Eyelid Surgery (Blepharoplasty)

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.

Susie, don’t take your surgeon’s reluctance to perfrom a facelift that you want personally. Most surgeons like certain techniques because either they are easier to perform (MACS lift much easier technically than deeper lift) or they are not familiar with a requested technique. Most surgeons would simply tell you their reasons for preferring one technique over another (for example, maybe you need less of a lift for now, so he is recommending something less invasive). However, a combination of reluctance and an abrupt manner probably mean that he just isn’t the surgeon for you, whatever the reason.

As for deep plane lifts, they are ideal for producing a great result in experienced hands, as long as the indications are there for them. They are far superior in my opinion to more superficial lifts, but take longer to perform and to heal from. You have to ask yourself if you can tolerate a week of more swelling for what will ultimately be a longer-lasting and more effective lift in the appropriate patient.

Minas Constantinides, MD
Manhattan, NY

Jowls after a facelift will always come back. The type of facelift you have will determine when. Jowls are the fat of the jaw line that sags as the SMAS layer sags over time. How that layer is lifted will be more or less successful in correcting the problem.

No one is doing a skin-only facelift anymore. Many surgeons do some version of a SMAS-lift; others (like me) do some version of a sub-SMAS or deep plane lift. In order to correct jowls, the lifting along the jawline has to lift the SMAS effectively at the jowl. This is best accomplished by lifting beneath the jowl. In my hands, I can do this best using a deep plane facelift approach.

Regardless of how well the lift is performed, as you age the jowl will return. The only question is, “When?” With deep plane facelifts, usually the jowls are improved for so long that a revision lift is not needed for over 8 to 10 years.

The pixie nose was once the most sought-after nose to have. In the 1960’s, many models had pixie noses. The rhinoplasties performed then, with the scooped bridge and turned-up tip, were designed to create the pixie nose. Today, we think of a higher bridge and less-upturned tip as more esthetically ideal, but the pixie nose look is not dead. Many of my patients from South America still want that look since there it is still popular in some areas. What matters most is: does your nose matches your face? A shorter, upturned nose may work beautifully with a small face, but less well in a face with larger cheek bones or a stronger jaw line. If your nose bothers you, a consultation with photo-imaging will help you decide if changing it will make you look better.
Improving a pixie nose typically calls for raising the bridge and lengthening the tip. Both these maneuvers are challenging, with nasal lengthening one of the most difficult maneuvers in rhinoplasty. I would recommend you select a surgeon with experience in this technique. Ask to see before and afters of patients with noses like yours. Assess whether he is an occasional rhinopalsty surgeon, or an experienced one. Talk to his other rhinoplasty patients. Trust your instincts on this and you are sure to have a good outcome.

The American Academy of Facial Plastic & Reconstructive Surgery has launched a new program for veterans of Iraq and Afghanistan with facial injuries. The Faces of Honor program connects volunteer surgeons from around the country with veterans with facial injuries. It is a program that veterans can take advantage of once our military and VA hospitals have done all they can do. The program was launched last fall but is only starting to gain momentum. If you know a veteran with a facial injury, please let him know about this program. Further contact information can be obtained at www.facesofhonor.org.

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.

Last week in South Beach, I attended the American Academy of Facial Plastic & Reconstructive Surgery’s (AAFPRS) winter Board of Directors meeting. As Group VP of Research, Awards and Development, elected last year by the facial plastic surgery national membership, I represent the committees whose job it is to build research efforts by the AAFPRS, to distribute research awards, and to help in developmental activities, including pro bono national and international activities. Here is a recap of the activities we discussed, with a bias to those I am working on:
1. Research: On Friday we met with senior leaders of 3companies to help pave closer affilitation that can benefit the AAFPRS membership. Each year we meet with several such companies, and this year we made an effort not to invite competitors. As a result, the companies that attended (LifeCell (makers of Alloderm), Sanofi (makers of Sculptra), PNC Skin (makers of skin care lines and peels) all spoke openly of what direction they were going in and how they wanted our Academy to participate with their growth. From our part, we discussed the possible formation of an LLC that could help to organize outcomes research at arm’s length from company oversight. This is important because most companies now fund their own outcomes research, but such research can be potentially tainted by bias from the funding company. Our company would be able to commission research that would be funded by industry, but not directed by industry. This will create tremendous value for industry, the AAFPRS, and for science at large.
2. Awards: The AAFPRS continues to participate with the CORE grant process administered by Otolaryngology. Last year due to the poor economy there were insufficient funds to pay for the CORE grant recipients. Otolaryngology stepped up and funded the awards, allowing worthy recipients to fund their winning research projects. This year we hope that the improved economy will allow us to continue to fund the awards, endowed by the generosity of Dr. Leslie Bernstein.
3. Development: Face To Face, the domestic and international pro bono arm of the AAFPRS, continues to find success. The Domestic Violence Project, that helps victims of domestic violence find volunteer surgeons to care for them for free, continues to help over 100 women per year across the country. The international program continues running successful trips to Vietnam, China, Russia, and Africa. With the launching of Faces of Honor, the AAFPRS has once again founded a worthy program where injured veterans of Iraq and Afghanistan can be paired with volunteer surgeons who are willing to help them. For more information see FacesOfHonor.org. We also discussed sending AAFPRS members information about how to volunteer in Haiti. The AAFPRS will soon compile a database of surgeons willing to deploy on short notice to areas of natural disaster world-wide.

Education: Although the VP of Education oversees these programs, I have been intimately involved in developing a new educational opportunity for our members. The Domestic Observership program was approved by the Board of Directors to pair mentors with mentees for 1 to 3 month observerships. This program will launch soon, allowing any member who wishes to spend time with a senior Fellow and mentor in the AAFPRS in a post-graduate learning experience. Although completely observational, so quite unlike our hands-on Fellowships, this program will allow members an additional learning a venue. The program will be overseen by the Fellowship Committee of the AAFPRS (of which I am immediate past-chairman).
Overall, the effort that our Board displays in working for more member benefits and opportunities continues to impress me. I look forward to continuing to serve our members in the years to come.

Our entire office would like to extend our warmest wishes for the best 2010 possible to all our readers. We look forward to celebrating your successes and helping you with your challenges in the year to come.

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.