Thursday, December 12, 2013

Nose Jobs


Perhaps no more elegant procedure has been saddled with such an inappropriate moniker.

The proper name for this operation is septorhinoplasty, implying that in most cases the nasal partition or septum is corrected while the external nose is altered for functional and often aesthetic reasons. Patients seek correction for a number of problems. Functional considerations center around obstruction to breathing, recurrent sinus infections, aggravation of the allergic reaction, and snoring. Aesthetic considerations involve primarily disproportion of individual external features and deformity secondary to trauma. The disproportion may be heredity or may follow early, often unrecognized, childhood injuries that ultimately influence nasal development.

Modern nasal surgery offers patients the option of achieving all of the above goals in one procedure. The ideal result is one in which proportion, with respect to the patient’s facial shape and overall body size, is achieved. An equally important concept to be considered in evaluating the profile is the adequacy of the patient’s chin projection. Unless both are corrected simultaneously, the result is never ideal. Instead of utilizing the conventional firm preformed “chin implant”, I prefer to construct the implant individually for each patient using a rolled mesh technique, the details of which I will explain during consultation. This soft implant is inserted through a submental (below the chin) incision which allows placement of the implant in a pocket under the connective tissue covering the “front” surface of the mandible (lower jaw). This makes the implant imperceptible to both the viewer’s observation and the patient’s sense of touch!

Attempts to achieve a certain “look” are doomed to failure. Over the past 27 years a technique for obtaining predictable results using the “open rhinoplasty” approach combined with grafts obtained from the patient’s own nose allows correction of the entire spectrum of deformity, especially those resulting from poorly performed primary surgery. Unfortunately adoption of this technique has not enjoyed widespread acceptance because of the additional training, aesthetic judgment, and surgical skill required. Stories of excessive pain, bruising, packing, and splints discourage many from seeking help. The currently utilized procedure eliminated the need for packing and splints over 25 years ago. My patients experience little discomfort and external evidence of the surgery (bruising and swelling) has almost vanished by the time of external dressing removal at one week.

Nasal surgery properly performed should not be feared and may be combined with other aesthetic procedures.

- Dr. James J. LaNasa, Jr. M.D. F.A.C.S.

Thursday, August 15, 2013

All Facelifts are NOT Created Equally

“ A facelift is a facelift is a facelift”—not really.

      In this time of rapidly advancing technology, no sophisticated consumer would purchase an item of computer hardware or software without first inquiring about the speed/capacity or version number. Yet patients daily “shop” for facial surgery by procedure, for example, facelift, and by price. There seems to be an apparent lack of awareness that within a single category of surgical procedure exists an array of differing techniques and widely differing degrees of training and experience among surgeons.

      One of the most important tenets that I acquired during my training stated, “There is no shortcut to quality”. In other words, the “week-end” facelift will probably not last much longer! Or as one of my male patients noticed after this technique was televised, “none of those patients looked like they needed surgery”. Within modern facial surgery lie procedures of markedly differing difficulty, efficiency, and risk. The task of the surgeon is to select the proper risk reward ratio.

      While none of the latest in procedures is technically easier than its predecessor, the benefits far outweigh the increased risk in terms providing a more natural, balanced, and long lasting facial rejuvenation. Prior to the introduction of the “transconjunctival blepharoplasty” (lower eyelid surgery) and the “deep plane” facelift too many patients had obvious changes in the shape of the eye often accompanied by a downward displacement of the lower eyelid margin and the “wind tunnel” facial deformity! These stigmata should have disappeared long ago but unfortunately have not.

(Wind Tunnel – you get the idea)

      The eyelid procedure noted above was first described by a West Coast ophthalmic plastic surgeon in the Archives of Ophthalmology (eye disorders and surgery) in 1983, but this technique was not noted in the “plastic surgery” literature until 1996. Eighteen years later, surgeons are still using the older open lower lid approach and experiencing the same problems. In 1989 one of the first articles describing a technique of “deep plane” facelift was authored by a Texas plastic surgeon, but 12 years later only 5% of surgeons performing facelift use this technique. Numerous articles touting endoscopic procedures as offering results equivalent to conventional surgery without the risks have appeared, but the results do not match the claims. Endoscopic surgery of the upper face is not appropriate in patients with a “high”forehead and then leaves the mid forehead muscles active. This failure of endoscopic forehead lift has led to the popularity of botox injections!

      In the past 20 years tremendous innovation and improvement have appeared not only in our understanding of anatomy and function but also in surgical implements, lighting, suture, and implant materials. A decade ago, an acceptable result in full-face rejuvenation “rolled the clock back” 10-12 years. Today an experienced surgeon using the above techniques in an ideal candidate can “roll the clock back” 20 years!

All facelifts are not created equal!

James J. LaNasa, Jr. M.D. FACS

Tuesday, July 23, 2013

Facial Surgery - What's New

If grocery checkout lines are any reflection of our society, we are fixated on sex and appearance! Perhaps I can offer some suggestions for improving the latter. Advertising would have use believe that there is a quick, painless fix for everything including our aging faces. Unfortunately, there is no shortcut to a quality result.

The good news is that surgeons in several fields along with dermatologists, have developed significantly improved techniques for not only altering the texture and pigmentary irregularities of our skin, but also for removing unwanted sagging and other stigmata of aging:

1. Laser Resurfacing/Chemical Peels - Best used for the removal of pigmentary irregularities and less severe wrinkling. There are various surgical procedures that are better designed to re-suspend the brow, remove excess skin and bagginess around the eyes, lift the face, and when necessary, augment the chin and cheek areas.

2. Forehead lifts - efficient and safe for rejuvenation. They simultaneously weaken the central forehead muscles to alleviate the deep creases between the eyebrows without the need for repeated Botox injections.

3. Eyelid procedures - There are also better techniques for improving the lower eyelids with much less risk of the telltale lid sag and flattening of the lid margin

4. The Standard facelift - the latest modifications due to an improved knowledge of facial anatomy has led to improvements. Dissatisfaction with the lack of correction of the cheek lip fold was a major complaint prior to the introduction of the "deep plane" facelift. In this procedure, the cheek fat pad is returned to its prior position allowing flattening of the offending fold.

5. Upper face procedures - First, the aged appearance begins in the forehead with a simultaneous descent to the eyebrows accompanied by a redundancy of the upper eyelid skin. Depending upon the patient's inherited facial characteristics, these changes may also be accompanied by fullness in the lower lid. The initial changes usually begin around age 40, but in some patients may begin much earlier.

6. Combined procedures - Within 4-5 years, accompanying changes begin to appear in the lower face and neck. These lower facial changes are the ones most likely to be noticed by the patient. However, in most cases simultaneous correction of the upper face is also required to achieve a pleasing balance. When indicated, these combined operations can set the clock back 20 years in the ideal patient!