March 16th, 2010
Who is a good candidate for facial plastic surgery?
New York, NY
The best candidates for facial plastic surgery are motivated individuals who are healthy, inherently happy and looking to enhance their appearance. Of course, health comes first. Cosmetic surgery is still surgery. It inevitably involves anesthesia of some sort, be it local, twilight or general. That means patients need to have normal healing, clotting and must be medically able to tolerate surgery and anesthesia. There are well established pre-surgical testing requirements that have been set forth by the national Anesthesia society. For a young healthy person, it has been shown through studies that doing a stack of tests are not necessary. Age, sex and medical status standards determine what each potential patient needs to deem them safe for surgery and anesthesia.
I have turned away a number of patients seeking facelifts who are on medications for heart conditions and/or have heart stents. This is because they cannot safely be off blood thinners for the necessary amount of time to heal normally from surgery. Some have begged me, or their primary care doctors, to take them off the blood thinners or operate on them anyway. Of course, I said no. This decision is really up to your primary care doctor. It is not worth looking good if there is a chance that you may have a heart attack, or worse.
Cosmetic surgery is to make patients look better and to improve self image and self confidence. However, no matter how good you look after, if you have a poor sense of self image, surgery may not help. The best patients are those who are happy yet look to improve features that may detract, such as a big nose or jowls. Fixing this aesthetic flaw then restores or enhances self esteem. I often see personality changes that far outstrip the cosmetic changes, but this is as a result of, not a reason for cosmetic surgery.
Over 15 years ago, I performed a rhinoplasty on a friend (at his insistence). He was extremely affable and a great person, plus the #1 salesman in the country for a large international corporation. So, he certainly didn’t lack self confidence. After surgery, his professional confidence spilled over to his social being. He finally asked out the girl he admired from afar for years. They are now married with two children. I didn’t make that much of a physical change, but the psychological change far outstripped what we did for his nose. He was able to apply that great personality to his social life.
In reviewing some articles on patient selection for facial plastic surgery, they said that an educated patient is part of the criteria to be considered a good candidate. But given the media attention to cosmetic surgery and enhanced beauty, too much is not good either. Airbrushed celebrities and models don’t help give accurate accounts of what they really look like. Actors can also take off months to hide and heal before appearing back in public (as they don’t have 9 to 5, 52 weeks a year jobs to get back to right away). The internet is full of excellent information, forums and blogs, but not all of these are helpful. Sometimes too much information is not good. Details of a surgical procedure can sometimes be daunting and confusing to patients; especially when highly respected surgeons even differ. How can a non-physician make a choice? Also, unhappy patients tend to be more prolific on the internet than happy patients.
Cosmetic surgery is an amazing way to enhance one’s appearance for healthy well motivated patients. It’s always a good tool to research your options but beware of misleading information from the internet. Steven J. Pearlman, MD, FACS
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February 24th, 2010
Septoplasty Part II
Fixing a Deviated Septum
New York, NY - Fixing a deviated septum is usually performed from inside the nose by a closed or endonasal approach. Crooked bone and cartilage is moved, removed and/or straightened. There should NOT be any changes to the way the nose looks or any “black and blue” whatsoever. As I tell my septoplasty patients, your mother couldn’t tell that you had surgery 3 days later. On the other hand, if you have a deviated septum it might be the ideal time to have a rhinoplasty if you have been thinking about it. Your surgeon will be operating in the neighborhood. Also, with modern rhinoplasty, often cartilage from the septum is used to strengthen the nose as we re-model it. Because of this, I suggest that if you are considering rhinoplasty and have a deviated septum, they should be performed at the same time. Other than the convenience of going through only one operation and one recover period, the fact that I often use cartilage from your septum to strengthen the nose during rhinoplasty is reason to do them together.
Please make sure that your surgeon looks inside your nose and checks for any causes of nasal obstruction; those that exist and those that may inadvertently occur during rhinoplasty. Based on Bernoulli’s Law of air flowing through a column, a minor asymptomatic deviation or other cause for obstruction can become more significant if the nose is narrowed. A rhinoplasty surgeon should be well versed in sinus surgery and all the associated consequences of functional nasal surgery.
A common misconception is that if you have or your doctor finds a deviated septum then you get a free or discounted nosejob. This might have been the case years ago. Insurance companies paid well and freely for nasal surgery. Doctors would call it a deviated septum and old nasal fracture or other creative names. Insurance companies got wise to this. Rhinoplasty is a cosmetic procedure and really isn’t the responsibility of your medical insurance company. Unless you broke your nose within the past year or so and have good documentation of a significant new deformity, don’t even think about it. There are some doctors who still add inappropriate codes to get higher reimbursement and others who will “throw in” a rhinoplasty if you have a deviated septum, but they aren’t necessarily the best surgeons. Be careful, you may get what you paid for: discount surgery.
There usually is some cost savings from doing a Septorhinoplasty together. Part of the operating room and anesthesia fees may be covered for the functional aspects of surgery. The functional portion of the Septorhinoplasty may also be covered by your medical insurance and may mean no or little additional cost beyond a cosmetic rhinoplasty for the functional (septoplasty) procedure. This depends on your insurance coverage.
This is the nose that you will have for the rest of your life. You want it done once and done right. You should find the best surgeon you can, one who specializes in noses and does what is necessary to get a great nose. Steven J. Pearlman, MD, FACS
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January 25th, 2010
Teenage rhinoplasty
Part II
New York, N.Y.
Last week I discussed the scientific background for who and why we can and should offer rhinoplasty to teenagers with big noses. I will now discuss the more personal aspect of caring for these sensitive individuals. Teenagers are under a lot of social pressure as they are finding themselves, establishing social skills and interacting with peer groups. It is easy for an outsider to criticize cosmetic surgery as unnecessary, but for a teen who has endured ridicule from the outside or put up a wall of self isolation due to lack of self confidence from a large nose, it can be a huge issue, no pun intended. Rhinoplasty is not about popularity but more about social acceptance.
All too often the consultation starts with the teenager staring at the floor because they are shy about their looks, yet they also may be embarrassed about the concept of having cosmetic surgery. We reassure them that this is a confidential consultation and that we plan to answer any and all concerns that both patient and parents have. Consultations usually last around 45 minutes or more. It is important to emphasize that we strive to create a natural nose. No one wants a scooped, pinched nose. Even parents can be reluctant since their generation was subjected to cookie-cutter, overdone noses. Today’s nose should fit the face, which the vast majority of our rhinoplasties do.
Computer imaging is an excellent tool as well for the consultation. Teenagers are very visual. Seeing potential results and discussing what we both feel looks right for them can help alleviate their apprehensions. We review healing time and how fast they can get back to school or embark on their summer activities. The minimum time I prefer is 2 weeks before going back to school. By that time, the swelling is down enough so that the nose often looks like the original and gets gradually smaller over the ensuing month. Patients are cautioned that they can’t participate in gym for 2 months (most love this and ask for more) and need to be careful about hitting the nose; today every teenage girl hugs and kisses their friends who they haven’t seen in two whole weeks.
What can result? The transformation I have seen is often amazing. Teens come back with new attitudes; chins lifted up, improved eye contact and they smile a lot more. The psychological changes often outdo the physical changes we made through rhinoplasty. For the teenagers who already were outgoing and social, it only serves to support their already well established self confidence.
Steven J. Pearlman, M.D., F.A.C.S.
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January 19th, 2010
Rhinoplasty can be very rewarding for teens
New York, NY
Discussing teenagers and plastic surgery always elicits deep emotional reactions from all sides. Those in favor of it realize that it can go far in enhancing one’s self image at a time when self confidence and social acceptance can be very important. Others feel that it is too early for teenagers to be having any purely elective surgery. I will be addressing rhinoplasty only; which comprises over 10% of facial plastic surgery procedures according to a survey by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Basically, I have seen so many teenagers come out of their shells after rhinoplasty that I support this procedure for a properly motivated teen.
Why the nose? Our face defines who we are, how others see us and who we see. The nose is the most prominent feature on the face. An important scientific study on physical attractiveness and peer perception states that “physical attractiveness may be an important personal characteristic primarily during adolescence…when social acceptance by a peer group is a particular salient issue.” (Dion KK, Bersheid, E. Physical attractiveness and peer perception among children. Sociometry journal 1974 vol. 3). Following cosmetic surgery, adolescents can gain self satisfaction from changes in their appearance which is beyond what would otherwise occur with natural development (Sills KH, et al. Plastic and Reconstructive Surgery Journal Vol .109, 2002).
What age should we consider rhinoplasty? The general teaching, going back decades, has been that girls can have rhinoplasty as soon as 15 years of age and boys by 16. This is when they are almost fully grown. What is more important than physical growth is the age at which teenager can make a mature responsible decision to undergo surgery. Given changes in society, this age is getting younger and younger. What I do during the consultation is gauge the teen’s level of maturity and motivations for surgery. Teens are also very visual. Computer imaging is an excellent tool for visualizing potential results and provides a positive reinforcement for the planned surgery.
One of the biggest obstacles is reluctant parents who saw too many overdone noses. I am about the same age as many of these parents and too many of my peers have pinched “fixed” looking noses. Today’s nosejob should look natural, one that fits the face. One of the most common and gratifying comments I get from former patients is that they saw old friends from camp or school and the remarks were: “you look great, did you lose weight? Change your hair?” NOT, oh, you had a nosejob. The other rewarding experience is seeing a once introspective quiet teen, one who barely looked up, now standing tall with pride and self confidence; often with changes far beyond anything I did for their nose.
Steven J. Pearlman, MD, FACS
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June 22nd, 2009
I just got back from the AAFPRS (American Academy of Facial Plastic and Reconstructive Surgery) semi-annual rhinoplasty course. I was honored to be a speaker at this prestigious course. This course is given every two years and is considered by many to be the premiere course for physicians who wish to hone their skills as rhinoplasty surgeons. I gave two lectures and ran one seminar.
My first lecture was entitled “What makes a nose look overdone?” I used my years of experience, as well as an important study that I am currently conducting, to teach other doctors what makes noses look fixed. I review how I restore them in both form and function. But most importantly, I teach how to avoid making these mistakes in the first place.
My second talk was “How to avoid the pinched tip and excess columellar show in rhinoplasty.” I guess the course directors like the way I teach prevention; prevention of noses looking fixed and how to create natural appearing noses. This is why patients often tell me that after surgery, old friends commonly ask if they had a makeover, a new hairdo or lost weight. Basically, they look better but not fixed.
My third assignment was a panel called “ask the expert”. I had three experts, Dr. Cook from Oregon, Dr. Harris from Maryland and Dr. Robinson from New Zealand. Each panelist presented two cases of difficult rhinoplasties. The other panelists then were quizzed on what they would do before the operating surgeon discussed the actual surgery. I asked pointed questions of each panelist asking them to justify any and all choices, so the audience can see what thought processes a master surgeon goes through when preparing for a rhinoplasty.
I find these courses informative and I always pick up a few pointers that I take home and perhaps incorporate into my own skillset. What I found interesting is that less than 25% of the speakers discussed techniques using the intra-nasal approach. Two of the best lectures I heard were Europeans talking on the intra-nasal approach: Dr. Berghaus from Germany and Dr. Palma from Italy. The intra-nasal or closed approach avoids any scars or external incisions on the nose. I find that I get equal if not better results in primary rhinoplasty using this technique (see earlier blog). I am one of the few remaining docs still teaching and offering the “closed” approach to the majority of my primary rhinoplasty cases.
The AAFPRS has been my professional home for many years. Much of what I learn comes from dinners with friends and colleagues from around the world at meetings and courses such as this. Last but not least, I get to catch up with good friends.
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February 10th, 2009
There has been a lot of hoopla over the past two decades over the incisions used for both primary rhinoplasty and revision rhinoplasty. There even has been name calling at medical meetings: open rhinoplasty is equated with and open mind and closed rhinoplasty attributed to a closed mind. Well this is not true and why I don’t use the term closed very often.
There is a lot of history behind the surgical approaches in rhinoplasty dates back to nasal reconstruction techniques in India in 800 BCE and in the 1600’s in Italy by Tagliacozzi. Modern intranasal or closed rhinoplasty is attributed to Drs. Jacques Joseph and John Orlando Roe in the 1890’s. In 1927 Rethi introduced the columellar, or modern open, incision. This fell out of favor until it was reintroduced by Padovan in the 1970’s. Since that time, many highly regarded nasal surgeons, such as Drs. Jack Anderson, Calvin Johnson, Dean Toriumi and Jack Gunter have advocated the open approach. Other experts, including Drs. Eugene Tardy, Frank Kamer, Jack Sheen and Thomas Rees still relied on a mostly the intranasal approach for their superior results.
So enough with the history, this is not a book chapter for doctors. Which of the two is the best way to get a superior result in rhinoplasty? There is no good answer and it really depends more on the individual surgeon. I feel that in primary (never operated) rhinoplasty I can obtain equal if not a better cosmetic result using an endonasal approach in over 90% of patients, without any incision across the bottom of the nose (this part of the nose is called the columella). It’s more important that your surgeon understands the anatomy of the nose and is an expert in rhinoplasty, than what incision they use.
Then, why would I use the open incision at all in primary rhinoplasty? The indications, medical speak for reasons, in my opinion for using the open approach are 1. A very crooked nose, 2. A short nose that needs to be made much longer, 3. A nose that requires many grafts.
For revision rhinoplasty, which comprises about a third of my nasal procedures, I use the open approach on most. My indications for this incision are 1. Unexpected changes that may have occurred during the first surgery, 2. scarring and 3. Altered anatomy from both surgical and changes during healing. These are findings that often occur in revision rhinoplasty, otherwise the patient wouldn’t be seeking revision. Going back to primary rhinoplasty, a good surgeon should be able to tell the patent’s underlying anatomy from an external exam alone, by looking at the nose, touching the nose and looking inside the nose. So, making changes should be predictable. When surgery has been performed prior, there are changes that may not be accounted for in old operative notes, scarring and often stitches that holds structures in place and defy moving (the technical term is delivering) the cartilage around as is done to modify the nasal tip in a primary case.
As for the open rhinoplasty incision, across the columella, this incision is tiny and usually barely noticeable if at all. Of course, all incisions are pink for up to 6 months, but as it heals, I feel that unless someone is looking up your nose, know what they are looking for and close enough to count nose hairs; they are unlikely to notice the incision.
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