One of the most challenging – and satisfying – parts of a full rhinoplasty is adjusting the rotation of the nasal tip. Tip rotation is defined by the position of the nasal tip relative to the nasal dorsum (bridge) and the lip. The angle between the lip and the nose (the nasolabial angle) is smaller in an under rotated nose than it is in an appropriately or over rotated nose. Under rotation of the nasal tip makes a nose look long and droopy and it ages ones appearance as this type of nose is associated with an older individual. On the contrary, over rotation of the nasal tip makes a nose looks short and chopped and often results in the nostrils being overly visible from the front.
During your rhinoplasty consultation, tip adjustments are discussed and computer imaging is used to give an impression of the post operative appearance. The more substantial the planned changes are to the nasal tip, the more likely I am to recommend an open or external rhinoplasty. In my opinion, this approach allows better access to the tip cartilages and therefore allows a superior surgical outcome.
After surgery to the nasal tip, most patients will return to non strenous activites within 1 week and to normal activities in 2 weeks. 80% of healing will be complete after approximately 8 weeks but it may take as long as 12 months for the final appeaance to be achieved.
Neck Lift, Submentoplasty and Playsmaplasty:
I often see patients who are unhappy with the age related changes that have occured in their neck. Often I am told that the changes happened literally overnight. What do patients notice? Mainly three things: first, skin changes – either a change in the texture and appearance of the skin or a change in the amount and tightness of the skin; second, muscle changes which manifest as cords and “banding” in the neck; and third, subcutaneous fat changes which manifests as heaviness in the neck. Different people age at different rates depending on genetic makeup (intrinsic factors) and other variables such as sun exposure, weight fluctuation, smoking, etc. (extrinsic factors).
Non surgical treatments of the aging neck are limited to fractionated laser skin resurfacing which will give mild improvement in skin texture. Many of the non surgical modalities offered and marketed as aging neck treatment options will leave the patient dissapointed.
Surgical treatments remain the gold standard for the aging neck. With significant skin excess, the only way to adequately tighten it is to remove it via a neck lifting procedure. Muscular bands and cords under the skin must be either pulled back and tightened (part of the necklift), sutured forward and tightened (submentoplasty or platysmaplasty) or both. Removing fat at the same time using liposuction further improves the result. In all cases, down time is minimized and incisions are inconspicuously placed behind the ear, in the hairline and, if necessary, in existing creases under the chin and in front of the ear.
Further information, including before and after photographs, are found by clicking through on the following links: http://doctordenton.com/surgical-procedures/facelift/ and http://doctordenton.com/surgical-procedures/facial-liposuction/
Upper eyelid surgery performed in a patient to create a symmetric eyelid crease. Also known as “Asian eyelid surgery” or “double eyelid surgery” the “after” photograph (below) was taken only 6 days following the surgery to demonstrate the rapid recovery associated with this procedure.
In a previous post, I discussed the details of double eyelid surgery – aka asian eyelid surgery. This is a commonly performed surgery in my practice which is due, in part, to location in downtown Vancouver which has a large and very vibrant Asian population. The main reasons prospective patients give for desiring Asian eyelid surgery and the creation of an eyelid crease (“double eyelid”) are: improved symmetry, a more alert appearance and an eyelid that makes the eye appear larger. Understandably, one of the main concerns patients have prior to surgery involves the recovery process. In particular, how much downtime is involved and how painful is the procedure. Very little discomfort follows this procedure. Regarding downtime, the photograph in this BLOG post is of a patient before and 6 days after undergoing Asian eyelid surgery. I took the “after” photo immediately after removing her sutures. Some swelling remains, but in this case, it will be completely resolved within the next few days. What is worth mentioning is the dramatic improvement in eyelid symmetry that now exists and also the more alert appearance of the eyes now that a crease has been created – but an appearance that is still ethno-appropriate.
We all know that people age at different rates. Major factors influencing the process include genetics and lifestyle choices. Despite thisthe general pattern of aging is quite predictable. Skin becomes lax as the elastin and collagen proteins lose their strength over time. The subcutaneous fat layer (fat immediately beneath the skin) which is associated with a youthful facial contour thins and the deeper fat tends to drop with age – resulting in hollow cheeks, deep folds between the nose and the mouth and excess skin along the jawline and in the neck. Many of the changes are slowly progressive but others appear suddenly. It is amazing how often a patient will tell me that the age related changes to her face that brought her to see me occured literally overnight.
We haven’t yet figured out how to stop the aging process but we can slow it down. The old saying “an ounce of prevention is worth a pound of cure” holds true. Moisturizing, cleansing and sun protection are important when used on a regular and consistent basis. We all know the damaging effects of smoking and excessive sun exposure on the skin. Excessive alcohol intake and frequent significant weight fluctuations can also be problematic. New and exciting non surgical treatments are also available. Lost volume can be restored via fillers and lines can be smoothed and relaxed with Botox treatments. Light based therapies (lasers, IPL and radiofrequency) can help tighten old collagen and stimulate the formation of new.
At the end of the day, however, surgery remains the gold standard by which all other anti-aging treatments are measured. And to date, no non-surgical treatment can deliver the same extent of anti-aging benefit that comes with surgical intervention. New and refined surgical techniques offer less down time and a speedier recovery.
We came across this very clever and well done video which shows the facial aging process in a time lapsed fashion. Note particulary the changes to the brow, the eyelids (both upper and lower), the cheeks, the lines between the nose and the mouth, the lines extending down from the corners of the lips, the jawline and the neck. Early on, non-surgical treatments would be beneficial in making the changes less noticeable, however, at a given point, the only way to reverse the visible changes is through surgical intervention.
Front view showing favorable change 5 years following chin implant and neck liposuction surgery*
Profile view showing favorable change 5 years following chin implant and neck liposuction surgery*
Oblique view showing favorable change 5 years following chin implant and neck liposuction surgery*
Facial cosmetic surgery is all about balance which is superbly demonstrated in this series of before and after chin implant and neck liposuction surgery photographs. The face can be divided horizontally into thirds. The upper third extends from the hairline to the top of the nose, the middle third from the top of the nose to the bottom of the nose and the lower third from the bottom of the nose to the tip of the chin. In this example the patient was concerned with the lower third of the face and felt that it was short and poorly defined. In addition, she was unhappy with the contour of her neck and desired a sharper angle between the chin and neck. By performing chin implant surgery, the lower third of the face was lengthened and defined. Chin projection – which refers to how far forward the chin is positioned – was also improved. This is best appreciated in the profile and oblique photo sets. A small amount of fat was liposuctioned from the neck and area immediately below the chin. When performed together in an appropriate patient, these procedures are synergistic and the final result is greater than the sum of the parts.
In most cases I prefer to use a silastic chin implant placed through an incision on the inside of the lower lip – thereby avoiding a potentially visible scar under the chin. The liposuction part of the procedure is performed first through 3 tiny skin incisions which are not visible once fully healed. Recovery time is approximately 7 – 10 days with full return to normal activities by 14 days.
More information on these surgeries can be found on our website by clicking on the following links:
Before and After Upper and Lower Blepharoplasty* – Dr. Andrew B. Denton, Vancouver, B.C.
Concerned about the tired and heavy appearance of his upper and lower eyelids, this patient chose to undergo upper and lower blepharoplasty surgery. Also known as the eyelid lift, blepharoplasty surgery is designed to remove excess skin, muscle and fat from the eyelids. The result is an appearance that is more alert, rested, approachable and youthful. When excess skin in the lower eyelids is a significant part of the problem (such as in this case), an incision is made just below the eyelashes of the lower lid. Although resulting in a slightly longer recovery time, the end result is far superior than one in which no skin was removed or one in which skin tightening was dependent on laser or some other non surgical treatment.
Blepharoplasty is day surgery and is performed under either local anaesthesia or light conscious sedation. Skin stitches, if present, are removed 5 – 7 days following the procedure and patients return to normal activities within 10 – 14 days. Once removed, eyelid skin and especially fat do not tend to reaccumulate, leading to excellent long term results (previous post with 5 year post lower blepharoplasty results: http://doctordenton.com/lower-blepharoplasty-for-eye-rejuvenation/).
For more information on upper and lower blepharoplasty, please refer to the blepharoplasty page on the website: http://doctordenton.com/surgical-procedures/blepharosplasty/ .
Before & After – Facelift in Vancouver*
Before & After Facelift and Skin Resurfacing in Vancouver*
The client was concerned with the skin laxity that was developing in the face, along the jawline, on the upper eyelids and in the neck. Also of concern were the lines developing on the upper lip.
An extended SMAS facelift was performed which places tension on the layer of tissue under the skin. This allows excellent tightening and rejuvenation of the face while maintaining a natural appearance. When muscular banding of the neck is present such as in this case, a submentoplasty (neck lift or platysmaplasty) may be necessary. This procedure involves sewing the muscular bands together through an incision placed discretely under the chin. Wrinkles of the upper and lower lip will not be improved by a facelift. I employ a carbon dioxide (CO2) laser to treat this area. The down time is greater than with the less invasive fractionated lasers but the results are far superior. In a case such as this, when a patient has some surgical downtime, the CO2 laser in my opinion is the treatment of choice. Finally, excess skin, muscle and fat on the upper eyelids was removed during an upper eyelid lift.
The following two sets of photographs are of a neck lift patient before and several months following the procedure:
Neck Lift Before & After*
Neck Lift Before & After – Side View*
A neck lift is used to rejuvenate the neck and reverse many of the age related changes that occur in this area. Over time, the skin of the neck becomes loose and the muscles in the front of the neck separate causing the characteristic “bands” apparent in the before photos on the left above.
During the neck lift procedure, inconspicuous incisions are made below the chin and behind the ears. The muscles under the skin are tightened and often sutured (sewn) together in the midline and excess skin is removed. The neck lift restores the natural angle that exists between the jaw and the neck and restores the jawline as demonstrated above.
I perform all surgery, including the neck lift, in our private and fully accredited surgical facility in Vancouver, British Columbia. Although recovery periods do differ from person to person, neck lift patients generally return to normal activities within 10 – 14 days.
For more information on neck lift surgery (and its close cousin the facelift) please refer to: http://doctordenton.com/surgical-procedures/facelift/
Before Lower Eyelid Blepharoplasty*
Five Years Following Lower Blepharoplasty*
I saw this patient last week 5 years after operating on her lower eyelids – lower blepharoplasty. In the top photograph which was taken before the surgery, the concerns that she had regarding the appearance of the lower eyelids are apparent. The lower eyelids are puffy and swollen which gives a tired appearance. This was constant and not related to allergies or any other reversible process. Simply put, the puffy appearance is caused by fat pushing out from around the eye.
A lower blepharoplasty is a surgery that is designed to remove or reposition this fat which improves and rejuvenates the contour of the lower eyelid. Excess skin, if present, can be dealt with at the same time. There is no non-surgical way to treat this as effectively, naturally and permanently as the lower blepharoplasty.
The bottom photograph was taken during her visit last week. After 5 years the lower lid remains tight and smooth. The result from the lower blepharoplasty (during which skin and fat was removed) has held up extremely well!
For more information including before and after photographs of upper and lower blepharoplasty patients see http://doctordenton.com/surgical-procedures/blepharosplasty/
Volbella is the newest hyaluronic acid based filler from Allergan. Other hyaluronic acid based fillers from Allergan include Juvederm, Juvederm Ultra, Juvederm Ultra Plus and Voluma. Volbella is the first hyaluronic acid based soft tissue filler approved for use in the lips that has been shown to last up to 12 months. Up to this point, all of the patients that we have treated with Volbella have been extremely happy. Advantages over other hyaluronic acid fillers include decreased discomort during the treatment and decreased bruising following the treatment. From an injector standpoint, the product flows very smoothly allowing for excellent placement accuracy. In addition to being used in the lips, Volbella is also indicated for cheek and temple filling. All in all, a valuable new addition to the array of soft tissue fillers available to patients in Canada.