The incisions are made and the skin and fat are lifted off the cartilage and bone which are the structural elements of the nose. Reshaping is done by some removal of the cartilage or bone. At times sutures can be used to help remodel the cartilage and at other times cartilage or bone grafts can be used to augment change or hide the shape of the native structures.
Usually the tip cartilage is addressed first then the dorsal hump is removed or reduced. That can be done by rasping the tissue or by direct removal with an osteotome or chisel. Removal of the dorsal bump usually leaves what’s called an open sky deformity which mean there is an open space on the top of the nose. That typically requires fracturing the side bones of the nose to bring them together on top. That can be done either internally or externally depending on the surgeon’s preference. At that point the incisions are closed, the nose is packed and an external splint is applied. Variations from these techniques are done depending on each individual patient and the surgeon.
Non-surgical: Non-surgical rhinoplasty refers to reshaping the nose with injectable substances rather than surgical means of altering the shape and structure of the nose. It is also called a "non-surgical nose job", and can be performed in the outpatient setting without anesthesia. Another non-surgical option used by some people are flexible "nose inserts" that are placed in the nostril area between the nose tip and back of the nose. The nose inserts reshape one's nose only while worn.
Recovery: The patient returns home after the surgery. Most surgeons recommend antibiotics, pain medications, and steroid medication after surgery. Most people choose to remain home for a week, although it is safe to be outdoors. If there are external sutures, they are usually removed 4 to 5 days after surgery. The external cast is removed at one week. If there are internal stents, they are usually removed at four days to two weeks. The periorbital bruising usually lasts two weeks. Due to wound healing, there is moderate shifting and settling of the nose over the first year.
Although rhinoplasty is usually considered to be safe and successful, several complications can arise. Post operative bleeding is uncommon and often resolves without needing treatment. Infection is rare and can occasionally progress to an abscess that requires surgical drainage under general anesthetic. Adhesions, which are scars that form to bridge across the nasal cavity from the septum to the turbinates, are also rare but cause nasal obstruction to breathing and usually need to be cut away.
Anesthesia and Surgery Facility: Dr. Yousif performs almost all of the rhimposlasties under general anesthesia. Operative time approximately 2-3 hours unless it is a more complicated case.
Dr Yousif does many surgeries to correct patients that have had poor outcomes. Some patients have had as many as 6-7 previous rhinoplsty operations. When patients consider having a surgery again after having had a previously bad outcome it is a diffiuclt decision to make. Consultaions for secondary corrective surgeries are long and with a long discussion about achievable results. Dr. Yousif will review all previous operative reports and have an indepth discussion with the patients. This might take 2-3 office visits.
The Face Lift: Also known, as a rhytidectomy is a type of cosmetic surgery proposed to give a more youthful appearance of the face. It usually involves the removal of excess facial skin, with or without the tightening of underlying tissues. According to the most recent 2008 statistics from the American Society for Aesthetic Plastic Surgery, facelifts were the sixth most popular aesthetic surgery performed after breast augmentation, liposuction, eyelid surgery, abdominoplasty or tummy tuck, breast reduction, and nasal surgery.
Facelifts are helpful for eliminating loose skin folds in the neck and laxity of tissues in the cheeks. The areas not well corrected by a facelift include the nasolabial folds, perioral mounds or marionette lines or lines around the lips. Although facelift requires skin incisions, which results in permanent scars, those scars in front of and behind the ears, if done correctly, usually become inconspicuous over a period of time. Hair loss in the portions of the incision within the hair-bearing scalp can rarely occur. In men, the sideburns can be pulled backwards and upwards, resulting in an unnatural appearance if appropriate techniques are not employed to address this issue. In both men and women, signs of having had a facelift can be a pulled-back, "windswept" appearance, widening of the corners of the mouth, visible lines of pull especially with movement of the face, and visible scars.
Commercial Lifts: Commercial lifts or Branded lifts have become a popular attempt to lessen recovery and have the same results as traditional lifts. They are usually advertised through infomercials. Unfortunately these lifts do not have a scientific basis behind them. There has been very little unbiased reviews written about their results and their long term effectiveness. The companies try to have a catchy name and use a hard sell to increase costs to the patients. The most notarized of these lifts include the Quick lift of Lifestyle lift. It is concerning that there have been no long term unbiased scientific review of these procedures while patients are tempted by the idea of short recovery for significant results. It is very important that patients investigate and evaluate any proposed procedure for its scientific basis and its potential to correct the issues they are seeking to improve.
The Mid-Face Lift: Also known as the cheek pad, is a combination of fat and fibrous tissue beneath the skin. It is not well supported and as those already weak support structures weaken further with time the constant effects of gravity cause a vertical descent of the mid-face.
In Dr Yousif’s opinion, mid-face descent along with aging of the neck maybe the most important parts of facial aging. The descent of the mid-face creates many of the most significant visible effects of aging, including deepening of nasolabial folds, jowls, marionette lines, visual lengthening of the lower eyelids, a sub-malar depression and widening of the lower part of the face. Many different types of procedures have been proposed for mid-face restoration. Most techniques involve some type of elevation of the descended mid-face upward and outward. Unfortunately that does not correct most of the problems of mid-face aging. The lower eye lids, the malar depression and the nasolabial folds are all not improved. Beyond that the face takes on an unnatural look because the fat layer has been placed in a place it was never intended to be. Some surgeons are injecting fat into the cheek area to make up for the lack of replacement of the mid-face. This just gives the face an unnatural round look.
Minimal Recovery Facelift: The term “mini-lift” refers to a variety of lifts that simply mean less than a full-face lift. The exact procedure done will differ depending on each surgeon’s ideas, training and experience. Some mini-lifts mean limited scars while others mean limited elevation of the skin. Some may or may not involve manipulation of the underlying soft tissue in some way or another. For a patient to be satisfied with a mini-lift it is important that the patient personally understand what the surgeon is suggesting and whether or not that is adequate to remedy the individual issues that the patient wants to correct. It is unfortunate when a patient goes through a procedure that does not and at times simply cannot correct the issues that the patient wants addressed. This is not good for either the patient or the surgeon. A mini-lift is appropriate for early facial aging with limited cheek descent and limited excess in the neck.
IN ALPHABETICAL ORDER
Eyelid Surgery (Blepharoplasty)
This is performed to correct drooping upper eyelids and puffy bags below the eyes by removing excess skin, fat and muscle. Upper eyelid surgery may be covered by insurance in cases where it is performed to correct excess upper eyelid skin which may interfere with vision.
Anesthesia and Surgery Facility: A local anesthesia with sedation is the most common approach except when performed with other facial rejuvenation, and then general anesthesia may be used. This is routinely an outpatient procedure. Operative time is approximately 1½ hours for upper or lower lids alone and 2½ hours for both upper and lower lids.
Endoscopic Brow Lift
This may be performed to minimize forehead creases, correcting drooping eyebrows, hooding over the eyes and furrowed forehead and frown lines. It involves removing excess tissue, altering muscles and tightening the forehead skin. It may be done using the traditional technique with an incision across the top of the head, behind the hairline; or with the use of an endoscope, which requires 3-5 small incisions in the scalp.
Anesthesia and Surgery Facility: This may be performed under local anesthesia with IV sedation or in some cases, general anesthesia may be recommended. This is usually an outpatient procedure unless combined with other facial rejuvenation where a 23 hour stay may be recommended. Operative time approximately 1½ - 2 hours.
Side Effects: There is temporary swelling, numbness and itching, a tightness to the scalp or headaches and bruising.
Risks: There is a slight risk of injury to the facial nerve which can cause loss of motion, muscle weakness or an asymmetrical look. Infection, wide or excessive scarring and hair loss are also possible.
Recovery: Return to work or social environments is usually 7-10 days. This may be sooner if an endoscopic forehead lift is performed. Avoidance of more strenuous activity is recommended for 3-4 weeks. Total recovery from bruising and generalized swelling may take anywhere from 1 week to 3 weeks. Limiting sun exposure is recommended for several months.
Duration of Results: Most individuals enjoy the results for at least 5-10 years.
Complete Facial Rejuvenation
Complete Facial Rejuvenation Typical Skin Lift: The typical full facelift includes elevation of the skin from both sides of the face connecting across to the other side by the neck. This typically does not include the lift of the mid-face or cheeks. It does usually include an incision beneath the chin and some type of tightening of the neck muscle.
This type of face-lift is indicated for patients who do not have significant descent of the cheek pads, deep nasolabial folds, jowls or marionette lines. The SMAS (Superficial Myo-Aponeutotic System) is a supportive structure that lies beneath the fibro-fatty layer of the face but above the muscles layer. This layer connects the platysma, a muscle in the neck, to the deeper layers of the face and the corner and muscles of the mouth. Some surgeons believe that lifting this layer helps the facelift last longer. There have been many papers trying to support or discount that idea. Whether the surgeon uses this lift may depend to a greater degree on the training he or she has had.
It is Dr. Yousif’s opinion that the lifting and tightening of the SMAS simply does not add any benefit to the face lift and in many respects contributes to many of the typically unwanted effects of the facelift such as the widened appearance of the mouth. It is also his opinion that the SMAS lift does not lengthen the results of the face-lift.
The neck is made up of various structures including skin, a variable amount of fat and the underlying Platysma muscle. The variations in those structures, along with their respective relationships to the chin and other internal structures, gives the shape of the neck. For some unknown reason we have defined the beautiful neck as a long, well defined structure with a visible angle from its vertical portion to its horizontal section. In some individuals because of genetic differences, or aging that visual appearance does not meet an individuals desires. Surgical correction may help ameliorate those relationships.
Dr Yousif has been studying the aging neck over the last 8 years. He and his associates recently presented a portion of their results on the anatomy of the neck and its relationships at the prestigious Association of Plastic Surgeon meeting. From those studies, Dr Yousif has devised new procedures to improve the results of surgery while at the same time limiting the surgical scars.
In youth there are typically two issues that may need correction. One is the excess deposition of fat in the upper portion of the neck obscuring the desired defined angle and the other is the platysma. This muscular laxity is often over looked in younger patients that are looking for a more defined neck therefore limiting the final results of surgery and in older patients the ability to create a well defined neck that last has been difficult.
There different aspects to the neck that at times may lead someone to want to change its visual presentation. There may be, even in youth, excess beneath the chin. This is usually a genetic deposition of fat in the area above or even below the muscle. The aging neck has many components. With time the soft tissue weakens and there maybe soft tissue descent giving visible excess beneath the chin. Different procedures may be performed to enhance the appearance of the neck by removing excess skin (cervicoplasty), altering neck muscles (platysmaplasty), or removing excess fat (liposuction.)
New Techniques: Dr Yousif has been performing the Hyoid Suspension Neck Lift for the last 10 years. This technique is a significant improvement over older procedures and allow a youthful natural contouring of the neck with long term results. Many patients have seen no change in their results even after 8-10 years.
In some patients these can be done only through small incisions beneath the chin. This new "limited scar neck lift" can have dramatic results with only a small scar beneath the chin.
Treatment Options: There are a number of procedures available to enhance the appearance of the neck. They range from very minimal in-office treatments with no down time, to more invasive procedures requiring anesthesia and time off for recovery.
Botox Injections: The vertical bands that extend from under the chin to the base of the neck are caused by the neck muscle called the platysma. Botox can be injected into the muscle to temporarily reduce the appearance of these bands. This is a simple in office procedure that requires no anesthesia and allows you to get right back to your normal activities.
Neck liposuction for fat removal: Removal of fat in the neck may or may not be part of the treatment of the aging neck. It can be seen in younger individuals as well as older patients. In younger individuals removal of fat alone to help define the neck may be helpful. In older individuals the laxity of skin may not allow appropriate tightening with liposuction alone to re-define the neck. So liposuction alone is usually reserved for younger patients. This is usually done through small incisions under local anesthetic with or without some sedation.
Anesthersia and recovery: Depending on the extent of the operation anesthesia can be either general or local with some sedation. Recovery is usually just a few days but some support of the skin may be required for 2-3 weeks. This is usually done with some type of elastic garment worn for a portion of time during the day and for a bit longer at night.