I was fortunate to have trained with the most established facelift surgeon in Los Angeles and this provided me with a solid foundation to build upon. In 1994 when I began my Fellowship with Dr. Frank Kamer, he had just completed developing his Deep Plane Facelift technique. This novel approach to face lifting offered many advantages over prior methods and, although I have modified things a bit, it has since remained the mainstay of my operation. My typical lift involves dissecting underneath the deeper tissues without first separating the skin. This allows for the deeper tissues to be freed and elevated and the mass of the face can be repositioned naturally rather than being pulled and distorted by simply tightening the skin and relying on it alone to hold those tissues up. Because the heavier tissues are independently supported, the results from a Deep Plane lift last longer than traditional SMAS or skin type facelifts as I reported on with a research paper in 1998. I tend to lift in a more vertical than horizontal direction and I do not use drains. I use many variations on this theme by dissecting more or less when indicated and sometimes extending the deep dissection underneath the muscles of the neck without any skin dissection. This latter modification renders a clean, beautiful jawline without the lumps and bumps that occasionally accompany a platysmaplasty (another way of handling the neck muscles). Of course there are times when a simple skin lift or tuck is preferred such as when some fat beneath the skin has fallen and needs to be isolated or for a revision lift. Because I was trained using the advanced technique I find it quite simple to perform skin or SMAS type lifts when the need arises. I do not believe the reciprocal is true however. Surgeons that typically perform the more superficial lifts are generally not comfortable or as competent doing the deeper lift and thus they do not get the optimal benefits out of that surgery. Those recognized benefits are better healing of the incisional scars, longer lasting results, more natural looking (less pulled) appearance, improved circulation to the entire face, fewer post operative lumps and bumps and less bruising.
My approach to the upper and lower eyelids has changed dramatically from when I first began performing this surgery 22 years ago. At that time I was taught to remove as much excess fat, skin and muscle as possible in order to get rid of all the hanging “extra” tissue. Over the years it became clear that removing all the tissue surrounding the eye did not make things look younger or better: It made the eyes look older. Youthful eyes aren’t prominent and round and don’t have much visible lid or hollow sockets or the whites of the eyes showing on the lower lids. Youthful eyes are surrounded by skin that is taut with fat. The lids have crisp folds and the lower lids blend into the cheek such that there is no delineation between the orbit and the face. Eyelid surgery, more than any other facial procedure, has the potential to alter the essence of someone’s appearance. Because of this I strive to be conservative with the eyes and to “restructure” rather than to remove the tissues. For the upper lids I almost never take away any fat. If I find the fat has herniated from behind the eyeball to underneath the skin I will delicately replace it back to where is once was to get rid of an unsightly bulge but without creating any hollowing. Muscle might be tightened and skin will be judiciously excised. Occasionally the lid skin can benefit from being intrinsically tightened by treating it with laser or other like-minded technology. The lower lids are usually approached from inside the lid to avoid any scar and potential eversion or dragging down of the lash line. Fat is gently teased out from inside of the orbit (where there is often a “bag”) and advanced over the rim and secured where it is most needed to fill in a visible trough or hollow. By moving fat from the “bags” to fill in the “hollows” I create a smooth contour that improves any “tired look”. This technique maintains the exact shape of the eyes as they were preoperatively. Occasionally it is necessary to place an incision immediately under the lashes to allow for smoothing out a superficial bulge or removing some excess lower eyelid skin. Such an incision is only performed when the lower liddemonstrates good support or when other measures are being taken to reinforce it.
As an alternative to surgery I often inject Restylane to fill in hollows that exist under the eyes. I began doing this in 1997 and over the years I have become quite expert at it. While there is no cutting involved and the results can be quite remarkable, there always is a chance for bruising and swelling. Fortunately, excess product causing any lumps can be dissolved if need be.
The use of the fiberoptic endoscope for performing brow and forehead lifting came of age while I was in my fellowship training and I was fortunate to be on the front end of that learning curve. Prior to 1993 most all brow lifts were done using a large incision from ear to ear across the scalp that often resulted in numbness of the scalp, hair loss, and a wide, visible scar. The endoscope not only obviated the need for that incision but ushered in a novel perspective for rejuvenating this area of the face. Rather than simply cutting and pulling the scalp, attention was directed on rejuvenating specifically those elements that were the result of aging. The technology improved as did our level of understanding about the aging process; and the “endoscopic browlift” evolved. My current philosophy is to use the scope to allow me to alter a few specific muscles and attachments in order to render a subtle softening of appearance. Although the maneuvers I employ in each case are different, I generally try to attain a similar aesthetic outcome. I prefer the center of the brows to be on the low side yet not too close together. The brows should arch but there must not be too much distance between the brow and the orbital rim, as this can make the person look startled or hollowed out. I usually move the brows out to the sides rather than vertically. The muscles that enable a person to frown are sometimes divided or sometimes left alone. There is no skin removed with my technique. The brows are secured to the bone in their desired position and any redundant tissues are redistributed backwards over the remaining scalp where there is a greater area to accommodate them. I feel that a well executed brow lift is more conservative than a blepharoplasty as there is no tissue removed and no visible incisions. Although one might be tempted to think of brow lifts and blepharoplasties as comparable operations with the same goal of improving the aesthetics around the eye they are not. Often times I find that performing both procedures allows for the optimal balance and aesthetics.
In 1998 I was analyzing the face of a woman who had undergone two prior facelifts. On close inspection it was obvious to me that the center part of her cheeks had fallen vertically over the years and the prior operations had not helped with this problem but merely tightened her lower tissues horizontally towards her ears. The net result was that she had that windswept appearance with “Nike Swooshes” emanating from the corners of her mouth. Of course one might expect this to happen if the skin had been pulled towards the incisions in front of her ears while all the weight of her facial tissues continued to drop downwards. The solution was clear to me. The face needed to be lifted vertically; as straight upwards as feasible. In order to accomplish this goal I tried several methods and over time evolved into what I firmly believe is the best way of safely performing a midface lift. What began as an operation to repair the consequences from prior facelift surgery eventually became a first line procedure to improve aesthetics in the central portion of the face. I now perform midface lifts on 60% of my facial rejuvenation patients and often as a stand alone procedure; even on specific young patients. The midface lift involves incisions inside of the mouth above the gums.
After freeing up the soft tissues from the facial bones they are suspended up to the temples with the aid of the endoscope. Two small incisions are made in the temporal scalp and tunnels are dissected down into the face to communicate with the lower dissection. Once mobilized, the tissues are engaged with an absorbable device, elevated and secured to the temples. The effect is to raise the high points of the cheeks to where they once were or a more optimal position. Because only soft tissue is being elevated, the midface lift creates a more youthful rounder look than one might get with placement of hard cheek implants. The face becomes less long and thin and more round and there is improved support to the lower eyelids. A midface lift prevents the “flattening” of the face that can result from a traditional facelift and certainly helps to prevent that “pulled look”. My midface lift is not at all like those “thread lifts”. Those procedures touted as “minimally invasive” often involve placement of many sets of permanent sutures and rely on them to hold the face up in a static manner over time. My midface lift actually moves the tissues by dissection and repositions them to heal in a new position against the underlying bone. As we age we lose volume in our face and I find the midface lift to be uniquely suited to addressing this problem without the necessity of filling the face up.
Of all the operations in the field of plastic surgery, rhinoplasty is considered the most difficult. It’s not that the operation involves more bleeding, dissection or physical exertion; it’s that rhinoplasty is exacting and unforgiving. The precise configuration of the tip cartilages is not always known until the tissues are freed up and decisions must be made on the spot. Any change in the amount or shape of the cartilage initiates a wound healing process that causes further changes to take place long after the operation is over. And because the nose is in the center of the face small imperfections can have large consequences. Many people seeking rhinoplasty or revision rhinoplasty have significant problems breathing through the nose. Additionally, any aesthetic changes might effect the function of the nose. It is for this reason that the rhinoplasty surgeon be well versed at functional surgery of the nose. I am board certified in both ENT (Otolaryngology-Head and Neck Surgery) and Facial Plastic and Reconstructive Surgery and have over 20 years experience fixing nasal airways with septoplasties, turbinate reductions, perforation repairs, nasal valve adjustments and various other methods. Many surgeons do not want to perform rhinoplasty except for the most simple of cases such as reducing a dorsal hump. In contrast, I welcome the challenge that nasal surgery poses and have developed a passion for it. Over the years I have performed thousands of rhinoplasties and I still find each case unique and educational. By critically analyzing my results I am constantly improving on the way I approach things. My patients have become more discerning and specific about what they hope to achieve and their expectations are higher than ever. While unrealistic expectations are certainly a source for concern, reasonable goals from sophisticated patients motivate me to “raise the bar”.
Very often patients will inquire if something can be done to improve their neck without having to do a facelift with the incisions near the ear. Over the years I have authored papers on this topic and gone through just about every described technique to accomplish this goal. What I am committed to is achieving an excellent result. If I believe I can do this without the need for tightening the soft tissues (facelift type incisions) then I will move forward. If I suspect that our ultimate goal might be compromised without removing tissue then I will do my best to persuade the patient to refrain from the surgery. If, however, the patient wishes to “try” then we will do so with the full knowledge that we might need to perform a lift to optimize things in the future. This discussion is based on the fact that skin cannot be removed from a small incision under the chin without the risk of having it look strange. If tissue is to be removed then it must be from the sides (generally from around the ears). When the isolated neck surgery is performed a small incision is created under the chin. Superficial fat is removed from beneath the skin and then usually the skin is widely freed up from the underlying platysma muscle. The platysma muscles are then separated and fat beneath them removed if indicated. The edges of the platysma muscles are then sutured together. The overall effect of these maneuvers is to create a smaller neck and now there is the challenge of redraping that piece of skin so that it doesn’t look all flaccid. This involves freeing up the skin even more widely to give it a greater surface area to “shrink wrap”. A compressive dressing is worn for several days to aid in this process. If someone has good elasticity to their skin then it will eventually contract fully to the new, smaller neck and things will look fantastic. If the skin fails to contract fully then things will probably still look better than they did pre operatively but there will be some bothersome laxity. As mentioned above, this can be addressed with a facelift or possibly with some of the newer technologies for tightening skin (although as of yet these have not provided much improvement in this situation). Thus, the answer to the question of whether someone is a candidate for an isolated neck lift depends on their anatomy, the elasticity of their skin and their goals. Sometimes a chin implant can be very helpful and tilt the decision in favor of the lesser operation. Likewise, losing weight prior to surgery can help in the decision making process.
Chin augmentation refers to creating a larger or more projecting chin and is usually done to provide greater balance with the nose or the rest of the face. There are ways of achieving a wider chin by using fillers but these do not do as good of a job with projection (the amount the chin sticks out from the plane of the face) as an implant. I prefer to use silastic (hard silicone) implants to create the desired changes. There are a myriad of shapes and sizes commercially available and I can also customize them when the need arises. These are solid implants, not gel-filled, and have been used for this purpose for over 50 years with a very good safety record. If a patient is unhappy with an implant or if there were an adverse event such as an infection they can be removed or exchanged via a very simple procedure. I have found that, when indicated, a chin implant can create an improved jaw line to frame the face and help to minimize jowls and rejuvenate the lower face. I often place a chin implant at the time of face lifting to enhance results as it will also provide for a more acute angle between the jaw and neck. An implant can allow me to leave a nose on the larger size rather than having to create a tiny nose to balance a tiny chin. In the same way, a larger chin makes the nose appear smaller and there have even been occasions over the years where a patients sought me out for a rhinoplasty and ended up with only a chin implant.
I place these implants through small incisions underneath the chin. The bruising is minimal and the swelling limited. The suture is removed at day seven and most patients feel comfortable returning to work within six to eight days. I believe it takes four months until the final shape can be appreciated, although in many cases the improvements are obvious from day one. As with many of the procedures that I do, a chin implant should enhance the overall aesthetics of the face and look entirely natural.
Over the years few procedures have provided me or my patients with as much gratification as shortening the upper lift when indicated. This procedure is usually suggested by me during consultation as most patients are unaware that there is an imbalance in their face or that such a procedure even exists. A beautiful face has a certain harmony to it and the length of the upper lip plays a vital role in creating a youthful, happy, or sometimes sexy appearance. I have been doing this procedure for 16 years and over that time I have gotten more discerning about when to employ it and when not to. The operation is relatively simple to perform but requires a great attention to detail and meticulous technique. Often this is a procedure that is done in combination with other facial procedures but it can also be done independently. The usual candidates are those born with very thin lips or a long distance between the bottom of the nose and the upper lip border. Aging also creates increased length and a loss of lip volume so that this procedure is very helpful for rejuvenating the face in many patients, both men and women. The trade off with this technique is an incisional scar at the base of the nose. The great majority of the time this scar heals to a point of being unnoticeable to any casual observer, even without makeup. However, healing is not completely predictable and there are times when the scar requires some help with such things as laser or injections or dermabrasion. If the patients are chosen carefully for this procedure then the net gain is always substantially greater than any downside and we have happy patients and surgeon.
There are other surgical techniques that I use to improve the appearance of the lips or mouth and some involve incisions inside of the lip or even on the face just above the corners of the mouth. It is not incumbent upon my patients to inquire about specific techniques, but simply to tell me what is bothering them or what ideally they would like their mouth to look like. I will make suggestions based on those things taking into account the individual person and the risk/benefit profile.
Prominent ears can often be a source for self consciousness and there are many surgical ways to address this problem. The specific technique utilized depends upon the particular ears in question. Often times some cartilage is removed from an incision created on the back side of the ear. Removal of this cartilage that pushes the ear out from the head doesn’t result in any change to the intrinsic shape of the ear but rather just the position of it. When the shape of the cartilage requires alteration then various techniques can be employed to achieve a specific goal. The most common shape-changing maneuver utilizes sutures to bend the cartilage and create a more developed anti helical fold. Sometimes the lobule (lobe) must also be brought in or reduced in size.
Surgery to change the shape of the ears (Otoplasty) is commonly performed on young children prior to their beginning school in order to prevent ridicule from other youngsters. It is also done in my practice simultaneously with facelifts as I will ‘already be there’ and people notice their ears becoming more notable with advancing age. The incision is extremely innocuous and the results are generally quite gratifying for the patient. The usual course involves some pain for 1-2 days and associated swelling of the skin around the ear with some red or bluish discoloration that subsides within a week. The patient is advised to wear a headband at night for the first three weeks but can usually return to their social life within days of the surgery.
The surface of the skin and its intrinsic quality play a major role in how healthy and youthful a person looks. Regardless of the specific procedure I am performing, my goal is always to enhance that patient’s overall appearance and this often will include treating the skin with some type of adjunctive therapy. At the Lasky Laser Center we have a myriad of state-of-the-art technologies to choose from in order to selectively treat our patients. The Lasky Laser Center is constantly acquiring new technologies, but only once the science has proven them to be effective These machines can be used to improve skin texture, pigmentation, fine lines and even bruising resulting from surgery or injections. Because we have so many different devices we can customize treatment to that particular patient’s needs rather than treat every patient with a single alternative. The coordinator of our Laser Center works hand in hand with my patients to ensure that they are treated in an individualized fashion and informed off all current treatment options. For those lasers that are more aggressive or that require sedation I personally perform the procedures, whether they are being done as stand alone operations or in conjunction with other surgery.
Since I began injecting fillers in 1994 the quality and number of choices of materials has grown exponentially. With improved products that have less risk of allergy, reactions, or pain and that last much longer I have expanded my usage to take care of all sorts of bothersome issues. I was fortunate to be in on the ground level with both Restylane and Juvederm and participated as a clinical investigator for the FDA trials; giving me a very early and insightful experience from which to draw on. I also happened to begin my fellowship training just after the first ever report of Botox for cosmetic uses was published; again giving me a head start with this fantastic drug. I researched and published the first-ever paper on using Botox for the purpose of elevating the eyebrow and subsequently became one of the world’s leading experts for this. All of my experiences have given me a comfort with these injections and helped me to address many subtle details and imperfections to provide for refined improvements.
When it comes to these injectables I want to emphasize that you, the patient, should merely articulate what bothers you and what you are hoping to achieve, and leave the decisions of exactly what needs to be utilized and how much up to me. Of course, once I decide on a game plan I will discuss it with you so that you understand my thought process. When large volume is required for the purposes of rejuvenation I often consider using fat. However, there are many advantages to using the above fillers for volumization as well as for fine lines, wrinkles, changing the brow or corners of the mouth or even rejuvenating earlobes. I can eliminate dimples in the chin or even increase chin projection with Botox or Dysport and often times provide for a stronger jaw line with Juvederm or Restylane. Often I can use fillers to stave off the need for surgery for several years and sometimes fillers and neurotoxins are necessary to enhance the results of an extensive surgery. There are times when some filler is helpful in the nose or when Dysport can help to shrink a large salivary gland that’s causing a bulge. The main point here is that there are many things that can be creatively used for all types of purposes and that every individual requires careful analysis to determine what and how to go about reaching the established goal.