Rhinoplasty: The Centerpiece of the Face

Rhinoplasty, or nose surgery, is one of my favorite operations. It is literally surgery of sub millimeters. Patience, precision, and attention to detail are the keys to beautiful, long lasting results. But my approach might be different than many other plastic surgeons. When I evaluate the nose, I don’t think of it as an independent unit on the face. The nose is one subunit of the entire face including the chin and mid face. Therefore, when I operate on the nose, I like to evaluate the chin projection and mid face projection so that all three are in balance. A balanced face is important to frame a beautiful nose. And a beautiful nose is the centerpiece of a beautiful face.

When we look at the nose, we actually measure it in our minds to its base at the mid face and its relation to the chin. Therefore, I often include facial fat grafting at no additional cost with my rhinoplasties to balance the mid face with the nose. Surprisingly, sometimes patients who want a nose job don’t really need one. I’ve corrected large noses by augmenting the chin and mid face with fat and small chin implants. The result is often a more balanced face and a rejuvenated, younger face.

Part of the aging face is actually seen in the nose. Young noses are thinner and perkier with an obtuse angle from the lip to the nose. As we age, the nose tends to widen and drop. Combination fat grafting to the face and rhinoplasty is a very powerful combination to take years off both a man or woman’s life.

The picture below on the left is BEFORE rhinoplasty and fat grafting. As we age, our faces lose fat. Gaunt faces look old. Young faces are full of volume. Areas highlighted are areas that fat was injected into. This includes the midface (blue), premasseteric region (yellow), and the cheek (white contour).

There are no external incisions on her face. The nose surgery was performed with incisions hidden inside the nose. The nose was tilted, shortened, and refined. Fat was taken from her ‘love handle’ where she didn’t want it, and injected into her face through the corner of the mouth. Below is a complete set of BEFORE and AFTER pictures:

All About the Face: A Younger, Fresher Face and Neck

Fine wrinkles are often addressed with lasers, skin care, and Botox®. Deeper wrinkles may require surgery. Significant facial volume loss which begins in the 20s can be managed by injectables or facial fat grafting. Fat grafting is where unwanted fat from the flank is sucked out and processed.

It has been discovered that liposuctioned fat is rich with stem cells. Stem Cells are the undifferentiated cells that when placed in contact with the other organs will actually create or repair those organs. We have known for years that fat (which contains stem cells) injected into the face has corrected problems with skin pigmentation, wrinkles, loss of facial volume secondary to decrease in bony size, and other aging effects.

So in essence, fat grafting helps accomplish many of the things that lasers and Botox® does. The results are synergistic when combined. The skin after fat grafting is often greatly improved as the stem cells do its magic. Pore sizes diminish, and the skin takes on a new, fresher shine.

I often suggest fat grafting as a first line treatment to the aging face. When done right, the results are subtle but significant. It’s quick, relatively painless, and it can be combined with liposuction to reduce unwanted deposits. Fat grafting is the future of facial rejuvenation. And there are no visible incisions. Face lifts are required when the tissue is sagging. There are many different kinds of facelifts, but in general, an incision is made that is carried behind the tragus of the ear and the underlying tissues are tightened and the skin is redraped. Fat is also injected into areas that are deflated. The results are natural because we are not just pulling the skin back. We tighten structures BELOW the skin, and redrape the skin without a tugged look. The addition of fat helps restore the volume that has been lost and the results are natural and long lasting.

The aging neck is often also addressed with the aging face either This by liposuction or a neck-lift. A neck lift tightens the underlying neck muscles, the platysma, to restore that tight neck line you once had. A nice neck is crucial for a young, fresh face.

EXAMPLES OF FACIAL FAT GRAFTING

Approximately 50 cc of fat was injected into multiple regions of her face. It was suctioned from an unwanted area and processed in the operating room.

A long lasting injectable was used to correct the pre jowl region and marionette line groove. I often find that combination therapy works best for an entire face.

The woman above had both facial fat grafting and rhinoplasty to better balance her face. Both the nose surgery and fat grafting leave no visible scars. The incisions for the nose are hidden inside the nose, and the fat is injected through the corner of the mouth.

Above, a 23 year old girl is ‘beautified’ through the addition of volume under her eyes and in the cheekbone. Indeed, fat grafting is not just for the middle aged. It is a wonderful way to freshen a face or highlight pre-existing beauty as in the case of this young lady. Although it appears as if the nose and lips were augmented, they were not. Sometimes just balancing the face highlights other beautiful facial features!

Beautiful Bodies

Liposuction is a great tool for sculpting the body for both men and women. There are several different types of liposuction that you may have heard of including traditional liposuction, vaser or ultra sound liposuction, Smart Lipo, Power Assisted Liposuction (PAL), and Slim Lipo. They all do virtually the same thing, that is, to reduce unwanted fat deposits to sculpt a better figure. In skilled hands, traditional, vaser, and power assisted probably provide the most predictive results. These methods have an excellent safety profile and high satisfaction rate among plastic surgeons and patients.

Also, one should keep in mind that liposuction is not a tool for weight loss. The actual weight loss from liposuction is rather minimal. The idea is to remove fat strategically from areas. The most common areas are the belly, outer thighs, flanks, back rolls, neck, and knees. If you’re planning on losing weight, the best time to undergo liposuction is after you’ve met realistic weight loss goals. I often follow patients who are dieting so we can appropriately time their surgery for maximum results. That’s a critical element to good, long term results.

Also, liposuction is a great adjunct for other body contouring surgery such as abdominoplasty, brachioplasty to remove excess skin from the arm, and thigh lifts.

With liposuction, up to 4 to 5 liters of fat can be removed in the outpatient setting. It’s one of the most popular procedures in the United States for a good reason. It’s fast, safe, and provides immediate and long lasting results.

Traditional liposuction of thighs in a 42 year old woman (and breast augmentation)

Traditional Liposuction of the Waist

Of course beauty is in the eye of the beholder, but to many, age is perceived as the enemy of beauty. When it comes to the buttock, aging often results in a loss of perkiness and volume in specific areas.

There have been many studies evaluating the perfect behind from Brazil, and this knowledge has allowed well trained plastic surgeons to understand the aesthetic goals and skillfully recreate a youthful bottom. For instance, when women wear high heels, two things happened: For one, the legs appear longer, and two, the arch of the back is exaggerated which gives the illusion of a firmer buttock. This is called ‘hyper-lordosis’ and is a very attractive feature in women which is created with posture, high heels, or yes, even plastic surgery.

A better butt can be created with your own unwanted fat. I prefer using a combination of liposuction above and below the buttock and take fat from the flanks or belly. This fat is then processed in the operating room and injected into the buttock mounds. The goal is to restore projection and perkiness. The results are immediate, dramatic, and long lasting. And there are virtually no visible scars.

Abdominoplasty, or ‘tummy-tuck’ is an excellent option to remove the ‘pudge’ below the belly button, particularly after pregnancy when the muscles separate. This is often combined with liposuction. The unwanted fat from lipo can be used to plump up the buttock – something that was suggested to the patient below. Or, the unwanted fat can be placed into the face to restore youth (see The Face page).

Abdominoplasty or Tummy Tuck

Injectables & Fillers

Fillers. It seems like everybody’s getting something injected somewhere.

The idea of fillers is to replace volume that is lost with aging. As we age, our face deflates like a balloon. If you look at pictures when you were in high school, even if you were thinner, your face was fuller, particularly in the cheeks, temples, and lips. Our face can lose up to a cc per year in our 20s and the fat loss accelerates as we age. Sometimes facial fat grafting is a great way to replace volume. Other times, injectables work well.

There are new injectable products emerging all the time. Most of these products are exceptionally safe. There are temporary fillers, permanent fillers, and semi-permanent fillers. The safest ones are the temporary ones. Silicone is a permanent facial filler that can lead to terrible deformities down the road. I won’t inject silicone into the face.

Man semi-permanent fillers are new and very safe. Common semi-permanent fillers include Sculptra® and Radiesse® among. These products are not used for lip augmentation, but they do work well for filling out cheekbones and smile lines. They can even rejuvenate the hands. Unfortunately, many plastic surgeons ignore the hands when it comes to rejuvenation. The hands are a critical aging zone that should not be neglected. Fat, Radiesse®, and lasers are wonderful ways to rejuvenate the hand.

The most common products are the hyaluronic acid based products such as Restylane®, Juviderm®, Perlane®, and Prevelle®. These last up to 6 months and are great for the lips.

Below is an example of ‘filling out the face’ with a hyaluronic acid product, Juvederm Ultra, in the office. Multiple areas were addressed to add subtle but significant changes to the face simulating a facelift including the cheeks, marionette lines, nasolabial folds, and the jaw line to ‘hide’ the presence of a jowl. This picture is taken 4 days after injection. There is very little down time. This patient went out to dinner the same night. A small, temporary bruise is apparent below the right lip. This was gone by the end of the week.

Sometimes a combination of fillers and fat grafting is necessary to restore youth.

Botox® has gained tremendous popularity over the last 5 years. It is most widely known as a vehicle to treat facial wrinkles particularly in the forehead, frown lines, or crow’s feet. It works by temporarily weakening or paralyzing the muscles that cause wrinkles. And it works well. It usually takes a few days for it to begin working and its effects can last over 4 months.

However, Botox® has some other very interesting uses in the cosmetic world. Botox is also FDA approved to treat excessive sweating in the armpits and palms. This is actually pretty common among celebrities before big events and among people who do a lot of hand shaking for work. Just one in the office treatment can last as long as 6 months. The results are amazing.

Believe it or not, Botox® is also used to treat migraines and severe headaches. Just a pinch in the frown line area has been shown to significantly reduce the incidence and intensity of migraines. Although the mechanism isn’t completely understood, it works. And it works very well.

Also, Botox® can also be used to feminize the face by shrinking the jaw muscles in women. This is done with just a few tiny injections in the jaw.