Lower Face and Neck Lift
Mid Facelift/Cheek Lift
Upper Blepharoplasty and Ptosis Surgery (upper eyelid surgery)
Lower Blepharoplasty (lower eyelid surgery)
Otoplasty (surgery for prominent ears)
Microtia and total ear reconstruction (surgery for small or missing ears)
Fat grafting (“liquid facelift”)
Fillers and Botox™
Abdominoplasty (“tummy tuck”)
Brachioplasty (“arm lift”)
Liposuction/liposculpture and Fat grafting
Fat grafting and Transfer
I am happy to say that a good portion of my practice is taking care of my male patients. Males in general have very different issues than women and your anatomy is also completely different. Males have much sharper edges to their face, stronger features and require a completely different “aesthetic eye.” My extensive training in the hospitals associated with the military gave me a true appreciation of the different problems and wishes of my male patients. Below is a list of operations that I commonly get referrals for although it certainly is not exhaustive. The information below has been adjusted for relevancy to my male clientele.
Surgery for gynecomastia can be done in a multitude of ways depending on the origin of your issue. Some men have a large breast bud (the hard tissue right below the nipple-areola complex) while others have an excess of fat throughout the breast itself. It is also possible to have both. While gynecomastia can be caused by different drugs, neoplasms and hereditary conditions, the vast majority are idiopathic—meaning there is no direct cause. After a detailed history and physical exam, we can create a surgical plan to correct the gynecomastia. Some patients can be treated with liposuction alone while others need direct excision of tissue. My preference if liposuction alone will not treat the problem is a small incision at the bottom of the areola, which usually hides the scar very well. Direct excision is then done in a conservative fashion.
Secondary gynecomastia surgery is for patients who have either failed a primary treatment or the gynecomastia has recurred. In addition, an overaggressive surgical procedure can leave what is called a saucer deformity where it appears that the nipple-areola complex is collapsed. I tend to use a combination of fat grafting, liposuction and /or direct contouring to correct this difficult problem.
In all cases, correction of gynecomastia is done in an outpatient setting under IV sedation or general anesthesia. Recovery time is minimal although I ask my patients to wear a compressive garment for a few weeks if liposuction is done. After a few weeks, the garment is worn only at night.
A very large portion of my time is dedicated to my facial aging practice. Unlike many other areas of the body, maintenance of the aging face is a continuum that links me and my patients over time. With age, the face changes in three ways:
1. The soft tissues of the face (skin, fat and connective tissue) fall with gravity over time
2. The facial fat atrophies over time leaving a hollowed appearance in very distinct areas
3. The skin ages with exposure to sun, tobacco use and the oxidation reactions that go on throughout our lifetime.
My goal as a physician dedicated to facial aging is to help my patients through the process from A to Z. I have spent a great deal of time and effort to study and to understand these three processes at a basic science level while also spending time with masters in each of these fields. Each face has a completely unique set of needs and challenges. I want to understand your wishes, to discuss what we can achieve, and to design procedures that will meet your needs and wants. One of my great mentors used to explain that aging is not always a problem that requires a surgical solution. Not all patients benefit from surgery. For this reason, I have dedicated time not only to understanding Plastic Surgery of the face, but also fat transfer and non-surgical solutions as well. In the right patients, neurotoxins (Botox) and fillers (Juvederm, Restylane, etc) offer a great deal of benefit. Likewise, skin care is paramount and the cornerstone to maintenance of facial vitality. My goal is to guide you through the process of maintaining the aesthetics of your face in perpetuity. In many people, the appropriate solution involves a combination of skin conditioning, surgery, fat transfer, and/or fillers and Botox over time. By being conservative and utilizing multiple tools to affect change, long lasting and natural results can be achieved.
Lower Face and Neck Lift
A lower face and neck lift can be a very powerful tool to rejuvenate the lower third of the face. Areas that can be greatly affected include the neck, jawline, jowls, and corners of the mouth. Most men concentrate on the loss of definition in their neckline as well as the muscle bands that occur in the midline. A lower face and neck lift can correct these issues by lifting the tissues below the skin and tightening the muscles of the neck. The skin is simply redraped over the tissues below and closed under no tension. For males, it is very important to define the jaw and chin line as this is associated with masculinity.
Skin stretches, and thus is used as a blanket over the tissues below. I believe that relying on the skin to hold up the face is a recipe for an operated look, wide scars and deformities of the ear and hairline that are tell-tale signs of a facelift. All my incisions are placed in natural creases and hidden in the hairline. Incisions are designed very differently for men as we tend to wear our hair short and have sideburns.
This procedure is done typically under general anesthesia and I am adamant that patients are observed overnight by a registered nurse in an accredited facility. This is for your safety and helps to make your post-operative experience more comfortable. Blood pressure control is absolutely paramount, and I will work with your primary physician if you have issues with hypertension to get this controlled before and after surgery.
What a lower face and neck lift will do:
Correct the neck line
Straighten the jaw line
What a lower face and neck lift will not do:
Treat the nasolabial (junction of cheek and upper lip) folds
Treat the lower eyelids
Lift the cheek
Treat wrinkles around the mouth or lips
For this reason, I often do a combination of other procedures, dermabrasion, fat transfer, and fillers with this procedure as well as skin conditioning. By using a balanced approach, results are more predictable, long lasting and natural. Facial harmony is often thrown out of balance by applying one surgical procedure to every aging face.
Mid Facelift/Cheek Lift
A mid facelift, also known as a cheek lift, can be a very powerful tool to rejuvenate the middle third of the face. Areas that can be greatly affected include the nasolabial folds (junction between the cheek and lip), tear trough (the junction between the lower eyelid and cheek), bags around the eyes, and wrinkles around the eyes. Most men concentrate on the heaviness and descent of their cheeks as they age. A mid facelift can correct these issues by lifting the tissues below the skin to rejuventae the cheek bones, lower eyelids and nasolabial folds. However, this procedure must be tailed for some men, especially if you have a wide midface.
When having a mid facelift it is very important that your surgeon be familiar with not only this procedure, but also its impact on the lower eyelids and width of the face. The procedure is done in a very different manner depending on whether your face is long and narrow, or short and wide. In addition, great care must be taken to resuspend and protect the lower eyelid to prevent retraction and eyelid malposition.
This procedure is performed under general anesthesia and is often used in combination with other procedures to rejuvenate the middle third of the face.
A brow lift can be a very powerful tool to rejuvenate the upper third of the face. Areas that can be greatly affected include the eyebrows, upper eyelids, glabellar (area between the eyes) wrinkles, forehead wrinkles, and crow’s feet (wrinkles next to the eyes). Like most procedures the brow lift can be performed in several ways depending on the patient’s length of forehead, hairline, and brow shape. Some patients are candidates for an endoscopic brow lift, which is a minimally invasive alternative where small incisions are made behind the hairline and all surgery is done with a camera and small instruments. Other approaches are used when the goal is to not only lift and contour the eyebrows, but also to shorten the forehead. A long forehead is a sign of aging (think of balding). For most men, I use an endoscopic or other minimally invasive approach to avoid scars in areas that may be devoid of hair in the years to come.
The attractive brow is very different in men and women. For men, the brow usually sits at the bony ridge above the eye itself and has a rather flat shape. Contrastingly, women have an arched brow that sits in a higher position. While the brow lift can be a very satisfying procedure, it must not be overdone because patients can look “surprised.” In men, I tend to spend a lot more time to contour the brow and muscles around the brows and eyes to reduce wrinkles in the future.
This procedure is performed under general anesthesia or IV sedation and also is used in combination with other procedures to rejuvenate the upper third of the face.
Upper Blepharoplasty and Ptosis Surgery (upper eyelid surgery)
Upper blepharoplasty can be a powerful tool to rejuvenate the orbit. As we age, excessive upper eyelid skin begins to weigh on the eyelid itself causing the lid to droop and the eyelashes to turn down. Often patients begin to complain of difficulty seeing because the eyelid skin and eyelid margin begin to obscure the visual axis. Especially in men, heavy brows and eyelids can lead to difficulty seeing and a “droopy the dog” appearance.
I must explain that you cannot look at the upper eyelid without also looking at the eyebrow as well as the muscles that hold up the eyelid. Many patients that come in requesting upper eyelid surgey, also have issues with their eyebrows, and at times, issues with the muscles that lift the eyelids. In order to correct these issues, you surgeon must be very familiar and comfortable with eyelid anatomy, aesthetics, and the interaction between each of the structures.
At times, this procedure can be done by just removing excess eyelid skin. More often than not, to truly rejuvenate the orbit, I must deal with a drooping eyelid (ptosis surgery) as well as the fat compartments within the eyelid itself. Believe it or not, there are 7 layers between the skin and the conjunctiva that overlies the orbit. Each has a very important function, and surgery in each of these layers has a different effect.
The Asian Upper Blepharoplasty requires even more expertise as the anatomy differs quite substantially from other ethnicities. The fat sits lower down toward the eyelid margin and normal attachments are often absent. For this reason, many Asian Americans have no eyelid crease. When performing blepharoplasty, if requested, this crease can be constructed by creating the normal attachments within the layers of the eyelid.
This procedure is performed under general anesthesia, IV sedation or with local anesthesia, and also is used in combination with other procedures to rejuvenate the upper third of the face.
Lower Blepharoplasy (lower eyelid surgery)
Lower blepharoplasty can be a powerful tool to rejuvenate the orbit. As we age, excessive lower eyelid skin begins to weigh on the eyelid itself causing the lid to droop as well as the muscle below that closes the eye. Behind the lax skin and muscle, orbital fat often protrudes. Patients complain of a baggy lower eyelid and/or wrinkled skin. This problem is exacerbated in males secondary to a heavier midface.
The lower eyelid has an intimate relationship to the cheek below. Depending on each patient’s individual lower lid characteristics, a unique operation is tailored. Some only need a minor pinch of skin removed, whereas others need either fat removal or repositioning. With these techniques and others, the junction between the lid and the cheek can be smoothed and returned to the convexity of youth. Several approaches may be used and the incision is either hidden below the lash line or behind the eyelid itself.
Revision lower blepharoplasty is a special interest of mine given that the most common complication of this procedure is eyelid malposition. Stigma of lower blepharoplasty can include a skeletonized eyelid, eyelid retraction, scleral show (the white below the colored part of the eye), and a rounded lateral eyelid margin. Special procedures must be used to reposition the lower eyelid, redistribute tissue at the lid-cheek junction, and resuspend the lateral eyelid margin.
This procedure is performed under general anesthesia, IV sedation or with local anesthesia, and also is used in combination with other procedures to rejuvenate the middle third of the face.
Otoplasty (surgery for prominent ears)
Otoplasty is the term used for changing the shape and contour of the ears. Children and adults often complain of prominent ears or earlobes. Prominence can be in either the upper, middle or lower third of the ear and has many different causes.
Correction of these issues is usually performed by making a small incision behind the ear and repositioning and/or removing portions of the cartilaginous framework below the skin. This procedure is performed under general anesthesia or IV sedation.
Microtia and total ear reconstruction (surgery for small or missing ears)
Microtia is a term used to describe a congenital deformity where children are born with extremely small ears or part or all of their ear missing. Correction and reconstruction requires a multi-stage procedure where the whole ear is reconstructed from rib cartilage. Likewise, a patient who is missing an ear secondary to trauma or cancer may need total ear reconstruction.
I prefer to use the patient’s ribs to carve a framework because the ribs are the best source of cartilage in the body. People with deformities of the ear due to any reason are missing the underlying cartilaginous framework. Similar to carving a sculpture out of ice, the rib cartilage is carved into an ear framework. After this is done, the framework is placed under the thin skin on the side of the head. In later procedures, this framework is lifted to give the ear projection and tissue is rearranged to form an earlobe. Every attempt is made to make the ear the same size as the opposite ear and similar in projection.
The initial rib procedure is performed under general anesthesia in an outpatient setting for adults and at times, in an inpatient (hospital) setting for children. Later procedures are all done as an outpatient. All procedures are performed under general anesthesia.
Fat grafting (“liquid facelift”)
Fat grafting is not a new concept, but may of its applications are and its role in aesthetic and reconstructive surgery continues to be expanded. A suction cannula is used to remove fat from one part of the body (hips, flanks, abdomen, etc.). Once it is removed, it is processed to preserve fat stem cells, also knows as adipose stem cells. These stem cells are separated and injected back into the patient. Thus, the main benefit of this procedure is using a patient’s own tissue to rebuild and sculpt.
As we age, everybody can see that our tissues become loose. However, two other very important things happen: 1) our tissues atrophy and we lose fat in our face, and 2) our skin suffers ongoing damage from UV radiation (sun) and toxins.
I use fat grafting as a technique for many of my aesthetic procedures. It is a phenomenal tool to augment the cheeks, eyebrows, eyelids, and jawline. Likewise, it can be placed in folds and valleys to correct wrinkles and blend unnatural junctions. Small aliquots of fat are carefully deposited in targeted areas and allowed to regain their own blood supply. At times, several treatments are desired and required for full correction. Because of the stem cell component of fat grafts, it is believed that fat also rejuvenates the skin. In fact, I have used fat grafts to heal wounds caused by radiation damage!
Good candidates for this procedure are people who are fairly stable in weight. While fat is a fantastic tool, it can have issues if used haphazardly or in a patient who has the potential to gain twenty pounds or more. The fat can grow can and give the patient a very bizarre look. Also, fat can be overused. Because it is such an exciting tool for rejuvenation, some patients’ faces have been filled with fat giving them a round appearance. Like most things in life, moderation is a good rule of thumb and I have unfortunately had experience taking out fat in patients who have been over-injected.
For me, fat transfer/grafting is a great way to augment an aesthetic result. What I mean is that it can be used with other procedures with a synergistic effect. Many of my patients who get facial procedures also have fat grafting because oftentimes it supplements conventional surgery. For example, a lower face and necklift can give a patient a nice, angular jaw and neck line. For patients who have small chins or a large jowl, it is often best to add a little fat and pull less hard on the face and underlying tissues. By being conservative but using each procedure in synergy, I can achieve a great result that does not appear surgical or “tight.” Likewise, I can use fat for patients who have been hollowed by previous surgical procedures that were overaggressive. A great example is the hollow upper eyelid or neck that has been over-skeletonized.
Fat grafting is done in an outpatient setting either under general anesthesia or IV sedation.
The chin is often an underappreciated area of the face. Many patients who do not like their lower face or nose often underestimate the impact their chin has on physical appearance. A weak chin results in a mandible that in underprojected. On the contrary, a large chin can be a very masculine feature.
Unlike many issues in Aesthetic Surgery, a small or retruded chin is most often a problem of bony structure. Once I realized this, I learned how to place chin implants, which would augment the bony structure of the chin. After doing these, I also realized the limitations of the implants. Most people have asymmetric chins, and the implants may make them bigger but this also augments the asymmetries. Also, implants really only change the projection of the chin in one plane. Many patients have issues in multiple dimensions. Because of this, I worked with Oral and Maxillofacial Surgeons to learn how to augment and reduce the chin my moving the mandible itself. Since I fix fractures of the mandible, I am used to working in this area but working with the Maxillofacial Surgeons gave me a true appreciation of how the bony structure of the mandible affects the way the face appears. Depending on the issue, I now use both techniques.
I do this procedure by itself but at times suggest it for patients undergoing rhinoplasty and lower face and neck lifts. It is done under general anesthesia or IV sedation in an outpatient setting.
Fillers and Botox™
Fillers (Restylane™, Juvederm™, Sculptra™, Radiesse™, etc) and Botox™ are one of the largest growing parts of my current practice. It is important to understand what they do and do not do. For the right patient, I can correct wrinkles, plump lips, accentuate brows and eyelids, and blend facial units right before my patients’ eyes. Since the results are immediate with fillers, patients love that they can help to direct their own aesthetic while I slowly enhance subunits of the face.
I work very hard to make sure that this is a good experience for my patients. I too often hear that these are painful procedures, and they really don’t have to be. Taking the extra time, being gentle, using ice and even local anesthetic when necessary, most patients have a relatively painless experience with very little downtime.
Botox™ is great for the prevention and treatment of wrinkles. Botox™ Cosmetic is approved for use in the glabella (the area between the eyebrows). However, I often use this “off label” for wrinkles of the forehead, eyes, chin, and neck. I also use it to raise the lateral eyebrows and corners of the mouth. In addition, I use Botox for the treatment of Migraine headaches and excessive sweating in the armpits.
Likewise, fillers are a great way to correct mild to moderate contour issues and wrinkles. I use them literally all over the face and often in conjunction with surgery to augment the final result. Conventional injections include the nasolabial folds (junction of the cheek and upper lip), but I also use them to augment the eyebrows, eyelids, area in front of the jowls, junction of the lower eyelid and cheek, chin, lips, and columns in between the lips and nose. These minor enhancements lead to a more refreshed look with the advantage that no surgery or incisions are needed.
While many doctors have their nurses and aestheticians do these procedures, I do all of my injections myself. The reason is that I do surgery in these areas on a weekly basis and know exactly where the muscles are, how they contract, and what is under the skin I am injecting. I truly think this improves the cosmetic results. First and foremost, I need to understand exactly what the patients expects to get from the treatments and what he or she desires. For example, I use different concentrations and different products depending on how “animated” patients are, what part of the face they wish to work on, and what they do for a living. If a patient is on television or in sales, it is often not advantageous to completely weaken facial muscles. If the whole face is moving while you speak or you smile but the upper third is completely lifeless, people will notice and wonder why your face looks abnormal. My goal is a very natural result, and doing the injections of fillers and Botox™ myself is paramount in any facial aging practice. Always ask yourself, is the person doing my procedures able to fix or adjust things if I don’t like the result? Can they deal with potential complications? If the answer is no, I would never let them work on my face.
These procedures are done in the office. Patients may drive themselves home and I often advise no exercise or bending at the waist that day and night. Aspirin and Ibuprofen should be avoided until the next day. Other than that, there are no restrictions.
Lip augmentation has become a very popular procedure. However, I would use the term lip sculpting. We have all seen people walking down the street who look like Daffy Duck kissed them.
The lip has a very specific shape. Surgically correcting cleft lips was a big part of my surgical training. In attempting to reconstruct the “normal” shape of the lip from cleft lip deformities, I learned a great deal about the shape and definition of the lips. I too often see very large lips with absolutely no definition. Not all lips are created equal, and I approach every lip with a different set of tools and techniques. Since I have operated on so many of these, I really do understand the importance of the very thin skin, the underlying muscle, the junction of wet and dry skin, and the junction of lip and facial skin. Without an appreciation for these characteristics, it is easy to see why people injected with filler have large, amorphous lips.
The first thing to understand is that a little goes a long way. When I do lip augmentation with fillers, I often use less than one third of a syringe in each lip. By the time you have injected four or five times, the lip is so swollen that it is hard to see any definition. I then ask patients to return in 5-7 days for the creation of definition and final symmetry if needed. I would say about 25% of patients need this done for an optimal result.
The fantastic thing for patients is they can show me examples of what kind of lips they do and do not like. The final result is created in a graded fashion and I often do this with my patients able to face a mirror so they can tailor their final aesthetic. Injections are done in several areas depending on if someone needs volume, definition, pout, or a combination of the above.
I always suggest that patients start with a filler that lasts for 6-8 months to make sure myself and the patient are comfortable with their new look. Once we nail your vision of beauty, we can use fillers that last longer or even permanent implants. In any facial aging practice, it is important to be able to undo your results when it comes to fillers or lip implants because people change their opinions of what they like and don’t like. For this reason, even my permanent implants can be easily removed and I carry an antidote for the fillers. I see many patients for revisions and second opinions so this has become a part of my facial aging practice.
These procedures are done in the office and if needed, with local anesthesia. My goal is for your procedures to be pain free. It is obvious to me that if you are in pain, you are not going to have a great memory of the experience no matter how good you look.
Dermabrasion has been proposed to do all sorts of things. Personally, I use dermabrasion for 2 specific purposes. Dermabrasion in my hands is an excellent tool to reduce wrinkles around the mouth and to reduce scarring from acne. With local anesthetic the area is numbed and dermabrasion is used to remove the superficial layers of skin. The area remains pink for approximately 7-10 days and the skin naturally heals over this time. I also use this technique in combination with other surgical procedures. It is important to note that this tool should never be used for severe wrinkles or deep scarring. Aggressive use of dermabrasion can cause more scarring and even pigmentation issues. For this reason, I do all of my own dermabrasion in the office and in the operating room.
Since my first years in training, I have had a true passion for surgery of the nose. This began with my first book chapter on nasal reconstruction, and has continued with my publications and presentations about the nasal tip, the relationship between the brows and nose, and the embryology of nasal shape and structure. I was VERY fortunate to have been mentored by some of the most famous and talented rhinoplasty surgeons in the world. My apprenticeship included reading their books, directly assisting in over 100 cases, doing my own cases, and constant re-evaluation of my results. I will continue to be a student of rhinoplasty throughout my career, and strive to give back to the specialty through my ongoing research, presentations and publications. In addition, the majority of my rhinoplasty experience for the first few years was primarily men as I was working with veterans at the Long Beach Veteran’s Hospital. It was there that I learned the major differences between male and female anatomy, breathing issues and expectations.
Rhinoplasty in my opinion is the most challenging operation in Plastic Surgery, and my passion has led me to study with amazing surgeons and to present my work at national rhinoplasty meetings and in the Aesthetic Surgery Journal, which is the most widely respected aesthetic journal in the world. I could dedicate a whole website to rhinoplasty including anatomy, indications, and all of the different techniques and issues that arise. A true understanding of this operation and its implications years after the surgery requires ongoing study and being a part of the ongoing knowledge that is generated in this exciting field. I currently am a reviewer for the Aesthetic Surgery Journal and review articles related to rhinoplasty.
I have divided the operations into primary and secondary/revision rhinoplasty. In breast augmentation, follow up operations are expected because implants should be replaced about every 10 years. However, in rhinoplasty, experienced surgeons often deal with the second, third, fourth, and even more operations. This is because this is such a difficult procedure and has changed more drastically in the past 20 years than any other aspect of Aesthetic Surgery of the face. I perform both endonasal (closed) as well as open rhinoplasty depending on the patient, including their underlying anatomy and wishes.
Primary rhinoplasty refers to a patient’s first operation on their nose. When I sit down with you during a consultation, I need to understand the 3 things that you do not like about your nose. Common complaints include:
- It is too big
- I don’t like the bump on my nose
- My tip plunges when I smile
- My nose is crooked
- I can’t breathe
- It looks like a woman’s nose
- My nose looks heavy
- My tip has no definition
- My nose doesn’t fit my face
After an initial history and physical examination (both internal and external), I will take pictures of your nose in 8 to 10 standard views so that we can sit down and begin the discussion of what can be done. Taking pictures and being able to go over them with you is paramount to a successful result. We need make sure that your goals are realistic, and what you nose can look like after an operation. At our pre-operative visit (final visit before the operation day), we will again go over your pictures and goals. By this point, I have formed a detailed plan for your operation, which will be confirmed.
Truly understanding the rhinoplasty operation involves understanding the dynamic changes that occur during the operation, and also how the function of the nose is affected. If you have difficulty breathing after your operation, then it was not successful. Part of doing each surgery is reconstructing the foundation of the nose. In the past, rhinoplasty surgeons used destructive techniques to make the nose smaller and more “refined.” Oftentimes, patients would have collapse of their airways and portions of their nose sometimes years after the operation. To avoid this, I will reconstruct the foundation of your nose during the rhinoplasty. Even though your nose may appear more refined, the functional areas of your nose are always strengthened as part of my operation. I spent a good portion of the beginning of my career doing rhinoplasties for patients with previous facial trauma (broken noses) and breathing issues because of previous rhinoplasties. In learning to fix these difficult problems, I apply many functional techniques for my primary rhinoplasty patients to prevent issues in the future.
Open vs Closed Rhinoplasty
Many patients ask me whether I do open or closed rhinoplasty, and the answer is both. Open rhinoplasty, involves a small incision on the outside of your nose at the columella (area between your nostrils). This incision is less than 5mm in length and the scar is virtually imperceptible in almost all patients. A closed rhinoplasty is done all on the inside of the nose with no external incision on the columella. So why not do all rhinoplasties closed and avoid the incision?
My approach always depends on the complaints of each patient and what needs to be done. During your consultation, I will go over exactly why and how the rhinoplasty will be done. An open approach gives me much more control over certain parts of the operation; for example, the nasal tip.
Secondary, also known as revision, rhinoplasty is a totally different operation than a primary rhinoplasty. The operations are more difficult because of scar, lack of graft material, unknown variables depending on the first surgeon’s operation(s), and functional problems (difficulty breathing). While some surgical maneuvers are the same as a primary rhinoplasty, more advanced techniques are also needed and often employed. These include the need to take cartilage grafts from the ear or rib. My preference is to confine the operation to the nose itself, but at times new donor sites are needed depending on the individual situation. The point is that your surgeon MUST be comfortable with these techniques to confront the unique challenges of secondary rhinoplasty. I will always try to get the operative report(s) from your initial operation(s) so that I can accurately plan a successful rhinoplasty. These reports help me to understand what was done in the past, and what graft material may be present to help with the reconstruction.
Just like in a primary rhinoplasty, I begin by asking each patient the 3 things that he/she does not like about their nose and wishes to be changed. Common complaints include:
- I can’t breathe
- My nose is still not refined
- My nose is still too wide
- My nose is turned up
- My nose has collapsed
- My tip is too pointy
After we have defined your complaints and goals, 8 to 10 standard photographs will be taken so that we can sit down and talk about what can be changed and what you can expect. Underlying factors such as very thick skin may limit certain improvements, and it is very important that we are on the same page in terms of expectations. We will look at all the views of your nose together and simulate possible changes. In doing this with each patient, we can set goals and understand what your nose will look like after the operation.
In secondary rhinoplasty, preserving function is very important. Unfortunately, I too often see noses that have been skeletonized by destructive techniques in an attempt to make the nose smaller. The nose may be smaller, but has lost its structural support. When doing your secondary rhinoplasty, I will make the desired changes while also reconstructing the foundation of your nose. For true success, your nose needs to look better and you need to breathe better. You may not realize it, but small improvements in your ability to breathe can help you sleep better and feel more awake during the day. With every rhinoplasty (primary and especially secondary), I am constantly evaluating how each surgical maneuver effects the structure of the nose. It is not uncommon that patients will have work done on their septum (which is often deviated), internal valve, external valve, and turbinates. By doing this, I am focused on the four areas of your nose that give it structure and good nasal air flow.
Ethnic rhinoplasty refers to rhinoplasty for patients of non-Caucasian backgrounds. Certain populations including Hispanic, African-American, Indian, Asian, and Middle Eastern (this list obviously includes others) present unique challenges because of differences in skin quality/texture, underlying strength of cartilage, and completely different objectives by the patients. For example, many of my patients from Asian descent want a larger nasal dorsum and radix (area between the eyes). This is in contrast to my patients of Persian descent who uniformly want this area to be smaller and narrower. Thicker skin in general in all of these populations presents new challenges as underlying changes are less likely to be seen.
Because of my training and subsequent practice in Southern California, and specifically Orange County, I am comfortable with the differences in each subset of patients and know how to deal with these unique challenges. These challenging cases are exciting to me, and I would estimate that 50% of my rhinoplasty practice is on patients of non-Caucasian descent. It is so important that your surgeon understands the differences between different ethnicities when it comes to rhinoplasty surgery. The problems are different, the techniques are different, and the realistic expectations can be different.
Male rhinoplasty is much different than female rhinoplasty. In general, men have thicker skin, larger structures, a higher likelihood of having a history of trauma, and different goals. My male patients are often looking to gently refine certain aspects of their nose. Breathing issues also seem to be a much larger issue with men. Let’s face it, because of our more aggressive nature we are much more likely to have hit our nose at some point during our life. This is oftentimes during childhood and we don’t remember it. Even I broke my nose twice during my life – once playing baseball and once surfing!
Similar to all my initial rhinoplasty consultations, we will discuss your goals and objectives. I always ask what are the 3 things about your nose that you do not like. We will take 8 to 10 standard photographs, and discuss what can be realistically changed, and what the result will look like. My physical examination includes both an external as well as an internal examination. It is very important that I look at your nasal septum, your turbinates (think of them as the humidifiers of the nose but also an important structure when it comes to airflow), and your valves. I will watch you breathe normally as well as on forced inspiration. I need to get an accurate picture in my head of what your nose is likely to look like under your skin and what may contributing to your aesthetic and functional issues.
Once the goals are clearly defined, I will design an operative plan from A to Z that we will go over during your final pre-operative visit. In all of my rhinoplasty operations, the complete plan is defined and structured up front. With this, the results are much more predictable and this equates to less time in the operating room for the patient.
As explained above, a large portion of my rhinoplasty training and initial experience was at the Long Beach Veteran’s Hospital. There I took care of a large number of male patients requesting and needing rhinoplasty for a large variety of indications. As a man, you need to make sure that your surgeon is comfortable with and has experience with rhinoplasty in males. Compared to women, the issues are different, the surgical techniques are different, and the goals are different.
What to Expect After Your Rhinoplasty
All rhinoplasties are done under general anesthesia in an outpatient setting (surgery center). After your rhinoplasty, there are several things you need to know. I always recommend that patients keep their head elevated as much as possible, and to sleep on 3 pillows for elevation at night. The swelling can be uncomfortable for the first 2-3 days, after which it will decrease. Bruising is often minimal, but can extend laterally to the eyelids. A cast will be placed on your nose for 5-7 days after the operation and you will have splints on the inside of your nose for the same amount of time. During your first post-operative visit, all dressings, casts and sutures will be removed. Although your nose will still be swollen, you will immediately recognize the changes made during your rhinoplasty.
Over the next few weeks, I will teach you how to tape your nose at night to minimize swelling and maximize the healing process. After the first 3 weeks, the majority of your swelling will be gone. However, you must understand that swelling will remain in minimal amounts for months after. Anybody who performs this operation and tells you differently is not being honest. The nose is a very sensitive organ with a thin skin sleeve (notice it gets cold when the rest of your face does not). Healing takes up to a year even though the subtle changes are often only apparent to me in photographs after the first 3 weeks.
During these first 3 weeks, I ask my patients to avoid nose blowing, spicy food, and salty food. After 1 week, saline nasal spray is OK. Your breathing is normally significantly better right when the splints come out, but it will continue to improve over 6 months as the inside of your nose heals. Patients with previous breathing issues often report better breathing, exercise tolerance, sleep, and energy during the day.
Body contouring is a passion of mine because these procedures can have such an enormous impact on the way my patients look. Body contouring is not just removing excess skin and/or fat. Achieving excellent surgical results begins by having an understanding of different body types and what will look good on each person. I am not really sure if this can be taught in school or in a book. Below I discuss the different body contouring procedures I do but a consultation is absolutely necessary to a critical evaluation and surgical plan. Good judgment depends on your Plastic Surgeon’s “aesthetic eye,” and it should be clear during your initial consultation that your doctor has this or not. These procedures are used to sculpt the body down from its original form.
Abdominoplasty (“tummy tuck”)
An abdominoplasty or “tummy tuck” is a common cosmetic procedure used to remove excess skin and fat from the area below the belly button. For my abdominoplasty, I tend to use an excision pattern common in Brazil because I believe that the final contour of the abdomen and flanks (love handles) is far superior to the traditional excision pattern used in the United States. In addition, a new belly button is made and I make several types depending on patient preferences. Your new belly button can be vertically oriented and/or have a hood at the top, which looks very natural.
Patients that are good candidates for this procedure have gained and lost 20-30 plus pounds from natural weight variance. As the weight is lost the skin unfortunately often does not contract back to its original state and there is an excess of skin that no amount of exercise will get rid of. In addition, this weight gain often leads to a rectus diastasis, or laxity of the abdominal muscles. During the procedure, these muscles are brought together to not only tighten the core, but also to narrow the waist and to give the body a more aesthetic shape.
This is not a difficult operation for a Plastic Surgeon to perform and get a mediocre result. What I mean by this is that by removing excess skin and fat, the patient will look better. However, getting a phenomenal result requires surgical skill, planning and operative time. Too often I see scars that are very high, unattractive belly buttons and patients who remain with a cylindrical shape. The patient looks better than before the operation, but the shape is far from ideal. I make every effort to hide the scars in your underwear or short lines and to create a masculine abdominal contour. This is what separates an average “tummy tuck” from an excellent one.
An abdominoplasty or “tummy tuck” is done under general anesthesia in an outpatient center. I often do this concominantly with liposculpture. Depending on the extent of your surgery, some patients go home the same day and some I have spend the night at Newport Beach Surgery Center for monitoring. It is imperative that patients begin getting out of bed and walking the night of surgery so I take several measures to assure adequate pain control including pain pumps and specially formulated nerve blocks.
Brachioplasty (“arm lift”)
A brachioplasty or “arm lift” is reserved for patients who have lost a significant amount of weight with deflation of their arm volume and excess skin. Some patients simply have excess skin, while others have a combination of excess skin and fat. I perform a simple pinch test in the office to determine the cause when a patient does not like his or her arm contour.
Depending on the cause either direct excision, or liposculpture followed by direct excision, is used to improve the contour of the arms. I prefer to hide my incision in the posterior part of the arm as it tends to heal better in this area. For patients with significant laxity of tissue the area of removal sometimes extends across the armpit and down the lateral chest wall. During my training, I had the privilege of working with one of the world’s experts in massive weight loss body contouring, and many of my principles and techniques are derived from my years of experience with him.
A brachioplasty or “arm lift” is performed in an outpatient setting and patients go home the same day. In patients who have lost a significant amount of weight, I sometimes combine this procedure with breast or abdominal procedures as well. In addition, for massive weight loss patients I combine this with a breast and back procedure known as an Upper Body Lift, which is discussed in the Massive Weight Loss section.
Massive weight loss (post – bariatric procedures) – Lower Body Lift, Belt Lipectomy, Upper Body Lift, thigh lift
Body contouring for massive weight loss patients is an important component of my practice. During my years of training in General Surgery, I spent a great deal of time taking care of these patients and doing multiple procedures including Lap Band, sleeve gastrectomies and gastric bypass. In addition, during my Plastic Surgery training I had the opportunity to work with one of the world experts in body contouring after massive weight loss. My work with him as well as extensive experience taking care of these patients both at UCI Medical Center as well as the Veteran’s Hospital in Long Beach has enabled me to take care of these difficult problems with excellent results.
After massive weight loss, the excess of skin surrounding a patient’s body can be enormous. This can lead to social embarrassment as well as difficulty with sexual intercourse, going to the bathroom, exercising, and simply walking. Now that my patients are healthy and have lost weight, they wish to return to a normal physical appearance. Using complex techniques, this is possible. It is my preferred approach to begin with the abdomen and lower back, followed by the upper body including the breasts/arms/back/lateral chest wall, followed by the thighs, and finally the face. Depending on my patient’s concerns and wishes, we can do them in any order although oftentimes multiple procedures are combined. A Lower Body Lift or Belt Lipectomy is used to recontour the abdomen, flanks, lower back, and buttocks. An Upper Body Lift is used to recontour the breast, upper back, upper arms, and lateral chest wall. A thigh lift is done to contour the upper legs and groin.
If you have had a weight loss of greater than 75 pounds, either by diet or surgery, you fall into a special category and my preoperative work-up is extensive to assure the safety and efficacy of the operation. I will check multiple lab and nutritional values to assure that you surgery goes well. I also use special techniques in the operating room to assure your safety and often recruit the help of my partners to help with these operations to get your surgery done as efficiently as possible.
These procedures are done in an inpatient setting with either an overnight stay or sometimes a 2-3 day hospital stay. My number one priority is your safety, and a team approach must be used simply because such a large amount of tissue can be removed. This involves not only a knowledgable Plastic Surgeon, but also an experienced nursing/ancillary staff in the operating room and the recovery room.
Liposuction/sculpture and Fat Grafting
Liposuction/sculpture including SAFE Lipo™
Liposuction or liposculpture are techniques that I use often in conjuction with other procedures to enhance my cosmetic results. It is important to understand that liposuction is used for contouring. Attempts at large volume liposuction in the wrong patients or wrong areas can lead to deformities that are very difficult to correct.
Liposuction uses special cannulas and suction to remove fat from the body. There are many common misconceptions about its uses. First of all, liposuction is not very difficult to perform. Therefore, some practitioners go to a weekend training seminar to learn liposuction. It is very important to go to a trained practitioner who has completed a Plastic Surgery specialty. Large volume liposuction and liposuction in the wrong areas can be not only disfiguring, but also dangerous. Half of my liposuction patients are revisions where there first procedure left him/her with major irregularities. I use liposuction/sculpture in my practice for minor contour irregularities and to enhance the result of other surgeries. This technique can be performed for contouring the neck, abdomen, flanks, lateral chest wall, hips, inner thighs, back, and knees. Your age, medical problems, ethnicity, and skin quality are all factors that will determine how your skin will react to liposuction/sculpture. The younger you are, the more likely your skin will retract to your underlying frame after liposuction. Have you ever noticed how some women have a child and their abdomen bounces right back to where they started, while others have hanging skin that they cannot get rid of know matter how much exercise they do? The same analogy works with liposuction. Some patients can undergo just liposuction, while others will need additional procedures to reduce their overlying skin envelope to match their frame. I can’t tell you how important it is to go to a trained Plastic Surgeon to get optimal results and to minimize complications. Too often I see patients in my practice and even in magazines that have undergone liposuction and now have major contour irregularities on their body.
In the last year, I am excited to report that I am now using a new technique developed by Dr. Simeon Wall in Louisiana termed SAFE Lipo. ™ SAFE Lipo is a technique that helps me to get an even better contour for my patients and is extremely helpful in secondary/revision cases. The term SAFE Lipo ™ is used because more aggressive liposuction can be done while minimizing contour deformities. I am happy to say that I have been gradually doing this more and more for patients over the last year using special cannulas and techniques learned from Dr. Wall and am now offering it to all of my patients requesting liposuction/sculpture. Many gimmicks have come out over the years including laser liposuction, ultrasound assisted liposuction, etc. I tried them all as they were reported to help with skin retraction. What I learned is that the techniques cause a thermal burn to the underlying tissue that in some patients can cause deformities and even skin injury. The majority of Plastic Surgeons are abandoning these techniques just as I have.
Liposuction/sculpture is performed in an outpatient setting under general anesthesia. I often combine this with other procedures although many patients have only liposuction for improvement of targeted areas. Downtime is minimal but it is important to understand that swelling can persist so compressive garments are ordered pre-operatively for my patients to wear.
Fat grafting and transfer (face)
Over the last 10 years, fat grafting and transfer has increased in popularity. For the right patients, this is an invaluable tool. Fat is harvested from one area of the body using low suction cannulas and then prepared for harvest. I have tried all of the proposed techniques for fat harvesting and preparation to increase the amount of fat that survives in the recipient site. After low pressure suction, the fat is placed in a centrifuge and the fat stem cells are separated from the remaining fluid and cells. Once this is done, I prepare the fat in 0.5mL aliquots that are injected into the body. Using small amounts and spreading it out over hundreds of passes allows the newly grafted fat to develop its own blood supply in the recipient bed of the face.
I believe that fat grafting more than any other injectable procedure requires the most precision and the most stringent criteria when selecting patients. Over injection can cause the face to look very round and even grotesque. Also, this is NOT a good option if you are a person that has the propensity to gain a lot of weight. I have seen patients that have not only been overinjected, but also gained weight and the grafted fat increases as well. In these patients, I have actually had to remove fat, which can be very difficult.
My preferred areas to fat graft in men is the face. Fat grafting to the face can really improve the look of the eyebrows and especially the midface—see liquid facelift. With precision, the cheek bones can really be enhanced and this looks very natural in most people. In the lower eyelids and pre-jowl areas I prefer to use injectables because they tend to settle better with less irregularities.
Fat grafting, like liposuction/sculpture, is done in an outpatient setting and can even be done in the office depending on the extend of the procedure. Downtime is minimal and results are immediate. It is important to understand that the real results are seen in 3-6 months as a portion of the grafted fat does resorb.