Question: When I stand in front of the mirror and gently pull the skin over my cheekbones up, I look great.  Is this what I would look like with a midfacelift?  I do not want a facelift that is really noticeable because I do not want the guys at work to know I had it done.  I am 43 years old and work in the trades.

Answer: Well, a midfacelift may be the answer to your concern as it is exactly what it sounds to be, which is an elevation of the midface or cheek structures.  The only difference that you may notice between you pulling your cheeks up in front of a mirror and the actual results of a midfacelift is that the smile line between the nose and the mouth is not going to be treated nearly as well through the surgical midfacelift as it seems to be when you elevate your cheeks with your fingers.  Furthermore, the jowl area does not tend to elevate nearly as much either.  But, if your goal is really elevation of the midface structures to give your cheeks more volume, then I think you would be extremely happy with a midfacelift, which in my personal hands is typically performed through an endoscopic approach through incisions in the temple area.  Many of my patients decide they would like an endoscopic browlift at the same time since the incisions are very similar and the cost is thus reduced when compared to performing these procedures separately.

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Question: I have several questions about your service:  Can I choose whether to have local or general anesthesia for a nose job, what determines whether it will be a closed or open rhinoplasty, and how do you determine which is used?

Answer: Well, you can definitely choose whether you would desire a local or a general anesthesia but, if you are going to have a local anesthetic for a rhinoplasty, you are also going to be given a significant amount of sedation through an IV.  The far majority, if not virtually all of my patients decide they would just as soon have a general anesthetic for their rhinoplasty, which seems to be easiest on both the patient and myself.  Regarding whether an external or internal approach is used is obviously dependent on my comfort level with performing the specific rhinoplasty techniques that the patient requires.  For relatively routine rhinoplasties for patients who have an overly large nose, I will typically perform this through an endonasal approach without an external incision.  For patients with a need for revision rhinoplasty surgery or patients who have significant asymmetries or need for multiple different cartilage grafts, I will typically perform these types of procedures through an external approach.  These sutures that are placed for the external approach are typically removed on the same followup day as the removal of the splint, which is six to seven days after surgery.  Whether it is an internal or external approach is a bit irrelevant as the external scar does heal exceptionally well.

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Question: I am 25 years old and feel that looks are everything.  I love to look at before-and-after pictures of nose jobs.  I know that the surgery must cause black eyes and other bruising.  How long is it before a nose job looks 100% natural?

Answer: When I personally perform rhinoplasty surgery, I am extremely meticulous with the infiltration of the local anesthetic.  I also am very careful with elevation of soft tissue off the areas where I am going to make some cuts in the bone, and then I use a very small osteotome, which is the instrument that actually makes the cut in the bone during most rhinoplasty procedures.  Because of the aforementioned techniques, most of my patients have very little actual bruising that is visible.  Most have a small amount underneath each eye and, by the time I see them back in six days for the removal of the nasal splint, bruising has typically already resolved and all they may have is a small amount of yellowish discoloration under the eyes, which is easy to camouflage.
Once the nasal splint is removed, I feel that, overall, the nose has a very natural look virtually immediately.  Now, there may be some swelling still present but this swelling seldom makes the nose look unnatural and, therefore, virtually all of my patients can resume relatively normal activities six to seven days after a rhinoplasty procedure.  They do realize, however, that there is a small amount of visible swelling, and this will improve over the first one to two months and, ultimately, it takes approximately a year for the final visible result to be achieved.

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Question: I am a 54-year-old man and hope to have a browlift to get rid of deep wrinkles that are making me look older than my years.  Since I shave my head, I wonder if the scars will be too obvious.

Answer: Historically, I would have said that the scars are too obvious for a patient who shaves their head or who is balding to undergo an endoscopic browlift but it seems that these incisions, when placed horizontally up in the area where the hair formally had been, can heal to the point where they are very inconspicuous and patients tolerate them quite well. If you have deep horizontal lines in the forehead, a browlift can actually be performed through the wrinkles and the resulting scar looks like one of the lines of the forehead. There are other alternatives though to browlifting such as Ultherapy, which is a nonsurgical, noninvasive treatment for browlifting that would leave no visible changes to the skin but can still elevate the brows in a nonsurgical way.  This device uses ultrasound to injure the deeper layers of the tissue so that the healing phase creates the deposition of new collagen which in turn tightens and lifts the brows.  I would highly recommend considering a consultation at Quintessa Medical Spa as, at this time, we are one of the very few facilities in the entire United States that has this advanced technology.  One other option that I will mention would be to perform browlift through a blepharoplasty incision, which would be through an incision in the upper eyelid where, if you have excess eyelid skin, this can be addressed at the same time and then the attachments of the brow to the bony rim are released, and a suture can be placed laterally to help elevate the lateral brow and, medially, the muscles that pull the brow down are partially resected and released, and this will allow the brow near the nasal side to elevate as well.  This would be the surgical option of choice in my hands for patients who are either bald or shave their heads but, ultimately, I would recommend a consultation with a board-certified facial plastic surgeon who can discuss various surgical and nonsurgical options for your concerns.

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Question: How do I know which nonsurgical facelift alternative is best for me?  I do not want anesthesia but I do want something done about all my wrinkles.

Answer: Well, for the most part, I find that there is a difference between facial laxity, which would require facial lifting, and facial wrinkling, which may be improved with some sort of a treatment on the skin.  If you are interested in lifting the facial features, there is only one nonsurgical, noninvasive device that has actually been FDA approved for facial lifting, and that is the Ultherapy device.  This uses ultrasound waves that are focused into a very small location beneath the skin.  This mechanical energy then heats up the tissue to the point where collagen denatures.  This in turn then creates the healing process, which lays down new collagen, which tightens the skin and can cause lifting.  It is currently FDA approved for browlifting but we do use it on other areas of the face such as the cheek, jowl, and area beneath the chin.  If your interest is more in wrinkling of the skin, then possibly treatment such as ProFractional laser resurfacing or MicroLaserPeel can be used in the spa setting for improvement in these wrinkles.

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