Facial Plastic Surgery
Forehead Lift
Browlifts can revitalize drooping or lined foreheads, helping you to look less angry, sad or tired. Using either traditional or minimally invasive (endoscopic) methods, browlifts involve the removal or alteration of the muscles above the eyes to smooth lines and raise the eyebrows for a more youthful appearance. The procedure is often combined with other operations such as blepharoplasty (eyelid surgery) and facelifts to improve the look of the eyes and other areas of the face.
While browlifts are typically performed on patients aged 40-60 to counteract the effects of aging, anyone with lined or inelastic skin on the forehead – whether it’s caused by muscle activity or inherited conditions – are eligible. The procedure is usually performed in an office-based facility or surgery center under local anesthesia and sedation.
Traditional browlift: First, the patient’s hair is tied with rubber bands near the incision site. Then the surgeon makes a coronal (headphone-shaped) incision behind the hairline, stretching between the ears and across the top of the forehead. The incision may be placed further back or made along the skull bone joints to minimize visibility in patients with thinning hair or who are bald. Then the forehead skin is lifted, tissue is removed, muscles are adjusted and the eyebrows may be lifted. Excess skin is trimmed and the incision is closed with stitches or clips. The site is washed and the rubber bands are removed. Some surgeons will protect the stitches with gauze or bandages.
Endoscopic browlift: After the hair is tied as with the traditional procedure, the surgeon makes three to five short incisions (less than an inch long) behind the hairline. The endoscope is placed in one so the surgeon can see beneath the skin without having to make a large incision, while he or she lifts the skin and adjusts muscles through the other incisions. If the eyebrows are lifted they will be stitched or screwed (temporarily) into place. The site is washed and the rubber bands are removed. Some surgeons will protect the stitches with gauze or bandages.
With both procedures, you will be on your feet and able to wash your hair in a day or two, and many patients return to work or school in 7-10 days or less. Swelling and bruising should fade by the third week.
Complications are rare and usually minor but may include temporary numbness, nerve injury, hair loss along scar edges, formation of a broad scar requiring surgical correction, and infection and bleeding.
Facial Resurfacing
Laser skin resurfacing, commonly called a laser peel, removes the outer, often damaged layer of skin for a smoother, younger look. Laser resurfacing can reduce the appearance of sun damage, wrinkles, fine lines, uneven pigmentation and superficial scarring, usually on the face. A carbon dioxide laser beam of intense, precisely-focused light vaporizes the surface skin and reveals the undamaged layer beneath. The procedure can take anywhere from a few minutes to two hours depending on the size and severity of the area being treated, and may be combined with other procedures such as a browlift or eyelid surgery for even more dramatic results.
Chemical peels remove damaged outer layers of skin on the face to smooth texture, reduce scarring, and remove blemishes and pre-cancerous growths to produce healthy, glowing skin. There are three types of chemical peels, ranging from mild to strong – alphahydroxy acids (AHAs), tricholoroacetic acid (TCA) and phenol – and formula strengths are tailored to each patient. Peels can be combined with other procedures such as facelifts for a younger look. They may be covered by insurance if they are performed for medical rather than cosmetic reasons.
AHAs are the gentlest of the three types of chemical peel. They consist of a group of glycolic, lactic and fruit acids that smooth and brighten skin by treating fine wrinkles, dryness, uneven pigmentation and acne. AHAs are typically applied once a week, or may be mixed in a milder concentration with a cream or cleanser to be used daily; treatment takes 10 minutes or less. Patients may choose AHAs if they do not want the lengthy recovery time of a phenol or TCA peel. Occasionally AHAs, Retin-A (a prescription medication containing Vitamin A) or hydroquinone (a bleach solution) are used to thin the skin and even its tone as a pre-treatment for TCA peels.
TCAs are commonly used for medium-depth peeling (though depth is adjustable) to treat fine surface wrinkles, superficial blemishes and pigment problems, sometimes in combination with AHAs. TCAs are the preferred chemical solution for darker-skinned patients and may be used on the neck and other areas of the body. Results are often less impressive and do not last as long as with phenol peels, and multiple treatments may be required, but treatments only last 10-15 minutes and recovery time is shorter.
Phenol, the strongest chemical peel, treats deeper skin problems such as coarse facial wrinkles, pre-cancerous growths, and areas of blotchy or damaged skin caused by sun exposure, aging or birth-control pills. Because phenol can lighten skin where it is applied, the patient’s natural pigmentation is a factor in determining eligibility. Phenol is used only on the face, as it may cause scarring elsewhere. Full-facial treatment can last an hour or two and recovery can take a few months, with possible permanent skin lightening and removal of freckles.
Eyelid Surgery
By removing excess fat, skin and muscle from the upper and lower eyelids, blepharoplasty can rejuvenate puffy, sagging or tired-looking eyes. It is typically a cosmetic procedure but can also improve vision by lifting droopy eyelids out of thepatient’s field of vision. Blepharoplasty cannot be used to raise the eyebrows or reduce the appearance of wrinkles, crow’s feet or dark circles under the eyes, but the procedure can be combined with others such as a facelift and Botox® treatments to achieve these results.
The procedure is usually performed in an office with local anesthesia and lasts 45 minutes to a few hours depending on how much work is done. Incisions are made along the eyelids in inconspicuous places (in the creases of the upper lids, and just below the lashes on the lower lids). The surgeon removes excess tissue through these incisions and then stitches them closed with fine sutures. In the case that no skin needs to be removed, the surgeon will likely perform a transconjunctival blepharoplasty, where the incision is made inside the lower eyelid and there are no visible scars.
Stitches are removed after three or four days and most people return to work in ten. Contact lenses may not be worn for two weeks. The effects of blepharoplasty can last for a long time and are sometimes even permanent.
Rhinoplasty
One of the most common plastic surgery procedures, rhinoplasty is performed to reshape, reduce or augment a person’s nose, remove a hump, narrow nostril width, change the angle between the nose and the mouth, or to correct injury, birth defects, or other problems that affect breathing. Results depend on the patient’s nasal bone and cartilage structure, facial shape, skin thickness and age (teenagers should have had their growth spurt). Insurance may cover rhinoplasty if it is done for reconstructive or medical reasons, but likely not for cosmetic purposes .
Rhinoplasty is usually an outpatient procedure performed under either local or general anesthesia and lasts one to two hours unless more extensive work needs to be done.
Surgeons use one of two techniques: the incision is either made within the nostrils, thus hiding scars after surgery, or across the columella (the vertical strip of tissue separating the nostrils) in an “open” procedure, where scars are small and hidden on the underside of the base. In both procedures the skin is lifted, the bone and cartilage sculpted, and the skin replaced and stitched closed.
For a short time after surgery you may experience puffiness, nose ache or a dull headache, some swelling and bruising, bleeding or stuffiness. Most patients feel like themselves within two days and return to work in about a week. Contact lenses can be worn immediately but glasses will have to be taped to your forehead or propped on your cheeks for up to seven weeks.
Complications are rare and, when they occur, minor. These may include infection, nosebleed, or a reaction to the anesthesia.
Otoplasty
Ear surgery typically serves two functions: setting prominent ears back closer to the head, and reducing the size of large ears. Surgery may also be helpful for “lop ear,” “cupped ear” and “shell ear,” large or stretched earlobes, and lobes with large creases and wrinkles. Surgeons are also able to construct new ears for patients who are missing them from injury or other causes.
Although surgery for adults is available, the operation is most often performed on children aged four to 14 — ears are almost fully grown by age four, and early surgery can prevent a child from being teased in school.
Otoplasty lasts from two to three hours and may be performed in a hospital, office-based facility or an outpatient surgery center. General anesthesia is recommended for very young patients, while local anesthesia and a sedative are used for older children and adults.
During surgery, a small incision is made behind the ear, revealing the cartilage which is then sculpted, bent into its new position and stitched into place. In some types of otoplasty skin is removed but the cartilage is left in one piece and merely bent back on itself for a smaller-looking ear. A bandage is wrapped around the head to ensure the new positioning. To achieve better balance, both ears may be operated on even if only one has a problem.
Patients of all ages usually feel back to normal after a few hours, although the ears may ache or throb for a few days. Bandages are replaced with a surgical dressing after a few days, and stitches are removed within the week. Adults often return to work in five days and children may return to school in seven. Otoplasty leaves a faint scar on each ear that fades with time.
You should not expect your new ears to match exactly; even normal, natural ears are not identical.
Complications are rare and usually minor, but may include blood clots and cartilage infection (usually treatable with antibiotics but occasionally requiring surgery).
Scar Revision
The extent of scarring after injury or surgery depends on a number of factors, including the nature of the injury or the surgeon’s skills, your body’s healing mechanism, the size and depth of the wound, how much blood supplies the areaand the thickness and color of your skin. Scars are by definition permanent, but surgery can narrow, fade and otherwise reduce the appearance of severe or unattractive scarring, which is especially helpful in areas of cosmetic importance such as the face and hands.
Because large, tight, dark and otherwise problematic scars can improve after many months, it is recommended to wait at least a year before considering sugery. In the meantime, itching and other symptoms can be relieved with steroid injection. There are many surgical methods of scar revision, only some of which may be appropriate for a particular type of scar or its location. These include surgical excision, skin grafts, flap surgery and Z-plasty (repositioning a scar so that it aligns with the face and is less noticeable). Keep in mind that there are nonsurgical alternatives, such as dermabrasion, which can soften scars, and phototherapy and laser treatments, which can lighten them.
Hair Replacement
Only professional treatment by a physician can counteract hair loss. Customized treatment plans for individual patients using the latest techniques and technology make it possible to succesfully compensate for thinning hair or baldness. Treatments vary depending on the extent and pattern of hair loss and the patient’s preferences, lifestyle and expectations, but typically include hair transplants, scalp reduction, skin lifts/grafts, medication or a combination of these.
In a hair transplant, thin strips of skin containing hair are removed from the scalp and replaced in tiny holes (often created with the use of lasers) in the bald or thinned area. The grafted hair falls out after the procedure but then grows back and should last as long as the hair from the area in which it was taken.
Scalp reduction involves surgical removal of all or part of the bald scalp, followed by the lifting and pulling-together of the remaining hair-bearing skin. Occasionally scalp extenders or tissue expanders are used.
During a skin lift or graft, a “flap” of hair-bearing skin is surgically created and rotated onto the bald or thinned area.
Additionally, drugs such as Minoxidil and Finasteride may be applied to the scalp alone or in conjunction with the above procedures to preserve existing hair and stimulate the growth of new hair.
Surgery of the Nose and Sinuses
Elective surgery to facilitate drainage of the sinuses by widening the openings and removing excess mucus or diseased tissue is easier, faster and safer today than ever before. Modern advances in medical technology, specifically the endoscope (a thin fiberoptic tube inserted through the nostrils) and surgical lasers, allow for aminimally invasive procedure with less post-operative pain and shorter recovery time. Three-dimensional imaging provides the surgeon with real-time visualizations of the patient’s sinuses to avoid damage to neighboring structures such as the brain, eyes and arteries.
The decision to undergo surgery may be made when sinus infections recur or do not respond to medications (antibiotics, decongestants, nasal steroid sprays, antihistamines) or to non-surgical procedures such as flushing. Pre-surgical testing includes nasal endoscopy, CT scan and allergy testing to determine the effect of allergies on the problems experienced.
Surgery is usually outpatient and may be performed in a hospital or surgical center with local or general anesthesia. Recovery time is minimal, with results appreciated within four to six weeks.
Surgery for Snoring and Sleep Apnea
Sleep-disordered breathing describes a group of abnormal breathing patterns experienced during sleep, which may manifest as light or heavy snoring, pauses in breathing (sleep apnea) or complete airway collapse. People with obstructive sleep apnea syndrome stop breathing while they sleep, sometimes hundreds of times per night and sometimes for a minute or longer each time. The soft tissue at the back of the throat closes, blocking (obstructing) the person’s airway. A common warning sign of obstructive sleep apnea is snoring (especially snoring interspersed with gasps or lack of breathing), although the two are not always related. Because the brain and major organs are deprived of essential oxygen when breathing isdisrupted, if left untreated sleep apnea can result in high blood pressure, cardiovascular disease, stroke, memory problems, weight gain, impotency, headaches, and daytime fatigue leading to job impairment and motor vehicle crashes.
There are many treatments available for sleep apnea and other sleep-disordered breathing problems. Snoring independent of sleep apnea can be lessened with changes in diet and weight loss and reduction of alcohol, tobacco and other drugs; if this fails, surgery of the soft palate may be elected. Traditionally, this involved a procedure called uvulopalatopharyngoplasty, which removes the tonsils, uvula and part of the soft palate to open the airway. Now, more advanced procedures such as Laser Assisted Uvula Palatoplasty (LAUP) and somnoplasty (radiofrequency ablation) are performed to stiffen the soft palate without the need for general anesthesia.
Before surgery is attempted, patients suffering from sleep apnea are given a breathing mask to wear at night that uses Continuous Positive Airway Pressure (CPAP), wherein air is forced past the obstruction for clear breathing. If this fails to correct the problem or if the patient is too uncomfortable to continue, surgical options may be considered, such as uvulopalatopharyngoplasty or a procedure using radiofrequency energy that shrinks the base of the tongue and the soft palate.
Nasal obstruction (stuffiness, congestion) affects millions of Americans. It arises from a number of causes, including a deviated septum (misalignment of the normally centered sheet of cartilage and bone which divides the nose into a right and left passageway); swelling of the mucosal covering of the turbinates (bony structures lining the inside of the nose) due to illness, allergy, infection or other irritation; sinus blockage; enlarged adenoids (masses of lymph tissue in the back of the throat); and aging.
Tests for nasal obstruction include nasal endoscopy and CT scans. If non-surgical methods such as nose sprays and decongestants prove insufficient to reduce chronic congestion, surgery may be elected.
Surgical treatments range from adhesive strips for minor blockages associated with aging, to in-office injection, freezing, radiofrequency, laser or cautery procedures for turbinate reduction, to an outpatient procedure called septoplasty. Septoplasty (called septorhinoplasty when it is combined with cosmetic improvements) involves the re-shaping of the cartilage and bone for improved air flow. Full enjoyment of results from septoplasty are usually experienced within a week or two when swelling is reduced and splints or packing are removed.
Surgery of the Ear
Tympanoplasty is an elective, ambulatory microsurgical procedure performed to close a perforation (hole) in the tympanic membrane (ear drum) when non-surgical methods are ineffective. Perforations may be caused by infections, injuries, flying with a cold and use of cotton swabs; symptoms include drainage or bloody discharge from the ear, hearing loss, dizziness when water enters the ear and frequent ear infections. Antibiotics, decongestants, ear drops and abrasion with a small hook are often tried before surgery is recommended.
Surgery may not be recommended for very young children or patients with chronic sinus or nasal problems such as severe allergies, acute infection in the sinuses or nose, or poorly controlled diabetes or heart disease.
Tympanoplasty can require either local or general anesthesia and may be performed in conjunction with mastoidectomy if infection is present there. An incision is made either in the ear canal or behind the ear, depending on the size and depth of the perforation. The damaged ear drum is lifted and the perforation located; skin from behind the ear or from the ear lobe (tragus) is removed, thinned, dried and applied to the ear drum.
The bones of the middle ear are examined for damage. In a supplemental procedure known as ossicular reconstruction, the damaged or eroded bones may be bridged with a bone or cartilage graft, re-shaped using an operating microscope, or strengthened by the implantation of an artificial bone strut made of hydroxy apatite to reduce risk of rejection. Another, rarer ossicular reconstruction procedure called malleus fixation involves the reshaping of the malleus bone (“hammer”).
The incision is then closed. Stitches beneath the skin will be required if the ear was opened.
Patients often return home in about three hours after tympanoplasty or the next morning if ossicular reconstruction is performed, and may return to work within the week. Swimming and showering without ear plugs may be resumed in three to four months. Antibiotics or Tylenol usually relieve any post-surgical pain. The graft is checked at ten days and again at three weeks, with a hearing test performed after four to six weeks. The perforation heals properly in over 90% of cases. Failure may result from immediate infection, water getting into the ear or displacement of the graft after surgery.
Complications are uncommon but may include temporary dizziness, tinnitus, loss of taste on one side of the tongue, facial nerve injury and further hearing loss.
Also called tympanostomy, myringotomy involves the removal of fluid from the eardrum and may be supplemented with tube insertion if drainage continues despite medication. Myringotomy with or without tube implantation is the most frequently performed ear operation and the second-most common surgical procedure in children younger than two years of age, after circumcision. Surgery is recommended for patients with hearing loss and the presence of fluid for four months or longer.
Myringotomy consists of making an incision in the eardrum and vacuuming out fluid under general anesthesia. Even the youngest patients typically recover within a few hours, with pain relief medications taking the form of acetaminophen, codeine or topical anesthetic ear drops. After surgery most patients experience a full return of hearing ability as well as less pain, fewer infections and increased speech capacity. The hole in the eardrum should close on its own and drainage should cease, although 20-30% of patients require a second procedure. Tubes are usually removed after several months, although they may remain in place for a few years or even permanently. Patients must be careful to avoid water contamination of the tubes.
Complications are rare and usually minor but may include infection (usually resolved with antibiotics) and additional surgery to correct perforation of the tympanic membrane or replace the tympanostomy tubes.
Located behind the ear, the mastoid bone connects to the middle ear and, when healthy, is filled with air. Infection or disease in the ear or elsewhere can cause the mastoid to fill with fluid, mucus or excess tissue (such as a cholesteatoma, a benign tumor that may grow out of a healing perforated ear drum and cause hearing damage). When medications and other non-surgical treatments such as antibiotics or professional cleaning fail to resolve the problem, mastoidectomy may be performed.
Complications from surgery are rare but may include drainage from the ear, infection, temporary dizziness or loss of taste on one side of the tongue, hearing loss and, rarely, nerve injury to the side of the face operated upon.
Stapedectomy is an elective microsurgical procedure that replaces the stapes bone with a prosthesis (artificial bone) to counteract calcium deposits in the ear associated with otosclerosis.
Surgery is performed under general or local anesthesia and can be done through the ear canal. The ear drum is raised and the middle ear opened, revealing the calcium deposit, which is then broken up with a laser. The remains of the vaporized stapes bone are removed and the bone is replaced. A tiny sample of tissue from behind the ear lobe is grafted to promote healing, and the incisions are closed.
Complications are rare and depend on the patient’s anatomy. These may include temporary loss of taste on one side of the tongue, dizziness, tinnitus (ringing in the ears) and, rarely, facial nerve paralysis or partial or total hearing loss requiring the use of additional surgery or a hearing aid.
Cochlear implants — tiny electronic devices surgically implanted behind the ear — have given the gift of hearing to thousands of children and adults. Cochlear implants are not hearing aids, which amplify sounds the ear already hears; rather, while the implants do not restore a deaf person’s hearing, they help a person to understand the sounds in their environment, such as speech. The implant consists of a microphone to pick up sound, a speech processor to process that sound, a transmitter/receiver which converts the sound information to electrical impulses, and electrodes that send those impulses to the brain. Over 20,000 adults and children in the U.S. have benefited from cochlear implants. Implants can be useful for adults who associate sounds made through the implant with sounds they heard earlier in life when their hearing was better; early implantation and therapy can help children as young as two years old to learn speech and other auditory comprehension skills.
Surgery of the Throat and Larynx
One of the most common throat operations, tonsillectomy surgically removes the tonsils, masses of lymph tissue in the back of the throat that work with the adenoids and immune system early in life to defend the body against invading bacteria and viruses. Occasionally the tonsils become infected or abscessed, and, if these conditions continue, enlarged, causing breathing and swallowing problems such as snoring, disturbed sleep, chronic mouth breathing (possibly resulting in deformations of the face and mouth), ear infections and hearing loss. Signs that you or your child may have tonsillitis (infected tonsils) include:
- Tonsils that are enlarged, redder than usual, or have a white or yellow coating
- Swelling that causes a slight voice change
- Sore throat
- Difficult or painful swallowing
- Swollen lymph nodes (glands) in the neck
- Fever
- Bad breath
The first stage of treatment for chronic tonsil inflammation is a course of antibiotics or steroids; if this fails to resolve the problem, the tonsils may be removed. Removal is usually recommended for patients with three or more infections of the tonsils each year and patients with sleep-disordered breathing, and may also be recommended for patients with tumors or difficulty breathing.
Tonsillectomy requires local or general anesthesia depending on the technique and the patient’s age and preferences. Patients are released a few hours or the morning after surgery.
Surgery may be performed with a scalpel (“cold knife dissection”) under general anesthesia with minimal post-operative bleeding; by electrocautery, minimizing bleeding but increasing the risk for tissue damage by heat; with a harmonic scalpel, which offers precision cutting through ultrasonic vibrations; with a carbon dioxide laser (laser tonsil ablation, or LTA) that vaporizes tonsil tissue in 15-20 minutes with minimal pain; with a microdebrider, a shaving/suctioning device that removes the part of the tonsil blocking the airway; by monopolar radiofrequency ablation (somnoplasty), where thermal energy causes scarring that shrinks enlarged tonsils; or by bipolar radiofrequency ablation (coblation), where an ionized saline layer is created to remove the enlarged portions of the tonsil without heat energy.
Post-surgical complications may include pain in the throat or ears, swallowing problems, halitosis, infection, vomiting, fever and, rarely, bleeding.
A very common throat operation, adenoidectomy surgically removes the adenoids, masses of lymph tissue in the back of the throat that work with the tonsils and immune system early in life to defend the body against invading bacteria and viruses. Occasionally the adenoids become infected and, after repeated infections, enlarged, causing breathing and swallowing problems such as snoring, disturbed sleep, chronic mouth breathing (possibly resulting in deformations of the face and mouth), ear infections and hearing loss. Signs that you or your child may have enlarged adenoids include:
- Breathing through the mouth rather than the nose
- Blocked-sounding nose when speaking
- Frequent ear infection
- Noisy breathing
- Snoring
- Sleep apnea (frequent pauses in breathing at night)
The first stage of treatment for chronic adenoid enlargement is a course of antibiotics or steroids; if this fails to resolve the problem, the adenoids may be removed. Removal may also be recommended for patients with chronic ear infections, tumors or difficulty breathing.
Adenoidectomy requires local or general anesthesia and patients are released a few hours or the morning after surgery. Post-surgical complications may include pain in the throat or ears, swallowing problems, halitosis, infection, vomiting, fever and, rarely, bleeding.