Teaching at the AAFPRS Rhinoplasty course

I just got back from the AAFPRS (American Academy of Facial Plastic and Reconstructive Surgery) semi-annual rhinoplasty course. I was honored to be a speaker at this prestigious course. This course is given every two years and is considered by many to be the premiere course for physicians who wish to hone their skills as rhinoplasty surgeons. I gave two lectures and ran one seminar.

My first lecture was entitled “What makes a nose look overdone?” I used my years of experience, as well as an important study that I am currently conducting, to teach other doctors what makes noses look fixed. I review how I restore them in both form and function. But most importantly, I teach how to avoid making these mistakes in the first place. 

My second talk was “How to avoid the pinched tip and excess columellar show in rhinoplasty.” I guess the course directors like the way I teach prevention; prevention of noses looking fixed and how to create natural appearing noses. This is why patients often tell me that after surgery, old friends commonly ask if they had a makeover, a new hairdo or lost weight. Basically, they look better but not fixed.

My third assignment was a panel called “ask the expert”. I had three experts, Dr. Cook from Oregon, Dr. Harris from  Maryland and Dr. Robinson from New Zealand. Each panelist presented two cases of difficult rhinoplasties. The other panelists then were quizzed on what they would do before the operating surgeon discussed the actual surgery. I asked pointed questions of each panelist asking them to justify any and all choices, so the audience can see what thought processes a master surgeon goes through when preparing for a rhinoplasty.

I find these courses informative and I always pick up a few pointers that I take home and perhaps incorporate into my own skillset.  What I found interesting is that less than 25% of the speakers discussed techniques using the intra-nasal approach. Two of the best lectures I heard were Europeans talking on the intra-nasal approach: Dr. Berghaus from Germany and Dr. Palma from Italy. The intra-nasal or closed approach avoids any scars or external incisions on the nose. I find that I get equal if not better results in primary rhinoplasty using this technique (see earlier blog). I am one of the few remaining docs still teaching and offering the “closed” approach to the majority of my primary rhinoplasty cases.

The AAFPRS has been my professional home for many years. Much of what I learn comes from dinners with friends and colleagues from around the world at meetings and courses such as this. Last but not least, I get to catch up with good friends.

To get ahead put your best face forward

It has been well documented in the plastic surgery community that when people have cosmetic surgery or minimally invasive procedures, it improves self confidence, often beyond the aesthetic improvement seen by others.  Given the current recession, aesthetic enhancement has become even more important for more people. I have a number of patients who are looking for new jobs in the work place. The competition is typically younger, less experienced candidates. My patients desire to look as young on the outside as they feel on the inside. I was quoted on Yahoo.com as well as in a live interview on CNBC, Thursday April 9 on the subject of people seeking cosmetic facial surgery to compete in the job market. 

For example, a recent patient is a very energetic, young appearing, 60 something year old woman. She is looking for a new job in publishing. Publishing is a very youth oriented business. She underwent a facelift and blepharoplasty. She looks and feels great. This has given her new vigor and she admittedly finds that she has renewed vigor when going on interviews. She intends to send me the “good news” when she gets that publishing industry job.

Minimally invasive procedures, such as Botox^R and facial fillers are quick, easy fixes for looking refreshed. I have a number of patients who get Botox^R to smooth the furrows between their brows, often called the “angry 11’s.” In business, they felt that it made them look worried;  that their portfolio, investment or business deal was being questioned, when it really was only overactive brow muscles. Relaxing these muscles relieves this harried appearance. The same applies to people going for job interviews, if you appear worried, it can undermine inner self confidence. You want to look cool and confident, smooth and ready to take on any challenge.

To reiterate my quote in Yahoo.com “People are fed up and are starting to figure that it’s time to live a little. Cosmetic surgery is about investing in yourself. It makes you look good and feel better about yourself, a dozen times a day when you look in the mirror.”

Looking Gorgeous: What Women Won’t Give Up

This was the title of an article from Forbes.com that I was quoted in: Looking Gorgeous: What Women Won’t Give Up. I have been lucky to have had very good media exposure in the past, including recent mentions in Vogue, More and New York Magazines. However, all I’m asked lately is how the economy has affected business.  Cosmetic surgery and other aesthetic treatments such as Botox and Facial fillers (Restylane, Juvederm, Radiesse, Cosmoderm,  Perlane, Sculptra, Evolence) really can be categorized as luxury items. Given the state of the economy, people are becoming more choosey about what they do and should be more choosey about who they go to.  I did send discount cards to many of my recent Botox and Filler patients. I apologize if we missed you; my lists aren’t totally up to date. If you were left out, just mention this blog when you come in for treatment and we will honor the same discount for the next 6 months.

My offering a discount was quoted in Crain’s in the February 16-22 issue. Or should I say misquoted. I did say that “I sent out discount cards to my loyal patients.” However, during the interview I also qualified that by stating that this discount was JUST for Botox and fillers. Surgery is a more personal issue. It should not be about negotiating fees. I feel that once you find the surgeon who you trust, it should be more about getting the right result from a specialist instead of discount surgery. If you go elsewhere and get discount surgery, will you also be getting a discount result?  

I feel the same about fillers and Botox. Any doctor can purchase Botox legally, even dentists! The physicians with the most experience using Botox and Facial fillers are termed “core specialists.” These include Plastic Surgeons, Facial Plastic Surgeons, Cosmetic Dermatologists and Oculoplastic Surgeons.  There is a website with information called the Physician Coalition for Injectable Safety. Treatments are now offered by Family Physicians, OB-GYN’s and many other specialists. And yes, dentists too. Don’t get me wrong, I know a few primary care and GYN docs who are excellent practioners of facial injections. They have advanced training and perform many of these treatments. It’s the doctors who only perform these treatments occasionally and learned at a one day for profit course you should steer clear of.

So first and foremost, it’s your face. Do you really want to skimp? Make sure your physician has the proper training and experience. If they give you a nice discount, GREAT. If not, is it really worth saving money to have a less than ideal result?

Open Rhinoplasty vs. Closed (endonasal) Rhinoplasty

There has been a lot of hoopla over the past two decades over the incisions used for both primary rhinoplasty and revision rhinoplasty. There even has been name calling at medical meetings: open rhinoplasty is equated with and open mind and closed rhinoplasty attributed to a closed mind. Well this is not true and why I don’t use the term closed very often.

There is a lot of history behind the surgical approaches in rhinoplasty dates back to nasal reconstruction techniques in India in 800 BCE and in the 1600’s in Italy by Tagliacozzi. Modern intranasal or closed rhinoplasty is attributed to Drs. Jacques Joseph and John Orlando Roe in the 1890’s. In 1927 Rethi introduced the columellar, or modern open, incision. This fell out of favor until it was reintroduced by Padovan in the 1970’s. Since that time, many highly regarded nasal surgeons, such as Drs. Jack Anderson, Calvin Johnson, Dean Toriumi and Jack Gunter have advocated the open approach. Other experts, including Drs. Eugene Tardy, Frank Kamer, Jack Sheen and Thomas Rees still relied on a mostly the intranasal approach for their superior results.

So enough with the history, this is not a book chapter for doctors. Which of the two is the best way to get a superior result in rhinoplasty? There is no good answer and it really depends more on the individual surgeon. I feel that in primary (never operated) rhinoplasty I can obtain equal if not a better cosmetic result using an endonasal approach in over 90% of patients, without any incision across the bottom of the nose (this part of the nose is called the columella).  It’s more important that your surgeon understands the anatomy of the nose and is an expert in rhinoplasty, than what incision they use.

Then, why would I use the open incision at all in primary rhinoplasty? The indications, medical speak for reasons, in my opinion for using the open approach are 1. A very crooked nose, 2. A short nose that needs to be made much longer, 3. A nose that requires many grafts.

For revision rhinoplasty, which comprises about a third of my nasal procedures, I use the open approach on most. My indications for this incision are 1. Unexpected changes that may have occurred during the first surgery, 2. scarring and 3. Altered anatomy from both surgical and changes during healing. These are findings that often occur in revision rhinoplasty, otherwise the patient wouldn’t be seeking revision. Going back to primary rhinoplasty, a good surgeon should be able to tell the patent’s underlying anatomy from an external exam alone, by looking at the nose, touching the nose and looking inside the nose. So, making changes should be predictable. When surgery has been performed prior, there are changes that may not be accounted for in old operative notes, scarring and often stitches that holds structures in place and defy moving  (the technical term is delivering) the cartilage around as is done to modify the nasal tip in a primary case.

As for the open rhinoplasty incision, across the columella, this incision is tiny and usually barely noticeable if at all. Of course, all incisions are pink for up to 6 months, but as it heals, I feel that unless someone is looking up your nose, know what they are looking for and close enough to count nose hairs; they are unlikely to notice the incision.

Internet and telephone long distance consultations

We are now in the cyber age. People communicate by email, text, phone, fax and sometimes even in person. The same is true for cosmetic surgery. Many of my patients find me and other plastic surgeons through the internet; from a direct search, forums, and specialty directed services from qualified board searches such as the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) and the American Board of Facial Plastic Surgery (ABFPRS).  Therefore we receive requests for consultations, and frequently operate on patients from around the country as well as Europe, South America and Africa.  Patients inquire about many of our services, especially rhinoplasty, revision rhinoplasty, surgical facial rejuvenation, facial fillers and laser treatments for the face. To facilitate this process, we offer initial phone consultations for potential patients if geographically necessary. Of course, nothing substitutes for a face to face conversation and evaluation in person. 

 

How do we conduct a phone consultation? First and foremost, once a physician and patient begin a dialogue about potential treatment, they have engaged in a doctor-patient relationship. This is why all discussions are accompanied by a disclaimer that any and all advice given prior to a personal consultation is merely a suggestion and should not be taken as conclusive medical advice prior to a personal evaluation. In order to make this a meaningful process, we may request photographs and a patient information sheet to be filled out. We also request a signed consent to confirm that any recommendations for treatment are supposition and predicated on a personal consultation and evaluation.

 

For example, to properly evaluate someones nose for rhinoplasty, I really need to touch the nose to determine the strength of the underlying cartilage, feel the thickness of the skin and look inside the nose to see if there are any structural abnormalities, such as a deviated septum. So, any opinions I give over the phone, even with photos, need to be confirmed or altered by a personal evaluation. I love computer imaging, especially for primary rhinoplasty. However, I won’t image a patient that I haven’t seen. Computer imaging can be fairly accurate, but I also need to feel the nasal structures to see how much I can alter a nose before this process. So if you really want imaging, you must come to my office. I also suggest you steer clear of anyone who will offer imaging without an examination.

 

For out of town patients interested in revision rhinoplasty; I try to be as helpful as possible when evaluating them through photographs, but a personal examination is even more important. I may even defer a phone consultation when multiple surgeries have been performed or I find it too difficult to suggest potential reconstruction based on the photos and information given. I hope these patients understand the increasing complexity of revision surgery and that a personal exam is even more important.

 

For long distance patients, we prefer seeing them prior but given travel restrictions, I need to see them at least the day before surgery to assure that we are planning the appropriate procedure. This also gives them time to relax prior to surgery and reduces other potential complications from travel then immediate surgery under anesthesia. As a general idea, plan on staying in New York for about 7 to 8 days after surgery before returning home. We also provide concierge services and can help with hotel arrangements. More on this will be in my next blog.

To discount or not to discount, that is the question (as seen in the New York Times)

Many of us, consumers and businesses alike, have been riding high on the last two decades of rapid growth in income and therefore consumer spending. And now the bottom is dropping out. This affects us all: clothing stores, car sales, home sales, restaurants, education, and yes, even cosmetic surgery. Cosmetic surgery is unlike surgery for medical conditions. If you have a hernia, for example, surgery can be put off for only so long. However, surgery is still surgery and therefore should not be taken lightly. Some patients who may have been thinking about a facelift or blepharoplasty (eyelid lift) know that putting that off is not going to affect their overall health, but it certainly is going to affect their sense of well-being, self confidence and outlook on life .  So where is the balance between personal desires and personal finance?

I have found for my own practice and that of a number of my colleagues that all surgeries are down. However, this has affected the number of rhinoplasties a little less than other procedures, especially revision surgery. I feel that this is because when people are unhappy with the appearance of their noses, especially if they can’t breathe well, it is more than just a cosmetic issue. An unsightly nose is a feature that has been with them for life and can affect personal growth as well as acceptance by their peers. For these people, rhinoplasty is more than a cosmetic procedure. A nose that doesn’t fit one’s face may supersede what might be considered more frivolous aesthetic procedures designed to combat facial aging.

In The New York Times last thursday http://www.nytimes.com/2008/11/06/fashion/06skin.html?_r=1&oref=slogin, there was an article by the renowned medical reporter, Natasha Singer, discussing which physicians discount surgery and other treatments such as Botox and facial fillers. This is a very personal issue. Personally, I had discount courtesy cards made up as gifts for my patients that we never got around to mailing. Well, we mailed them today. I think these are great pick-me-ups for looking better fast and I want to share that with my patients. According to a recent survey of patients by the American Academy of Facial Plastic and Reconstructive Surgery [AAFPRS], when it comes to surgery feeling secure with their choice of surgeon is more important than price.

To quote Dr. John Conely, one of the greatest teachers of both cosmetic and reconstructive surgery of the face, head and neck of the past 50 years: “I have never seen anyone die from a wrinkle, but some thought that they might.” 

In closing I would like to reassure you that my practice is still thriving and that, as always, I am plugged into the zeitgeist. To show my sensitivity to these more austere times in which we presently live, I am offering you a 20%-off Botox, Juvederm and Restylane through the end of 2008. 

 

Medical meeting I just attended

Fall meeting AAFPRS

I just got back from the Fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS).  This is our big annual meeting. I always look forward to this meeting. It is a chance to see the most respected teachers in our specialty, meet with my peers and visit with friends that I have made from around the world.

As I get older, for me, the meeting is more about the great friends I have made in my speciality. We share common training, backgrounds and interests; yet we come from all over. From attending at least two meetings per year plus sharing the podium on one or more major teaching courses, we really get to know each other.  These are the people I can pull aside and get serious answers to clinical and patient questions that might not otherwise be found in the medical literature.  For example, there was a panel on facelifts. There were experts presenting short flap minimal facelifts, deep plane facelifts, bi-planer SMAS facelifts and the new Smartlift^TM. The Smartlift is really a standard facelift using the smartlipo cannula to assist the surgical dissection. So, am I doing the best lift for my patients? From what I saw and conferred with other top doctors, I know I am. In reality folks, there is no one specific lift for every patient. Younger patients with minimal jowls and minimal excess neck skin would benefit from a mini-facelift. More facial sagging requires a more intensive SMAS treatment.

If I come away with as little as five pointers from a meeting, I feel it was successful. Part of the definition of “doctor” is to teach. And that is what we do, we teach our peers, our residents and sometimes we teach our teachers as well. I usually speak at this meeting but this year was different. I was asked to speak but I now have twin 11 month old babies. So, I elected to attend and not spend my off time over the past few months preparing lectures for the meeting. As a matter of fact, last year was the first fall meeting of the AAFPRS that I missed in 21 years. My babies were due in 2 weeks, and no way would I chance that happening with me being away.

I did receive one huge compliment. I was in the elevator with a young facial plastic surgeon. He pointed to my name badge and said “that purple ribbon is certainly a special one that not just anyone can wear.” This was the ribbon that said “Past President AAFPRS.” As past president, I also walk around with pride that the AAFPRS is thriving and fulfilling its primary mission: to teach Facial Plastic Surgery.

 

Runway Cheeks (TM)

Runway Cheeks^TM

The “must-wear” look for fall.

New York is still buzzing from the recent fashion shows in Bryant Park. So what did I see? That fashions are always changing but one thing remains the same: beautiful models. What do all these models have in common?  Spectacular cheekbones. Regardless of the trend for more “quirky” fashion faces what has remained the same for decades are those angular cheeks; they frame the face and create highlights that distinguish beauty and frame the face.  Structured cheeks are also a sign of vitality. Great cheekbones highlight the eyes, too, adding overall balance to one’s facial features. Cheekbones are the foundation of a drop-dead gorgeous look.

Patients seeking celebrity cheekbones are fast on the rise. Not long ago, it required a surgical procedure with insertion of cheek or malar implants. This is still a feasible operation for those who desire permanent results. However, with the myriad new facial fillers, I can create stunning cheeks without surgery.

The fillers that I use to create Runway Cheeks ^TM are hyaluronic acid: Juvederm Ultra Plus and Perlane, or calcium hydroxyl appetite: Radiesse. The procedure is performed in-office and takes just about 20 minutes. There is minimal discomfort and little-to-no bruising. You can go straight out to lunch, back to work, or shopping on Madison Avenue directly after.  So, if you want to look like you just stepped off the runway, this procedure is your dream look and the right option for you.

 

 

 

 

 

Beautiful cheeks

As I perform more and more facial fillers to restore youthful cheeks, I continue to be excited about the wonderful changes we see with only one or two cc’s of filler. Most patients who are candidates either ask about treating nasolabial lines and folds (they run from the corner of the nose to the mouth). However if you look more closely at their cheeks, as people age beyond the mid 30’s we lose the baby fat that gave us youthful fullness. Remember those cheeks that your aunts and grandmother used to pinch?

Now, when I look closely at these cheeks, I often see a mound (cheekbones), hollowness beneath, then a nasolabial “mound” then the nasolabial fold. Filling just the nasolabial fold doesn’t go very far in making patients appear more youthful. What I prefer, and most patients agree, is to first restore volume to the cheeks. I use filler to restore volume under the cheekbones. Then I need only a little filler in the actual nasolabial fold since the volume restoration lifts the nasolabial folds up and out. On “beginners” we often start with only 1 cc (syringe) of filler. For more volume, 1 per side is sufficient. To enhance cheekbones, the filler can be tailored to each patients’ needs by highlighting, restoring or creating beautiful cheekbones as well.

What filler do I like to use? On a first-timer, I usually start with Juvederm Ultra. This is the smoothest, most mold-able filler and it gives the most subtle enhancement. I sometimes use Restylane as well but find that Juvederm is more mold-able. These fillers typically last from 6 to 9 months in the cheeks. For more volume and a longer lasting effect the next choice is Juvederm Ultra Plusor Perlane (basically, this is thick Restylane). These fillers provide more volume. Plus they often last from 9 months to a year. Want even longer lasting effects, especially for building high cheekbones? I will address this in a future blog. It is what I call Runway Cheeks. The next choice following hyaluronic acid fillers (Juvederm, Restylane and Perlane), I use Radiesse, for a 1 year plus result.

When patients have very hollow cheeks and require a large volume replacement. My first choice is Scuptra. Using one’s own fat for fat transfer is also an option.

So for beautiful, youthful cheeks there are many options. The best option is to come in or visit your favorite facial plastic surgeon for personalized recommendations. By the way, the same choices and process applies to melolabial folds or marionette lines that run from the corners of the mouth downward.

Pucker up with the new “CUPID’S BOW LIP” treatment

Instead of aiming arrows, I try to hit the love mark with cosmetic injectables.

Gravity eventually takes a toll on every part of the body, even the lips. As we get older, the upper lip loses its firmness and definition. As a result, the Cupid’s bow, a sign of youth and beauty, is lost leaving an undefined, flat line in its place.

Thinning of the lips becomes evident from generation to generation. I did a comparison of 4 generations of lips right in my own family; from my baby girl to my wife to her mother and my wife’s grandmother. What I can see is the loss of shape firmness (the medical term is turgor) as well as volume of the upper lip. By the eldest generation the upper lip becomes flat with vertical lines.

CUPID’S BOW LIP is performed by using a half cc, or touchup size of Restylane or a half a syringe of Juvederm. The filler is used to create new shape to the lips. To the contrary, to create larger lips, I use a full syringe or 1cc of filler. However if overdone, as is seen way too often, patients can look puffy and get an awful “trout pout.” Additionally, I use a tiny amount of Botox to smooth the vertical lines above the lip as well as relax the muscle in this area.

I am looking to re-introduce the power of glamour. Celebrities have long been the inspiration for what patients look for. However, the latest trends have been to make lips too large. They look great on Angelina Jolie, but how many other celebs have lips that are way too big, plus upper lips that are twice the size of their lower lips? For truely aesthetic lips, the lower lip should be at least 1 1/2 times the size of the upper lip.

So who do I look to emulate? I create more coy, flirtatious lips. This more refined and natural look references the Holywood glamour of yesteryear when starlets like Gloria Swanson, Carole Lombard and Greta Garbo were the defining power of beauty.

 

                      

 

Below are a few examples of lips that I have created using this technique, after photos are on the bottom.

       

a VERY happy patient

Both upper and lower lips