Eyelid Surgery (Blepharoplasty)

This week I spent 3 days at the Multidisciplinary Facial Cosmetic Surgery meeting in Las Vegas. This is my third year as an invited faculty member at this impressive meeting. The first day of the meeting is a scheduled “Rhinoplasty day”, where I gave three talks on rhinoplasty: 1. Functional Rhinoplasty; 2. The Thick-Skinned Tip; and 3. Running, Micro-Perforating and Cross-Root Osteotomies. The Bellagio Hotel is a great venue for the meeting and it was great seeing colleagues from around the country and from around the world. My next meeting will be the American Academy of Facial Plastic and Reconstructive Surgery’s (AAFPRS’) Annual Fall Meeting in Boston, where I will present talks and run a panel on nasal cosmetic and functional surgery. This will also be my second year as an elected member on the Board of Directors of both the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) and the American Board of Facial Plastic and Reconstructive Surgery (ABFPRS).

My local and national speaking opportunities continue to increase. Last weekend I again participated in the NYU Rhinology Update, where I have been speaking for some years now. I spoke on the importance of preserving function in rhinoplasty and discussed my own innovations in functional rhinoplasty. I shared the podium with Dean Toriumi, who is still acknowledged by most as the foremost and most innovative rhinoplasty surgeon practicing today.

Today I arrived in Bodrum, Turkey. Here I am attending RhinoCamp, a 3 day nasal extravaganza with many international attendees and instructors. As the honored visiting professor from the U.S. in Rhinoplasty, I am speaking tomorrow on “The Fundamentals of Rhinoplasty”, “The Crooked Nose”, “Functional Rhinoplasty”, “Cartilage Grafts in Rhinoplasty”, and “Alloplasts and the Saddle Nose”.

Bodrum is on the Aegean Sea, with the Greek Islands of Rhodes and Cos just off its coast. Today I swam in a 72 degree Aegean which was sparkling and crystal clear. I plan on exploring the corner of Turkey before I leave on Saturday.

Q: I have been disappointed with fillers to correct nostrils- I would like less nostril show from the front; thought of using sillikon 1000 but that is permanent. Am scared of vascular probls/necrosis since I have had 2 rhinops. So, thought perlane as it goes away. Will it hide nostril show?
My answer: I have been disappointed with injectible fillers for nostril show in general. The problem is that most fillers are too soft to really force down the nostril edge. Every one of my patients that have tried fillers have, in the end, had surgery for correction of the nostril asymmetry or nostril show. That operation is complex and requires the experience of a skilled rhinoplasty surgeon, so pick carefully. Hopefully that helps.

Last Saturday, April 10, I had the honor of being invited to participate in a Rhinoplasty Panel at the Spring Meeting of the NY Regional Society of Plastic Surgery. This is a particular honor for an Otolaryngology-trained Facial Plastic Surgeon. To the credit of Dr. Alan Matarasso, the scientific program chair of the meeting, he invited a balanced panel of 2 ENT Facial Plastic Surgeons and 2 Plastic Surgeons. The participating panelists were: Me; Dr. Rollin Daniel of Newport Beach, CA; Dr. Russel Kridel of Houston, TX; and Dr. Mark Constantian of Nashua, NH. All are top minds in rhinoplasty. I was indeed honored to be a part of it.
I spoke about Combining Functional and Cosmetic Rhinoplasty. My talk centered on how the application of structural support for nasal obstruction must complement the aesthetic goals of the patient. A enthusiastic discussion about the role of spreader grafts in rhinoplasty occurred during the Q&A session after the talks, originating with my observation that spreader grafts are not always as effective as we expect them to be in the severely obstructed patient.
Later that day my wife Melissa and I hosted Dr. Daniel at a wonderful dinner at Oceana Restaurant. The owner, an old friend, happened to be there, making the dinner all the more memorable. My next talks on Functional and Cosmetic Rhinoplasty will be during our upcoming 10th International Facial Plastic Surgery Symposium in Hollywood, FL at the end of April. Stay tuned!
Minas Constantinides, M.D.

Before & after rhinoplasty photos are good way to EXCLUDE a surgeon, but may not help in picking one. Some things that should warn you off a rhinoplasty surgeon:

1. Do the noses look natural or done? Obviously if a rhinoplasty surgeon is showing his results on his website for everyone to see, he must be proud of them. Use this information to your advantage. You will get a very good idea of what the rhinoplasty surgeon feels looks good by looking at his photos. If you don’t think that his rhinoplasty results look good, then he is probably not the one for you. His esthetic should match yours.

2. What about the rhinoplasty surgeon that doesn’t show any before-and-afters on his website, citing “confidentiality”? Today, if I have a website, I need photos. If I don’t show them, then I probably haven’t gotten permission to show them from my patients, or I haven’t been in practice long enough to have any that are any good! Beware in either case.

3. What views are best? Everyone loves to see the profile views because they are the most dramatic. However, they can also hide a lot of problems. Any rhinoplasty surgeon with a good rhinoplasty result (and not just a good profile view) will show at LEAST an oblique view and, in really successful cases, a frontal view. It is these views that are the most representative of a good result. All-profile websites should not be trusted as “best in class”.

Hope that helps.

Minas Constantinides, M.D., F.A.C.S.

Successful rhinoplasty surgeons. Here are my thoughts:
1.The best surgeons do not compete, but rather do the best they can for their patients. Given our competitive society, you would think that in order to become a busy and famous rhinoplasty and facial plastic surgeon you have to compete with your neighboring surgeons. Having met dozens of top surgeons personally and having shared many a podium, drinks and dinner with them, I have found that the opposite is actually true. They all share one striking quality when you meet them: they are remarkably selfless. Indeed, when asked to what they attribute their great success, they all reply with some variation of, “Well, I’m just very fortunate and lucky.” Anyone who does complex primary rhinoplasty and revision rhinoplasty knows that this is actually very far from the truth. Rhinoplasty surgery is so difficult and predictable results so hard to master, that no one can consider himself a master without having done at least 1000 of rhinoplasties and revision rhinoplasties, learning from their mistakes along the way. This pain-staking process of learning through long-term follow-up requires a dedication to self-discovery and self-criticism for which there is no parallel in any other field that I can think of.
2.The best rhinoplasty surgeons have their own style; they are not all things to all people. I know that the selection of rhinoplasty patients on my website reflects a certain style. I prefer noses that look natural. What this means to me is that I would rather leave a high, straight bridge and a less-pointy tip in my rhinoplasty patients. Of course there are rhinoplasty patients on my website that look more “done”, but usually it is because that is what my patient had wanted based on a one-hour discussion and after photo-imaging. However, if a patient pushes the envelope of “doneness” too far, I try to persuade him/her to back off that outcome. If he/she is insistent, I don’t accept him/her as my patient. Fortunately, most New York patients don’t want that overdone look.
3.The best rhinoplasty surgeons care about each individual patient. The best rhinoplasty surgeons spend more, not less, time with any patient that is having difficulty with their recovery. This difference came into sharp focus for me during my recent trip to Ecuador (See: http://www.newyorkfacialplastics.com/blog/?p=1941 ). I had the pleasure of spending one hour of uninterrupted, up-close and personal time with Dr. Fernando Pedroza of Bogota, Columbia. Dr. Pedroza has single-handedly put Facial Plastic Surgery on the map in South America. Imagine the most famous plastic surgeon of the U.S., double his reputation and surgical volume, and you will come close to getting a picture of Dr. Pedroza’s practice. Dr. Pedroza and I spoke about our rhinoplasty patient consultations and it was startling how similar our methods are in speaking to our rhinoplasty patients for the first time. We both spend an inordinate amount of personal time with our rhinoplasty patients (45 min to one hour), and the rhinoplasty patient spends another 1-2 hours with our staff being further educated before they are asked to schedule surgery. The amount of personal effort that each of us invests is huge, so that our rhinoplasty patients know that we are committed to providing them with as much information as they need to make an educated decision. Dr. Pedroza commands the highest prices in South America and could easily spend less time with his rhinoplasty patients and not have his surgical volume suffer. That he does not is a testament to his commitment to insuring the deepest satisfaction in his rhinoplasty patients.
4.The best rhinoplasty surgeons educate others to their philosophies, approaches and techniques. One of the things that distinguishes surgical education from other forms of intellectual capital is that we surgeons give away our intellectual capital for nothing. The more famous the rhinoplasty surgeon, the more he teaches others his rhinoplasty techniques and publishes them in books and professional journals, expanding the knowledge base for everyone to share in. It astounds me how much this point is overlooked by the general public. There are numerous rhinoplasty surgeons in most communities who have terrific websites and are good salesmen, but who simply do not participate in the educational process. Most of us who teach, write, and perform research do so to further the knowledge base of rhinoplasty. The best rhinoplasty surgeons even travel around the world to try to further rhinoplasty in other countries. I personally have traveled to Vietnam, Columbia, Turkey, Portugal, Germany, Peru, and Ecuador to educate the local surgical communities in rhinoplasty, all in the last two years.
Knowledge of rhinoplasty alone does not make a top rhinoplasty surgeon. A top rhinoplasty surgeon is someone who derives extraordinary positive energy and focus from caring for his rhinoplasty patients as individuals, and caring for his surgical community without guarantee of fame or personal gain. The core values of the best rhinoplasty surgeon makes him someone that you would want to trust with your face and nose. The best rhinoplasty surgeon never promises perfection, but does promise to do his best using all of his abilities to give you as good a result as you can possibly have. The best rhinoplasty surgeon promises to take care of you in times of fear and uncertainty, getting you through difficult healing periods or unexpected revisions. The best rhinoplasty surgeon understands the leap of faith it takes to choose him as your surgeon, and values his responsibility to you, his patient, above all else.

Last week, I traveled to Salinas Beach, Ecuador for the 4th Equatorial Conference in Rhinology and Facial Plastic Surgery. This resort area of Ecuador is on the Pacific coast near Guayaquil and attracted an audience of over 150 surgeons. Also speaking at the conference were Dean Toriumi and Fernando Pedroza (of Bogota) among others. I gave rhinoplasty talks on “Basic Principles of Rhinoplasty”, “Advanced Tip Techniques in Rhinoplasty”, and “Complications of Rhinoplasty”.

Ecuador is on the verge of joining the International Federation of Facial Plastic Surgery Societies with intensifying interest in facial plastic surgery in general. I look forward to seeing them make a successful bid for this in the next year.

My wife Melissa and I just returned from a week-long trip to Peru. The trip began in Cuzco, which was the capital of the Inca Empire when the Spanish colonized the area. Cuzco is at 12,000 feet and travelers are often affected by altitude sickness. Fortunately the hotel we stayed in, the Monasterio, had supplemental oxygen available in the guest rooms. The next day we took the Hiram Bingham train to Macchu Picchu. This was an enchanting area, deeply spiritual in its feeling in the heart of the Peruvian Andes. The area left us with a profound feeling of peace and wonder, so much so that a return trip to spend several days in the area is part of our future plans.

Upon returning to Lima, I taught a 3-day course on Rhinoplasty, joined by Dr. Ted Cook from Portland and Dr. Roxana Cobo from Columbia. The course was jointly administered by the Peruvian Society of Otorhinolaryngology and Facial Surgery and the Latin American Society of Rhinology and Facial Plastic Surgery. It drew 180 surgeons interested in expanding their rhinoplasty techniques. The lectures I gave were on Fundamental Concepts in Rhinoplasty, Functional Rhinoplasty, Advanced Nasal Tip Techniques, Revision Rhinoplasty, Internet Marketing and Rhinoplasty, The Crooked Nose, and Complications of Rhinoplasty, totaling 6 hours of lectures. Our hosts, Dr. Francisco Saliverry (President of the Latin American Society of Rhinology and Facial Plastic Surgery) and Dr. Miguel Garcia-Calderon (President of the Peruvian Society of Otorhinolaryngology and Facial Surgery) made the time in Lima memorable and filled with wonderful food and social events. The educational enthusiasm of the Peruvian surgeons was so impressive that I have promised to return next year for another course, this time including live surgery.

I have been writing about the Patient-Physician Relationship for facial plastic surgery journals lately, and wanted to share some of my thoughts with you. I believe that nothing is more valuable for my patients than helping them achieve their personal goals through surgery. However, how will surgery actually help each patient with achieving their life goals? I believe that I can be a better doctor when I know the answer for each of my patients. I start each consultation with a new patient with what Dan Sullivan [developer of The Strategic Coach (www.strategiccoach.com )] calls the R-Factor Question: “If we were to meet here in one year, looking back over that year that’s passed, what would have had to have happened for you to be happy with the progress in your life?” Notice that this question has nothing to do with surgery, but rather with my understanding my patient’s immediate life goals and dreams. During the consultation, I explore with my patient how surgery can help them meet their own goals, taking them to the next level in their life. I believe that we are all about 80% happy with our lives, but we are constantly looking for that next 20% that will make us reach the next level in our lives. When that includes surgery, then I can help my patients see what potential can be unveiled by successful surgery for them.

I also believe that no one can make any important decision in life if he/she is paralyzed by fear. Fear, in fact, is what keeps most of us from making needed changes. During our consultation, we explore what fears a patient has regarding surgery and progress in life in general. For each fear, I try to help them see a way past it. If it is fear of anesthesia, for example, I give them real facts about that risk, and also discuss how I have considered every risk and have minimized it for them. This has an amazing calming effect on most patients, so that this fear no longer stands in the way of their having surgery. After every fear is discussed, most patients feel empowered to take the step towards surgery. Our consultation doesn’t end there.

After fears have been discussed and eliminated, we talk about hopes. I ask my patient to imagine their life after successful surgery. What will it look like? How will it be different than it is now? What new opportunities will be unveiled for them? What personal strengths will be reinforced? What will this do for their personal and professional lives? A picture of life at the next level is even more empowering; few patients have trouble committing to surgery after such a vision is created by them of their future. This consultation process is what I call the Transcendent Consultation. It helps patients transcend their fears and reach for the opportunities that will be provided by surgery. This creates tremendous value in my patients’ lives. The consultation is not a superficial review of what surgery is like. It is a deep exploration of how surgery will improve all aspects of my patient’s life.

Its been too long, but my absence from the blog scene was for good reason. I’ve been busy traveling around Europe speaking about Functional Rhinoplasty, Cosmetic Rhinoplasty, and the Patient-Physician Relationship. Our trip spanned the two weeks between the last week of August and the first few weeks of September, with the Labor Day weekend as the middle weekend of the trip. Accompanying me were my wife Melissa and our son Dimitri. Our trip started in Paris, the only stop that had nothing to do with Facial Plastic Surgery. Dimitri loved the Louvre, where he was able to visit the Mona Lisa, who he had studied in school. I recently saw a History Channel segment hypothesizing the Mona Lisa was a self-portrait of Leonardo DaVinci. Kind of takes the wind out of one’s sail thinking about that. Whoever she was, she certainly captured a mysterious beauty that is more androgynous than feminine, but certainly not masculine.

After Paris, we flew to Porto, Portugal for the European Academy of Facial Plastic Surgery’s Annual Meeting. I gave lectures about Cartilage Grafting in Rhinoplasty and the Patient-Physician Relationship, and a one-hour course on Rhinoplasty: From Planning through Recovery. Porto is a beautiful city perched on a hill overlooking the Douro River and resting beside the Atlantic Ocean. Famous for the center of port wine production, it is an old, beautiful city with winding streets. It is also the musical and cultural center of Portugal. The closing dinner was a highlight of the trip, held in Taylor Wine Cellars where great food and wine was accompanied by a cabaret of Broadway show numbers. Portuguese wine is an amazing value for its price, with rich reds that stand up to the biggest meats. Fortunately they are becoming easier to find in New York.

Munich, Germany was our last stop. This was my first visit to Germany, and I was surprised that Munich, the capital of Bavaria, was a beautiful old city with numerous outstanding restaurants and the ever-present Bavarian beer. Our hotel, Tobrau House, was in the center of the old city having been built in 1490. Many of the buildings withstood the heavy Allied bombings that leveled most of the outer city during WWII, so Munich retains much of its old-world charm. It is an easy city to negotiate, and the locals are friendly and very proud of their heritage.

In Munich, I spoke at the largest Head & Neck training program in Germany at their annual Rhinoplasty Course. Day 1 included lectures by me on Functional Rhinoplasty, Cartilage Grafting in Rhinoplasty, Advanced Tip Techniques in Rhinoplasty, and the Patient-Physician Relationship. Day 2 was Live Surgery, where I performed a Functional Rhinoplasty on one of the most crooked noses and septums that I have seen in my career.

My patient was an Iranian immigrant who spoke only Arabic. He had a friend who spoke Arabic, German and Greek, so we were all able to communicate with only one level of translation. He had been a boxer and was known for his immense nose. I could imagine the young attending in the clinic seeing him and thinking, “Have I got a case for the famous visiting professor (ME!).” Surgery, piped in live to an auditorium of 50 course participants, was difficult and tedious and took 4 hours to complete. In the end, after extensive reductions of tissue volume while adding strengthening structural grafts, I left him with a nose that would work a lot better and look much straighter and smaller, though still masculine. The audience was impressed and I was confident that I had taught them something beneficial, thanks to this courageous Iranian.