Facelift (Rhytidectomy)

Indications for a facelift include sagging facial skin and jowls and loose neck skin. The usual candidates are men and women over the age of 40 years. Performed on patients under either general or local anesthesia with intravenous sedation, the procedure takes several hours. The setting may be an outpatient surgical facility, with or without aftercare services, or at a hospital. (Patients undergoing combined procedures or those who have medical conditions that warrant it may require brief hospitalization.)

Patients should expect to experience temporary bruising and swelling. The facial skin may feel numb and tender, as well as dry. Typically, the patient will have a "tight" sensation in the face and neck.

Risks include bleeding, infection, excessive scarring, asymmetry and an undesirable hairline change. Occasionally, injury to the nerves controlling facial muscles and temporary numbness occur. When injury does happen, it usually resolves, but on rare occasions, it is permanent. Poor healing is another possible risk.

After a facelift, the patient generally can resume work in 10 to 14 days and more strenuous activities within two to six weeks. Sun exposure should be limited for several months, and the patient should always use sunscreen.

The effects of a facelift typically endure for five to 10 years. One special consideration for men: the procedure results in repositioning beard-growing skin behind the ears, so after a face-lift, it will be necessary to shave the area behind the ear or seek hair removal treatment.

A facelift may be done in conjunction with other procedures, such as eyelid surgery (blepharoplasty), chin augmentation, forehead or brow-lift and skin rejuvenation procedures such as dermabrasion, laser peel or chemical peel.

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Facial Implants

Plastic surgeons can recontour and reshape the face with facial implants. Indications include receding chin and poor definition of cheeks or jaw, which may give the face a sunken or perpetually tired look.

Most implant procedures are performed in same-day surgical facilities on patients under either general or local anesthesia with sedation. However, combined procedures or preexisting medical conditions may warrant brief hospitalization.

A chin implant is a 30- to 60-minute procedure in which the surgeon makes a small incision either inside the mouth at the bottom of the lower lip or on the skin under the chin to create a pocket over the front of the jawbone. An appropriately sized implant is inserted into the pocket and sutured in place.

For cheek augmentation, the incision to form the pocket is made either through the lower eyelid or from inside the upper lip, unless the implant is being placed in conjunction with another procedure. When the patient is also undergoing a face-lift, forehead lift or eyelid surgery, the surgeon may use those incisions to form the pocket and insert the implant. The procedure takes 30 to 45 minutes per side.

Jaw implants are placed in pockets created directly on the jawbone on either side of the face. Incisions to create the pockets are made from within the mouth at the bottom of the lower lip. The procedure takes from one to two hours.

With all facial implants, the patient should expect temporary swelling and bruising. The duration of discomfort and the severity of the swelling will vary, especially if the patient has undergone several procedures at the same time. Significant swelling generally subsides within a few days, but it may be several months before mild swelling subsides and the final facial contours become apparent. Smiling, talking and eating may be temporarily affected, depending upon the location of the implants.

Risks associated with facial implants include bleeding, infection, asymmetry, sensory change and implants shifting out of alignment. If complications occur, implants may have to be removed.

During the recovery period, oral and dental hygiene require special consideration and diet may be restricted. For several weeks, the patient should refrain from activities during which the face could get bumped.

Unless they have to be removed, facial implants are permanent.

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Forehead Lift (Brow Lift)

Indications for a forehead lift include visible signs of aging, such as deep forehead creases, hooding over the eyes, drooping eyebrows and frown lines above the nose and in the crow's feet area. The procedure involves removing excess tissue (see section on Endoscopic Surgery) and redraping the skin to smooth the forehead, lift the upper eyelids and minimize frown lines.

The forehead lift is typically performed on men and women in their 40s to 60s to slow the signs of aging, but it is also appropriate for younger patients with droopy brows or furrows above the nose. The surgery takes from one to two hours and is generally performed in an outpatient setting on patients under either general anesthesia or local anesthesia with sedation.

After a forehead lift, the patient may experience temporary headaches as well as swelling and bruising that may last from two to three weeks. Itching is another transient side-effect. Numbness and itching in the forehead and scalp region may be prolonged, and the patient may have to endure some hair loss for a few weeks to several months.

Infection and bleeding are risks, and noticeable and excessive scarring can occur. In some cases, hair loss may be permanent along the scar edges. Nerve injury can cause muscle weakness and loss of forehead or eyebrow movement on one or both sides, either temporary, or rarely, permanent. However, complications are rare and usually minor.

After a forehead lift, the patient can generally go back to work within seven to 10 days and resume strenuous activities within a few weeks. Sun exposure (even with sunscreen) should be limited for several months.

The effects of a forehead lift endure for five to 10 years, sometimes even longer.

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Eyelid Surgery (Blepharoplasty)

Indications for eyelid surgery include drooping, hooded upper lids and puffy bags and/or extra skin below the eyes. Eyelid surgery can correct these conditions, but it does not eliminate crow's feet, raise the eyebrows or completely remove dark circles under the eyes. Neither does it eliminate evidence of ethnic or racial heritage, although the surgeon can add the upper-eyelid crease that some Asian patients request. Eyelid surgery can be performed alone or in combination with other procedures such as a face or brow lift.

Eyelid surgery consists of removing excess fat, skin and muscle from above and/or below the eyes. The surgery may be performed in an outpatient setting on patients under local anesthesia with sedation or general anesthetic. Very occasionally, brief hospitalization may be required. The duration of the procedure is one to three hours, depending on whether all four lids are done.

Tightness of the lids is a normal side-effect after eyelid surgery, and some discomfort is likely. The patient will experience bruising and swelling, particularly at the corners of the lids, that may persist for two to three weeks. Dryness, itching and burning may last about as long, and the patient may have temporary eyesight problems, such as double or blurred vision. Excessive tearing and sensitivity to light and wind are common, but should disappear within a few weeks. Tiny whiteheads, called milia, may appear, but they are easily removed, and often disappear on their own.

As with any invasive procedure, there is always the risk of infection. Occasionally the tightness of the lids will prevent the patient from closing his/her eyes completely, but this problem nearly always resolves with time. Ectropion (a pulling-down and turning outward of the lower lids) is a rare complication that could require further surgery to correct.

After eyelid surgery, the patient must refrain from wearing contact lenses for at least two weeks. Eyedrops may be necessary to lubricate dry eyes. The patient can resume reading and watching television in two to three days, go back to work after a week or 10 days and resume strenuous activities another week after that.

The effects of eyelid surgery will last for several years, and in some people, they are permanent.

If upper-lid surgery is done to improve vision, the procedure may be covered by insurance, so it is important to maintain excellent documentation. Insurance carriers require preauthorization, preoperative assessment of visual fields, photo documentation, and occasionally, other testing by an ophthalmologist.

A patient with visual problems­such as glaucoma or a detached retina­should have an ophthalmologic assessment before considering eyelid surgery. Thyroid imbalances, Graves' disease, hypertension, cardiovascular disease or dry eye are associated with greater risk of complications after eyelid surgery.

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Nose Reshaping (Rhinoplasty)

Indications for rhinoplasty include over- or undersized, misshapen or humped nose; breathing problems associated with the nasal structure; aesthetically displeasing nasal tip or bridge; unattractive angle between nose and upper lip; and dysfunctional or unappealing nasal openings. Cosmetic or functional problems with the nose can occur in people of any age, and it is the facial feature that causes the most dissatisfaction in people displeased with their appearance. In most cases, adolescents should wait until they have finished their growth spurts before undertaking rhinoplasty, usually at 14 or 15 for girls, a bit later for boys.

During rhinoplasty surgery, the surgeon separates the skin of the nose from the supporting framework of bone and cartilage, reshapes the framework and then redrapes the skin. Rhinoplasty surgery can be either open or closed, with the choice depending upon the nature of the problem and the surgeon's preferred technique.

In a closed procedure, the surgeon makes the incision inside the nostrils and reshapes the nose from within, without direct vision. In an open procedure, the surgeon makes a small incision across the columella (base of the center of the nose) and resculpts the structures under direct vision. In some cases, cartilage or bone grafts may be required. Open procedures are preferred for more complicated cases. After surgery, the nose is splinted. Nasal packs or soft plastic splints may be placed inside the nostrils to stabilize the septum when it has been operated upon.

Simple procedures take from one to two hours; more complicated surgeries will take longer. Many patients undergo rhinoplasty under local anesthesia with sedation, while others require general anesthesia. Surgery is usually performed in an outpatient setting.

The patient should expect temporary swelling and bruising around the nose and eyes. Headaches and nosebleeds may also occur, and temporary nasal stuffiness is to be expected.

Risks include infection, bleeding and burst blood vessels that leave small, permanent red spots in the nasal skin. Some patients have incomplete resolution of the problem that requires further surgery, but this occurs in less than five percent of patients. Because the appearance of the face can be greatly altered by reshaping the nose, a psychological risk is that the patient may not look as he or she expected.

After rhinoplasty, patients can return to work or school within one to two weeks and resume strenuous activities within two to six weeks. Patients should avoid sun exposure for about eight weeks. The nose takes some time to settle into its new shape, and the final appearance may not be achieved for a year or more.

Rhinoplasties performed to correct congenital deformities, relieve breathing problems or repair defects caused by trauma may be covered by insurance. Cases are judged on an individual basis and usually require preapproval.

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Hair Replacement

Aging, changes in hormone levels and family history of baldness are the most common causes of hair loss. The onset of hair loss at a younger age usually results in more severe baldness. Hair loss may also result from burns or injuries.

Candidates for hair replacement must have healthy hair growing at donor sites on the back and sides of the head. The color, texture and degree of curliness of the hair may affect the cosmetic result.

A number of hair-replacement techniques are available, and the surgeon may use several techniques to achieve the desired effects. For those who desire a modest improvement in hair fullness, punch grafts, micro- or minigrafts, slit grafts and strip grafts are all appropriate. Pedicled and microvascular flaps, tissue-expansion and scalp-reduction are methods that provide greater hair coverage, but also carry greater risks.

Hair replacement is a somewhat lengthy procedure requiring multiple sessions with an interval of several months between sessions. For the simpler grafting procedures, anesthesia is accomplished locally, with or without sedation. More extensive and complicated procedures, such as tissue-expansion or scalp-reduction, require general anesthesia. The surgery is usually performed in an outpatient setting, and the duration of the procedure depends upon the technique used.

Temporary side effects include a feeling of excessive tightness and/or numbness, throbbing and aching. Bleeding and hair loss at the grafted site may also occur.

Risks include infection, bleeding problems, wide scars­called "stretch-back" scars­and failure of the procedure, i.e., grafts do not "take" or hair does not grow.

After hair-replacement surgery, patients can resume work and light activities within a few days and more strenuous activities in about three weeks. Scars that would otherwise be apparent are usually concealed by the hair. Occasionally, the direction of hair growth in the new areas changes.

The effects of hair replacement are permanent, but the surgery does not prevent hair loss at other sites. After the results of healing and new hair growth become apparent, the patient may require some touch-up procedures to achieve a more natural look.

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