty” in the inner upper eyelid to allow some extra skin to be present and avoid webbing.

In the outer part of the eyelid, several variants of the procedure end the incision at different locations. For patients whose extra skin does not go out beyond the edge of the eye, the incision can end just above that location. However, most patients have extra hooded skin that extends to the side, and for those patients my preference is to extend the incision to the side, remove the extra hooded skin, and place the final scar along one of the wrinkle creases where it tends to hide well.

Lower eyelid blepharoplasty can be more complicated than upper eyelid blepharoplasty. The main difference is that it is difficult to safely remove skin from the lower eyelid, as skin removal can pull the eyelid downwards. Therefore, in the lower eyelid, most blepharoplasties are aimed at reducing the herniating fat that can be seen protruding. This operation can be performed either in the operating room under general anesthesia, or in the office setting under local anesthesia.

There are two approaches to the lower eyelid blepharoplasty. In the transconjunctival approach, the eyelid is gently pulled forward, and an incision is made on the inside of the eyelid that allows access to the protruding fat pockets. These fat pockets are removed through these small incisions. In a second approach, an incision is made on the skin of the lower eyelid, just below the eyelashes, and the skin and muscle are gently pulled down. The protruding fat pockets are then identified and removed, and then skin and muscle are placed back and sutured closed.

The lower eyelid is one of the most complicated parts of the face, and the lower blepharoplasty can improve the appearance, but we do not have a reliable, safe approach to smoothen the skin on the lower eyelid. Some procedures exist (canthopexy or canthoplasty) that pull the eyelid skin sideways and try to tighten the attachment to the side of the eye, however I find these approaches to be suboptimal. First, canthopexy and canthoplasty sometimes make the appearance unnatural. Second, these repairs sometimes are short-lasting, and laxity recurs. I find that currently, we do not seem to have the surgical techniques to achieve smooth lower eyelid skin that does not lower the eyelid, and so removing any more than 1-2 mm of skin is something that many plastic surgeons rarely do. Interestingly, if there is redundant skin following a lower eyelid blepharoplasty, a non-surgical resurfacing technique such as a TCA peel or fraxel laser might improve the appearance.

Blepharoplasty

This surgery is performed in an operating room under general anesthesia. You will go home after surgery and need a responsible adult to drive you home and stay with you for the first 24 hours. On the day of the procedure, wear loose-fitting clothing, and avoid any aspirin, ibuprofen, or other blood-thinning products for at least one week. Make sure you have absolutely no exposure to tobacco, marijuana, or any products (hookah, nicotine gum, or any other agents) for at least 30 days before and after surgery. Please keep in mind that second-hand exposure can be just as damaging as direct use of these products, so please avoid any exposure at all for at least 30 days before and after the procedure.

On the night of surgery, you will have some bandages that are applied at the time of surgery. There is usually a Velcro attachment, and if the bandage is too tight, you can loosen the Velcro and release it by one to two inches so that you are more comfortable. Sleep on two to three pillows, and you can apply ice to the sides of the face and neck during the night. If you have drains, empty the drains twice a day, or more frequently if they are ½ full. Try to minimize activity outside of going to the restroom.

The day following surgery, you can remove the dressings and shower gently. If you prefer not to remove the dressings, you can keep them on until your follow up appointment. However, it is completely safe to remove the cotton and gauze dressings, discard them, and shower with soap and water.

For the first week following surgery, minimize strenuous activity that would raise your blood pressure. In addition, you will find tightness in your neck and in opening and closing your mouth; be gentle with your movements and eat softer foods like soup or rice that do not require strenuous biting and chewing. It is best to maintain these gentle movements for the first one week, and then slowly increasing activity over the next three weeks.

In your postoperative visits, the sutures will be removed, the drains removed, and you will be evaluated on several criteria. There are four main issues to be examined with each visit, fortunately each of which is very rare: hematoma (bleeding), ischemia (poor blood flow), neuropraxia (weakness), and infection. Most patients do extremely well, and in fact even if one of these concerns does arise, they can often be resolved in a straightforward manner.

Instructions before & after surgery:

Nose reshaping is one of the most valuable yet challenging procedures in plastic surgery. The goal of the nose is to not be noticeable when looking at a face, so that a well-proportioned nose should blend right into the rest of the face.

There are two main techniques for rhinoplasty, open and closed. In the open technique, an incision is made across the columnella (the strip of skin at the bottom of the nose), and that continues to incisions on either side on the inside of the nostrils. The skin is then raised upwards, and access is gained to the structures of the nose. In the closed approach, which I prefer for most patients, incisions are made in the nostrils on both sides, and dissection allows access to the structures of the nose.

Most rhinoplasties are reduction rhinoplasties, that is, the operation is meant to reduce features of the nose. There are classic features that are frequently enlarged that we are trying to reduce: the dorsal hump (the top of the nose that bows out), the alar cartilages (the nostrils that are too large), the nasal bones (the widened upper part of the nose). Reducing these classic areas is performed in a stepwise fashion to achieve a nose that fits the face, and whose components aesthetically fit each other.

In addition to the aesthetic improvement of the appearance, three other maneuvers are often considered during rhinoplasty that affect breathing. Realistically, in a reductive rhinoplasty, the airways might become narrower, so compensatory techniques are sometimes needed to improve airway dynamics. First, the septum in the internal, midline of the nose is often deviated in most patients and can be quite deviated in some. Repairing this nasal deviation is straightforward and is often done in many patients, improving air flow dynamics. Second, the inferior turbinates’ are soft bones that protrude into the airways to moisturize the inspired air; in many patients these bones are enlarged (turbinate hypertrophy) and so they can be mobilized to the side. Third, in some patients, there is restriction of airflow in what is termed the internal nasal valve. A maneuver can be performed with the placement of “spreader grafts” that opens the internal nasal valves. These three maneuvers, individually or in combination, can significantly improve airflow and can compensate for any reduction in flow from a reduction rhinoplasty.

One of the most important aspects of undergoing rhinoplasty is understanding the dynamic nature of the healing. The components of the operation are performed and brought together, but then the nose swells and healing can take six to twelve months. The left and right halves of the nose can swell at different rates, and asymmetry during the healing process is extremely common. Even after the swelling resolves, some degree of asymmetry is almost universally present (although not always obvious). Obvious, problematic asymmetry and other concerns to occur in rhinoplasty, and in fact rhinoplasty is reputed as having the highest revision rate of any plastic surgical procedure—across the world. Revision rates as high as 25% have been quoted—across surgeons, across countries—and is a testament to the dynamic nature of the healing process. Even if the operation is performed perfectly, the swelling and its asymmetry healing can result in the result having asymmetry or problems, with the resultant high revision rate. Interestingly, one reality that is often overlooked is that the natural nose has imperfections, and the operated nose will also; the challenge is to determine which imperfections mandate a revision versus which ones are acceptable in the goal of a balanced, natural-appearing nose.

Rhinoplasty

Wear loose-fitting clothing on the day of the procedure, and avoid any aspirin, ibuprofen, or other blood-thinning products for at least one week. The procedure usually takes about one to two hours and is under local anesthetic.

Following the procedure, gargle with tap water every six to eight hours for the first three days. You will find it difficult to chew and eat for the first week as there can be significant swelling, but you should find this sensation to resolve within two to three weeks. The final results start to appear after two weeks and are usually visible by about three months.

Instructions before & after surgery:

Some people have fullness on the lower, front part of their cheeks that is due to a fat pad called the buccal fat pad. This fat pad is large and extends from just under the inside of the mouth to the lower cheek. While this is a natural fat pad that is appropriate, when it enlarges it can create a fullness in an area of the cheek where a more slender or gaunt appearance is desired. Buccal fat pad resection removes a portion of this fat pad and often results in this more chiseled, gaunt appearance.

The procedure can be performed under anesthesia or in an awake patient under local anesthetic. A small incision is placed on the inside of the mouth, and a portion of the fat pad is removed. While there is swelling that occurs over the first two to three weeks, as the swelling subsides, the newer, more narrowed appearance becomes evident.

Buccal Fat Pad Resection

Wear loose-fitting clothing on the day of the procedure, and avoid any aspirin, ibuprofen, or other blood-thinning products for at least one week. The procedure usually takes about two hours and is under local anesthetic.

Following the procedure, you will have a garment to wear on the neck, and it is best to wear it at least until the following morning. You can take it off to shower. Afterwards, wear the garment at night for the first two weeks.

The results of the procedure usually start to show after one month but can take up to six months. If there are areas of firmness, you can gently massage the skin daily until it softens; these areas of internal scar tissue usually resolve within several months.

Instructions before & after surgery:

Many patients seek to improve the appearance of their neck. Specifically, on a more youthful neck there is often a sharp crease; in some people of all ages, this crease becomes blunted.

The solution to improving the neck contour depends on several factors, including the quality of the skin, the amount of skin, and the amount of fat under the skin. The fat is important as it helps the skin glide on the underlying muscle, but in excess it can push the skin down and blunt the neck crease. In some patients, by removing the fat through liposuction, the skin will “fall down” to the next layer, which is paradoxically higher up on the muscle. In other patients, this alone will not suffice as there is excess skin laxity, and reducing the fat will make it less thick but won’t compel it to stick to the underlying muscle.

When I evaluate a neck, I am looking at the quality of the skin, its thickness, its amount and if any wrinkling is already present, and the amount of fat underneath it. I am also evaluating the underlying muscle and the distance from the muscle and the skin. In many patients, particularly those with thicker skin (which tends to retract/snap back more), neck liposuction alone can be incredibly effective. Performed under local anesthetic often on the awake patient, one to three small incisions are used to place a liposuction cannula under the skin. The cannula removes much of the fat (some fat needs to be left behind to allow the skin to glide), and at the same time abrades the undersurface of the skin. The skin then retracts to the underlying muscle, and abrading the skin tends to make it contract and more adherent.

The results following liposuction can take several months to achieve; usually by one month a difference is apparent, while it can take six or even nine months to see the complete results. In patients with thicker skin, the results can be striking and significant. In some patients, especially those with thinner skin, the skin will retract back to the muscle, but might not do so to as great an extent and there can be wrinkled or loose skin. Sometimes the result is still significantly better than the original appearance, but at that point any further improvement would need skin resection such as in a neck lift, or sometimes tightening such as from a peel. In most patients, however, neck liposuction results in a profound improvement.