Look Naturally Beautiful...

Plastic Surgery

Procedures

FACIAL SURGERY/
FACELIFT
It is usually done under intravenous sedation or general anesthesia administered by an MD anesthesiologist. It is performed as an outpatient at a hospital surgical facility.

The traditional facelift is done with an incision around the ears and mostly hidden in the hair. The skin is then all separated from the underlying muscles. Then, the layer over the muscle (Fascia) is then pulled back and tightened.

Most of the tension is placed on this layer so less is placed on the outside stitches which should decrease the scarring and prolong the results of a facelift. Also, if there is fat, I also liposuction under direct vision at this stage.

Then, I pull back all the excess skin and tailor it into the scars. I do not use any drains but do place a bulky dressing on which is replaced the next day with a smaller one which the patient removes at the third or fourth day after surgery. At that time, you would be able to wash your hair normally. I then see my patients on the four or fifth day to remove some of the sutures.

All the rest of the sutures, except for the deeper layers are removed within 10 days. If the patient is from out of the area, they are removed at about the sixth or seventh day and they can return home.

The bruising depends on the patient but usually is gone by the tenth to twelfth day. The patient should be presentable by then also though with swelling which slowly subsides. You should look normal and not weird or unnatural after a facelift, like you have had a nice vacation/lost weight. A facelift is a bit of a misnomer for it does definitely improve the neck.

The aging process does not stop but is pushed back.

You can resume light activity after a few days and any activity after two weeks.

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FACIAL SURGERY/
RHINOPLASTY
Rhinoplasty or nose reduction- Nose surgery is to reduce and refine the nose and make it fit or blend into your face. It usually is done in a hospital outpatient surgery center under either intravenous sedation or general anesthesia administered by a MD anesthesiologist. It usually takes about one hour to change the shape of your nose by altering the cartilage’s and bone that form the architecture of it.

After surgery, a plastic-type cast is placed over your nose for one week to protect it while it is healing. You may also have light packing placed within both nostrils that is removed the next day. After this, tape is placed for several more days.

Light activity can be done after several days and heavy activity after about three weeks. You do get black and blue around your eyes for about two weeks and breathing may be limited for a week.

Nose surgery can be combined with other procedures like chin implant, facial or neck liposuction or repairing a deviated septum(after nose injury and difficulty breathing). The latter may be reimbursed by your insurance.

About 60% of the nose swelling is gone by about two months and the remaining takes about one year. Problems like bleeding, infection, nasal revision, difficulty breathing can unusually occur. For more information, please see our page on Preparing for your Cosmetic Surgery Procedure.

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FACIAL SURGERY/
BLEPHAROPLASTY
It is usually done under Intravenous sedation or general anesthesia administered by an MD anesthesiologist. It is performed as an outpatient at a hospital surgical facility. I remove the excess skin from the upper eyelid as well as the excess fat that causes the puffiness and fullness and lead to a “tired” look. You are left with usually a good scar in the upper eyelid crease which is not seen with your eyes open.

In the lower eyelid I either make a cut as close to the lid margin which allows me to remove not only the bulging fat, but also some excess skin if present. Or, I can just remove the excess fat causing the puffiness from the inside portion of the lid without an external scar. Finally, I now am doing the latter and repositioning the fat so a hollow look does not result later.

The procedure takes about one hour and the only bandages are steri-strips over the incisions.

You can resume light activity after a few days and any activity after two weeks. You are bruised for about 10 to 14 days.

Complications may include bleeding which is one of the rarest complications and can lead to blindness. More prolonged bruising or even bruising within the white part of the eye may occur. It usually does not change the shape of the eyes. Dry eye with excess tearing can occur which is probably due to the eyes staying partially open during the night.

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BREAST SURGERY/
BREAST ENLARGEMENT
Breast enlargement is performed as an outpatient at a hospital center under anesthesia by an MD anesthesiologist. I usually place the small cut around the areola, but can place it also in the armpit/below the breast or even through the belly button. Where I place the implant, either underneath the pectoralis (chest) muscle or on top behind the breast tissue only, depends on how the patient looks.My preference is underneath the muscle to hide the implant more and allow better visualization of the breast tissue by the radiologist.

Also, the type of implant I use, either saline(smooth or textured) or silicone(smooth or textured)(and various shapes and profiles) depends on how the patient looks, where I place the implant. I always am trying to achieve the most natural result for my patients so I individualize for each one depending on their appearance when I see them. The surgery takes about one hour.

I do not use any drains but can use a pain pump if the patient wishes. It is more uncomfortable (and frankly can be painful) if the implant is placed underneath the chest muscle). The patient is prescribed something for pain and sleep as well as an antibiotic.

Usually you can return to light activity within several days and full activity after two weeks. Usually you are able to take a shower, drive, go back to school/work in several days. I only place stitches that dissolve to minimize the scar and also that I do not need to remove them after surgery.

Complications such as bleeding (about 4%), infection (3%), loss of sensation (no matter where the incision is placed- 1%), deflation with the saline implant (about 5%) occur. The scars usually heal well and breast feeding is possible wherever the incision is placed. Finally, if your breast are different before the surgery, they will probably still be different after. For more information, please see our page on Preparing for your Cosmetic Surgery Procedure.

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BOTOX & FILLERS
These two categories of products have flamed the tremendous increase in cosmetic procedures since their introductions. According to statistics of the American Society of Plastic Surgeons, non- surgical procedures like Botox and fillers, have increased 100% in two years.

This increase is also due to non- plastic surgeons offering this to their patients or expanding their practices to include these non- surgical treatments. Furthermore, indications and applications of Botox have expanded since its original application in eye disorders. Overall, complications are minimal and I will discuss these specifically later.

Even though I am sometimes combining Botox and fillers, there are distinct and varied differences between them. Botox is a toxin derived from anaerobic bacterium Clostridium Botulinum and it produces its effects by paralyzing the muscles that it is injected into. It is manufactured by Allergan (Irvine, California) and is supplied as 100unit/vial of Botulinum neurotoxin type A complex to which one adds a differing amount of solution, usually saline, and preferably bacteriostatic, to minimize the burning upon injection, which yields a varying amount of liquid suspension.

A common dilution is to add approximately 3 cc of bacteriostatic normal saline to the vial provided to achieve a 33 and third unit per cc dosage. One normally injects this suspension with a tuberculin 1 cc syringe with a fine gauge needle (30 gauge or even 31 gauge). The patient is asked to contract the hyperactive muscles and the needle is introduced into the muscle and a small (approximately .1 cc dose) is injected into it. A topical anesthetic can be applied prior to needle insertion to help relieve the pain of injection (it is allowed to remain on the skin for about 15 minutes for maximum effectiveness). This process is then repeated for different muscles that one wishes to paralyze. There is really no end point, except for a slight raising of the skin. No dressing is placed.

Some bleeding and possible ecchymoses can occur and is usually controlled by applying pressure. The wheal usually disappears within one hour. Patients with more hyperactive muscles, like males, may require more units of Botox injected or it may not cause the desired effect or last a shorter time.

By paralyzing the muscles, they will no longer contract and the crease which is a direct result of the muscular contracture may subsequently diminish. Botox can be injected into virtually any muscle causing its paralysis, but usually for cosmetic purposes is limited to the muscles that cause frowning, namely, the corrugator supercilii, procerus, and orbicularis oculi. Since these muscles are also depressor’s of the eyebrows, some elevation of the eyebrows may result due to the unopposed action of the frontalis muscle.

Another common area treated is the forehead as well as the crow’s feet area. The latter will only show improvement when one squints. Other areas such as the chin and even the wrinkles above and below the lips can be carefully treated, but one needs to worry about paralyzing muscles that are required for proper smiling and so, at the very least, smaller doses are used. Botox applications have been extended into many other areas for cosmetic improvement like to attempt to diminish platysmal neck bands,torticollis, masseteric and even calf hypertrophy or enlargement, and common migraine headaches with variable and uneven success. Botox is also quite useful to gain symmetry by paralyzing the functioning muscle on the opposite side from a paralyzed muscle like in facial or Bell’s palsy.

It takes from about two to 10 days after the injection of Botox for it to produce its desired effect, and this lasts from weeks to months, depending on how quickly it is metabolized.

Fortunately, the complications from Botox are usually minimal and transitory. Even though allergy has been reported, I have not seen this. One of the most significant problems as I have alluded to, is the unwanted paralysis of adjacent muscles. This is a specially disturbing when the levator superiores is paralyzed, which results in a drooping of the upper eyelid. Fortunately,an antidote in the form of eye drops can sometimes relieve this until this unwanted effect disappears, usually in a matter of weeks. Overall, the effects of Botox are positive and beneficial, and this is why we have seen such a tremendous increase in its use.

Let us now turn our attention to fillers. These work in a totally different manner by filling the offending crevice or line. Fat harvested from one part of the body and injected into another was probably the first filler used. Unfortunately, consistent results are yet to be had. Each physician has his or her own technique to increase the transferred fat’s survival. The patient who would most benefit from fat transfer usually is the one that has the least amount of fat available for transfer. Some physicians had even stored the harvested fat cells for future injections. However, the latter fat cell’s survival is even more limited.

There are many artificial or man-made fillers available at this time. For many years, the only artificial filler was Collagen. This material was manufactured from highly purified bovine collagen. A skin test was required and allergy to this material was not infrequent, as evidenced by a small lump or bump. When Collagen first appeared in the marketplace, it was touted as very long lasting, if not permanent. It became quickly apparent that this was not the case. None of the other available fillers now make this claim. Collagen is now still effective and used but has been supplemented by a plethora of new injectables.

Within the past few years, many fillers have faded from the marketplace like dermalogen, fascian, while new fillers have been introduced here and abroad. Only a few have gained FDA approval, among them restylane and sculpta. Fillers can be broadly categorized into those that are derived from chemicals like Restylane, Perlane, Hyalaform, Captique, Radiesse, Sculpta or those derived from byproducts of either humans or animals. Artecoll fits into both categories for it consists of a combination of bovine collagen and polyglyic acid. However, even though it is available overseas, it is presently in clinical testing only in the United States and awaiting FDA approval.

The abundance of fillers attests to the fact the ideal filler still has not been found, i.e. that is non reactive and permanent. For the goal, is to provide a long lasting filling effect with little or no reaction to the material from the patient. All have only partially succeeded, for they may cause local and even, unusually, systemic reactions and all are absorbed in differing periods of time. However, most patients are not sensitive to their injectables,though granulomatous reactions by the body to them have been reported and can be troublesome. If the patient is hypersensitive to other materials, like creams, has any autoimmune type diseases, they should not be exposed to these fillers for their chances of reactions are greater.

Most of these fillers are mixed with carriers which themselves may precipitate allergic reactions and result in a loss of remaining volume and a return of the crease within a variable period of time. Collagen is mixed with approximately 40% Xylocaine. The latter dissolves quickly and,therefore, the patient will notice its effects partially disappearing quickly. Therefore, some overfilling is acceptable and even desirable. Because of this same effect, Restylane which is the active material but combined with a gel carrier was repackaged and now is supplied as a 1.3 cc vial instead of 1cc. Even Radiesse is used off- label in facial filling pending FDA approval, loses approximately 20% of its injected volume, usually in the first three months after injection. With Sculpta, only the polylactic acid remains after the added water, used to reconstitute the product suspension, is absorbed.

Let me also mention silicone or Silskin as its injectable form is called today. It is a wonderful filler and the results last longer than any other available material. However, the sometimes disastrous effects that occurred many years after silicone injections in the past, and were extensively reported in the 1990s have, apparently, conveniently been forgotten. Even though only droplets are now recommended and used, unwanted migration and granulomas with an inability to remove this material still may occur.

So, the myriad of fillers available and those others awaiting FDA approval, give the physician many probably confusing choices. This, ultimately, depends on what the individual physician feels the most comfortable injecting and what he feels works the best for his patients! However, it may not be so bad that the paralysis of Botox or the filling of the fillers is relatively short-lived!

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OTHER PROCEDURES
We can now perform most plastic surgery procedures at our center instead of at the hospital, making your entire surgical experience more convenient and efficient.

  • Breast Surgery-Gynecomastia
  • Breast Surgery-Pectoral Implants
  • Breast Surgery-Breast reduction
  • Facial Surgery-Coronoplasty
  • Facial Surgery-Implant/chick, chin
  • Facial Surgery-Lips
  • Facial Surgery-Minicision Lift
  • Facial Surgery-Otoplasty
  • Facial Surgery-Hair Restoration
  • Buttock-Butt Implant
  • Body Contouring-Abdominoplasty
  • Body Contouring-Body Lift
  • Body Contouring-Liposuction
  • Body Contouring-Thighplasty
  • Lasers & Thermage-CO2 Laser
  • Lasers & Thermage-Pursed Dye Laser
  • Lasers & Thermage-ND Yag Laser
  • Lasers & Thermage-Thermage
  • Male Cosmetic Surgery

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