Facial Plastic Surgery FAQ

Full Question: How do you personally define a “good” rhinoplasty and do you have any memories about learning how to do the procedure?

I define “good” Rhinoplasty as I do every other facial cosmetic procedure: one whose result makes my patient happy and more content with their appearance. My response to this question, by my definition, is limited and incomplete. My answer to this question, as the surgeon, does not completely answer the question posed— a “good” rhinoplasty is defined by my patient. It is my job as their surgeon to ascertain from each patient what their goals are from the rhinoplasty and then to try my best to meet and surpass those goals. Importantly, given my background as an otolaryngologist (Ear, Nose and Throat), one of the goals which I bring to every rhinoplasty is to improve and/or maintain the ability to breath well through the nose: a goal which cannot be compromised with any rhinoplasty. For those patients who suffer from nasal obstruction, a result of the surgery needs to be the improvement of nasal breathing and, for those who do not have breathing issues, the rhinoplasty procedure needs to preserve this ability. A “good” rhinoplasty whether from the patient’s or the surgeon’s perspective needs to have this as an outcome. Additionally, a “good” rhinoplasty needs to not only make the patient happy in the short term but throughout the life of the patient. Too often patients are ‘satisfied’ with the results of their rhinoplasty as soon as the cast is removed or in the short term period only to notice changes to the nose years later causing them to seek consultation for a revision. These changes which take place over time may also lead to compromises in nasal breathing. This is what I think is the most challenging aspect of rhinoplasty—to achieve good and long-lasting results. It is why I believe that long term follow-up is essential after rhinoplasty. I have immersed myself in the study of rhinoplasty. I am passionate about this procedure. My passion stems from the very challenges the surgery poses. Rhinoplasty is a very challenging procedure to perform both technically as well as artistically. Given this challenge, I am very fortunate to have received training from one of the most well-respected rhinoplasty surgeons in the world, Dean Toriumi, M.D. My experience with Dr. Toriumi was invaluable in that it exposed me to extremely difficult revision rhinoplasties. Oftentimes, Dr. Toriumi was performing surgeries on patients who had already had multiple previous revisions from other surgeons. As a surgeon, I feel that you learn a great deal about a procedure by seeing and exposing yourself to the complications from the procedure. Given that most of my training was alongside surgeons who performed a lot of revision rhinoplasty, I was exposed to patients who sought consultations secondary to their dissatisfaction with their previous procedures. Many of these patients presented for their revision rhinoplasty years after their initial procedure. Oftentimes you heard the concern that they were, at first, happy with their surgery but over time their nose began to change to the point where they were now concerned about its appearance or the inability to breath well through it.

If there is one memory I have preserved from my learning to perform this procedure is that the nose will continue to “heal” itself years after a rhinoplasty has been performed. The healing process after a rhinoplasty entails, as it does throughout the skin in our body: by contraction. It is for this reason that I have a firm belief in the modern approach with regards to rhinoplasty which is a structural approach to rhinoplasty. Simply stated, you need to set a strong, structural foundation to combat the normal scarring and healing that is expected after the surgery. I have had the privilege of learning under the tutelage of some very talented surgeons who have themselves made great contributions to the body of knowledge we have of rhinoplasty. Throughout the time I have been performing this procedure, I have drawn from this knowledge and executed techniques that produce long-lasting results to try and exceed each individual patient’s goals.

Full Question: I’m from New York City and I have a very ugly “hook” nose that I’d like to improve. How does a nose job fix this?

Rhinoplasty or a “nose job” would address your concerns. The removal of a hump is not an “easy” rhinoplasty as I have heard some patients think of it as simply removing the hump. It, like anything else, needs to be performed with delicate intricacy and skill. First, you must think of the nose in three dimensional terms. During my rhinoplasty consultation, right after listening to their concerns, I think the most important aspect is the photographs. Photography in a rhinoplasty consultation is key. These images require proper lighting and proper positioning to maximize their usefulness. Photos need to be taken from various angles to at a minimum include a frontal view, a profile view from either side if the face, a three-quarter view from either side, a view of the base of the nose, and a close up frontal and lateral views. Additionally, these pictures should all be taken in a uniform manner where the head is properly aligned with the ground. I too often see pre and post-operative pictures of patients which do not include these views and thus do not tell the whole story. These pictures today help serve as a means of analysis for the surgeon and as a means of communication between the patient and the surgeon. Morphing software is also employed today by many physicians. I use morphing software specifically and only as a means of communication to express to the patient what I see as a realistic goal of rhinoplasty.

To return to the initial question, the removal of the hump merely addresses the nose aesthetically from one angle—the profile—an important view where there needs to be proper alignment between the dorsum or the upper aspect of the nose and tip. For there to be a precise and proper alignment there needs to exist a distinction between the two. This proper distinction between the tip and the dorsum is accomplished by the Supratip break. A displeasing tip would be one where there is no separation between the tip and the dorsum but instead the tip and the dorsum are connected by a straight line. Look at some aesthetically pleasing noses and you will notice this distinction between the tip and the dorsum. Additionally, the placement of this Supratip break is different between men and women. I think it is attention to these details which separates results in rhinoplasty. It is why I stress the importance of good photography to help highlight these subtleties. Lastly, and I would argue as the most important, is that these subtleties need to last. All too often do I see patients who may have had a rhinoplasty in their teenage years or in their twenties or thirties who present ten or twenty years later complaining that their nose has changed or their tip has dropped and now they have a “bump” on their nose again. In fact, it is not a new bump on their nose it is just that the techniques employed at the time of their rhinoplasty did not lend themselves for long-lasting results and like everything else gravity took its course and the tip dropped to a level below their dorsum and they have lost their Supratip break.

Full Question: Is 2 weeks enough time to recover after getting an eyelid lift?

2 weeks is an adequate time in order to recover form an eyelid lift or blepharoplasty. Blepharoplasty needs to be distinguished between an upper eyelid lift and a lower eyelid lift. The recovery from an upper eyelid lift is generally faster than a lower eyelid blepharoplasty. The sutures from an upper eyelid lift or upper blepharoplasty are removed in about 5 days after your procedure. Typically, an upper blepharoplasty is recommended when there is an excess of upper eyelid skin referred to as dermatochalasis. You may notice that as you age you may see a redundancy of upper eyelid skin and with it you lose the demarcation of your upper eyelid crease. Additionally, you may also notice some bulging through your upper eyelid. This bulging is from the herniation of fat from around the eye. Commonly, you see a slight amount of bulging from the medial aspect of the upper eyelid which is the part of your eyelid closer to the nose. It is common to see a protuberance of fat in this area. After a detailed physical exam of the upper eyelid, I will communicate to you where I could see addressing the eyelid for more youthful changes. It is very important before any eyelid procedure to adhere to not taking certain medications and over the counter remedies that may increase any propensity for bleeding. It is also often helpful to take Arnica tablets before and for a few days after your procedure in order to help prevent bruising. If some bruising were to occur it can be covered with makeup once the sutures are removed. It is common to get some eyelid swelling after an upper eyelid blepharolplasty. This swelling usually resolves within several days. You can help the swelling by applying cold compresses to the eyelid for the first 24 hours after your procedure, keeping your head elevated while sleeping, and maintaining a diet low in salt. Upper eyelid blepharoplasty can be performed as a sole procedure under simple local anesthesia where only the upper eyelid receives numbing medication. If more sedation is needed this can also be administered as well. I perform the majority of my lower eyelid procedures without external incisions or transconjunctival. The recovery from a lower eyelid blepharoplasty on average takes a little longer than from an upper eyelid blepharoplasty—a week to ten days. In your lower eyelids you will again often notice with aging the bulging of fat. The mounds we characteristically see form under our eyes is from fat around the eye. During a lower eyelid blepharoplasty this eyelid fat is removed or repositioned. In a youthful lower eyelid, there exists a smooth transition between the lower eyelid junction and the cheek. However, as we age we often notice a shadow forming in this area in part due to the bulging of fat in the lower eyelid. A lower eyelid blepharoplasty addresses this demarcation creating less of a distinction between these areas of the face. The same care must be adhered to before lower eyelid surgery as in upper eyelid surgery in the avoidance of certain medications and over the counter vitamins and herbs. A detailed list of these will be provided to you before your procedure.

Full Question: I’ve got a lot of loose skin on my neck like a turkey wattle. Can a facelift fix this?

Yes, with aging the skin and underlying tissues in our face and neck sag. These changes tend to happen simultaneously in the neck and face. Often times, however, secondary to hereditary factors, the ‘turkey wattle’ may be a prominent feature. To address these issues, a nearly hidden incision is made mostly behind the ear. If you have very prominent neck bands, a small, hidden incision may also be made under the chin. During your consultation, it will also be determined if there is any excessive neck fat which may need to be removed with a liposuction procedure to the neck as well. There are no additional incisions made for the liposuction. The greatest “tightening” that takes place is actually of the underlying tissue surrounding the muscles of the face. To achieve a natural look, it is important to tighten the underlying tissue which in turn ‘tightens’ the overlying skin. Tightening the underlying tissue removes the tension from the skin itself, and then the excess skin which results is removed. Performed in this manner, tension on the skin is decreased obviating the ‘wind-blown’ look of a facelift as well as the potential widening of the scars. The result is a great improvement to neck sagging.

Full Question: Can rhinoplasty fix a deviated septum and how do you do this?

At the time of rhinoplasty, a septoplasty is performed to correct a deviated septum. Strictly speaking a rhinoplasty is the reshaping of the outside if the nose to change its outward appearance. A septoplasty addresses the septum of the nose which is the cartilage and bone that divides each side of the nose. The septum is composed of both cartilage and bone and the deviation of either one can cause obstruction of the nose. An aspect of nasal breathing that is all too often overlooked are the components of the nose which contribute to nasal obstruction (nasal blockage). A mistake that is often made is attributing difficulty breathing through one side of the nose solely to a deviated septum. In order to help appreciate this concept, one needs to understand the nasal valve. The nasal valve is a three dimensional area inside the nose which provides the narrowest point to nasal breathing. If a cross-sectional area is taken of the nose at this point it would include the inferior turbinate, the septum, and the nasal sidewall. Therefore it is imperative that all these structures need to be properly examined to help with nasal obstruction. I am a otolaryngologist therefore nasal breathing is my top priority with any rhinoplasty I perform. If the patient has a pre-existing nasal obstruction prior to the rhinoplasty, I attempt to properly diagnose the cause of the obstruction and thereby perform techniques during the rhinoplasty to address these causes. If a patient does not have a pre-existing breathing difficulty it is then extremely important to not create an obstruction during the rhinoplasty through the techniques employed to change the shape of the nose. Performing a septoplasty during a rhinoplasty is often performed during my procedures particularly if cartilage grafts are needed to reshape the nose. I would thus use the cartilage removed from the septum as cartilage grafts to help reshape the cosmetic appearance of the nose. The septoplasty is performed through the same incision as that of the rhinoplasty.

Full Question: How permanent is blepharoplasty, and how long will it take for me to need another one?

The way I like to think about any aging facial procedure (i.e. facelift, neck lift, blepharoplasty, brow lift) is like the “resetting of the clock”. These procedures typically “reset the aging clock” by 10 years. That is, they generally make the area addressed with the procedure appear 10 years younger. You then continue to age at the same rate. The rate at which you age is determined by a multitude of factors between your genetics and environmental factors such as smoking, sun exposure, etc. You have control over the latter. Smoking cessation, exercise, proper diet, and sun protection will aide in diminishing the rate of facial aging.

Full Question: What’s the average recovery time for rhinoplasty? When should I be able to go out in public without feeling too embarrassed?

One week after your rhinoplasty your cast is removed. I recommend a week off from either work or school during this time. I say this mostly for my patients to relax and recover during this time period. Although I encourage my patients to remain somewhat active during this time (light walking, staying up and about the house but most importantly not lying around all day). It is best that you allow time for healing during this week. You do need to avoid activities that may elevate your blood pressure. You will also find it helpful to maintain your head elevated as much as possible by sleeping with three to four pillows or sleeping in a recliner. Importantly, for the first 24 hours after your rhinoplasty, apply ice to the lower forehead and the upper dorsum of the nose as much as you can tolerate while ensuring that the cast does not get wet. All these measures help to decrease the initial swelling after surgery. This being said, in one week you will be very presentable. There will, however, be some residual swelling at this point which will take several weeks to resolve. In general, you will notice this swelling, I as your surgeon will notice this swelling, but most of the people around you will not notice the swelling. It is important to keep in mind that everyone heals differently and your individual timeline will vary.

Full Question: My nose has a piggish appearance as it’s upturned and it’s also very wide. Can these be fixed?

Yes. If your nose is too upturned you end up with too much nostril show on your frontal view. The upturning is a result of too obtuse of a nasolabial angle (i.e. the angle formed from the upper lip and the columella of the nose). Your rhinoplasty would entail decreasing this angle so as to not give your nose such an upturned appearance. Often times whiles implanting techniques to help decrease the nasolabial angle the nose can also be narrowed simultaneously.

Full Question: During a facelift, is only the skin pulled tighter or is work also done to the facial muscles?

Facelifts which give the most natural and safest results are those where the underlying tissues are tightened while the overlying skin is only re-draped over this newly tightened tissue. In essence, the surgery is safely performed by lifting the skin, tightening the underlying tissue which envelopes the muscles of the face, then laying the skin down once again. After the underlying tissue has been tightened the result is excess skin. The excess skin is thus removed. In this manner the skin itself does not look “pulled” and you do not get the “wind-blown” appearance that is the tell-tale sign of a facelift. Additionally this technique helps to avoid some of the complications often seen with facelift surgery such as the pulling down of the earlobe or the widening of the scars.

Full Question: I’m from New York City and I had a facelift about ten years ago. Is it safe for me to have another one now? And how many could a person safely have during her lifetime?

Yes. In fact, it is quite common to have a revision facelift with this time frame (10-15 years) apart. 10 years is adequate time to have allowed for the face to heal between procedures. While there is no exact “safe” number of facelifts which a person can undergo in their lifetime. You often see with someone that may have had their fist facelift in their late forties and for them to have 3 throughout their life every 10 to 15 years thereafter without any problems.

Full Question: Are there any additional risks to revision rhinoplasty compared to primary rhinoplasty?

Revision rhinoplasty is a more complicated procedure and thus has more risks because the normal anatomy of the nose has already been altered. As a surgeon with a lot of experience with revision rhinoplasty, I will gain a sense of what to expect from the appearance of the nose but will not know exactly what was done until the time of the procedure. It is therefore imperative to be prepared and have a multitude of options available to fix the deformity. Often times with revision surgery, I will use cartilage grafts to help reshape the nose and provide long term correction. These cartilage grafts are taken from either the septum, ear, or rib.

Full Question: Will blepharoplasty change the shape of my eye?

Blepharoplasty is a procedure performed either in isolation or safely in combination with other procedures. Also blepharoplasty can be limited to just the upper eyelids and/or lower eyelids. This being said, blepharoplasty removes or repositions fat which maybe protruding underneath the eyelids and removes excess skin. To answer the question, it is important for me to clarify what I understand as the “shape” of the eye. What I define by giving the eye its “shape” are the margins of the eyelids and the opening between the upper eyelid margin and the lower eyelid margin. These provide the “opening” to our eyes. The shape of the eyes is not altered using this definition. However, excess skin and protruding fat underneath the eyelids do detract from a beautiful eye shape.

Full Question: Is it true that Juvederm provides the most natural lip augmentation?

In general I like to use HA fillers (hyaluronic acid) for lip augmentation. Fillers like Juvederm and Restylane are naturally occurring sugar based fillers which provide a soft and natural result.

Full Question: I’ve heard that the thickness of the skin is a greater factor in ethnic rhinoplasties. Why is this?

Certain ethnicities have thicker nasal skin. If you looked carefully yourself you’ll be able to make out this distinction in the people around you. In individuals with thin skin you can see the structure of the cartilages underneath the skin of their nose. You can easily make out the bumps and crevices that correspond to the bones and cartilages underneath their skin. Yet in individuals with thicker skin making out these structures is more difficult. You can, however, certainly create more definition in individuals with thicker skin particularly through augmentation in specific parts of the nose. This concept may initially sound counterintuitive but by augmenting or projecting into certain areas if the nose you are in essence “thinning” the skin. Take, for instance, the example of a thick blanket covering an object on the ground. The lower that object is to the ground the less definition it will appear to have. However, if you took that same object and build up from it the more its shape will start to “show through” the same blanket. The same hold true for individuals with thicker nasal skin: the more definition and structure you create in the underlying cartilages the more defined the nose takes shape.

Full Question: Where do people usually have fat removed from when getting facial fat transfer?

With fat transfer fat is removed from one or multiple sites depending on how much fat is needed for volume restoration and the availability of fat at the different donor sites. In thin people it is often necessary to remove fat from multiple different sites in order to obtain enough for volume restoration in the face. Fat can be removed from the abdomen, the outer thigh, inner thigh, and anterior thigh. If there is an adequate amount fat from these areas then I prefer to use these sites.

Full Question: I’ve always had trouble breathing but how would I know if I have a deviated septum. What are some of the common symptoms of a deviated septum?

The very first thing I recommend with anyone with nasal breathing problems is a thorough medical history and physical exam. Breathing problems through the nose may be the result of any one of multiple factors. A deviated septum typically results in difficulty breathing from one side of the nose. However, some severely deviated septums may cause difficulty breathing from both sides. Patients with deviated septums classically describe this problem as a fixed obstruction (i.e. the breathing difficulty does not fluctuate from side to side). However, breathing problems that do fluctuate from side to side does not preclude the fact that you have a deviated septum in addition to likely turbinate enlargement. An examination will determine if you have large turbinates as well.

Full Question: Will a blepharoplasty help improve excess skin above my eyelids that impairs my vision?

Yes. If you have difficulty seeing out of the corners of your eyes and your visual fields are impaired removing the excess skin from your upper eyelids will greatly help. An upper blepharoplasty is a minor procedure which can often be performed under straight local anesthesia or with sedation if needed. The excess skin and, at times, fat is removed from both upper eyelids. The sutures are in place for 5 to 7 days and the recovery time is about one week.

Full Question: I am a 48 year old woman. I have a lot of wrinkles under my eyes which make me appear at least 10 years older. Is it safe to have Botox injections under the eye?

A very small amount of Botox can be safely placed underneath the eyes; however, this will not adequately address severe wrinkles. I at times use a very small amount if Botox underneath the eyes to address those patients who have some degree of the crow’s feet wrinkling that extends to the skin under the eyes when they smile. In order to adequately address these wrinkles and the quality of the skin under the eye I have seen the best results with either laser resurfacing or chemical peels. These help to remove the overlying fine wrinkly skin and replace it with new skin. Plus, if the wrinkles are due to excess skin, a conservative removal of the skin may also be needed.

Full Question: I’ve heard about otoplasty procedures in the past, but wasn’t exactly sure what they entail. What types of ear problems does otoplasty surgery fix?

Typically otoplasty corrects protruding ears. I perform an otoplasty by making an incision in the back of the ear so there are no visible scars. Sutures are then placed in specific locations through the cartilage to set back the ear and give it a less protruding shape. Otoplasty can also address excessively long earlobes as well.

Full Question: I’m a fairly young-looking 56 year old. I’m pretty happy with my overall appearance except for my neck which has been getting a bit saggy looking over the past year. What are my options for improving this?

Given your description, your best bet is a necklift. A neck lift is performed by making hidden incisions mostly behind the ears and performing a “tuck up” by removing the excess skin. If you have very prominent neck bands from the muscles in your neck, a small incision would be made underneath the chin to address these neck bands. Results from a neck lift are dramatic restoring a youthful neck line immediately. After the surgery you will need to where a head-wrap dressing which is removed the day after surgery and then replaced for one more day. The recovery time takes about a week to 10 days.

Full Question: How does a facelift improve facial contour?

A facelift allows for a more youthful re-draping of the skin of the face. Youthful facial skin adheres to the contours of our faces yet as we age our skin losses its adherence and simply put begins to ‘sag.’ Gravity plays a role in this process but others factors do as well particularly the loss of volume in our faces. Restoration of facial volume can be restored with facial fillers or facial fat transfer. Modern and proper face-lifting techniques tighten the underlying structures of the facial skin (fascia) and remove the excess skin that results. In this manner the results are natural appearing and the face does not appear unnaturally ‘tightened.’ The greatest gains from a facelift are in the restoration of the contours of the jawline. With age the skin in the face heads ‘south’ and we tend to lose the sharp demarcation we had between the face and the neck. A very nice result is attained from a facelift around the jawline by restoring this distinction between the face and neck thereby improving facial contour.

Full Question: I had a rhinoplasty eight months ago and I now have an open roof deformity. Can you explain why this happens?

An open roof deformity results after removing a hump on the nasal dorsum. Essentially every time you remove a hump, the surgeon is purposefully creating an open roof. Imagine if you will removing the very top of a roof and not bringing in the walls on the sides of the roof to close the hole you created, what you have left is an ‘open roof.’ When removing a hump from the nasal dorsum it is thus important to also perform lateral osteotomies (fracture each nasal bone) and allow the bones to shift inward. By doing so the ‘walls’ are brought in and the overlying hole that was created is now closed. The deformity is either created by not performing lateral osteotomies or performing incomplete osteotomies.