Facial Plastic Surgery

Procedures - Facial Plastic Surgery

Occuloplastic Surgery - Bletharoplasty
Blepharoplasty or Eyelid Surgery involves the removal of excessive skin and fat of the upper eyelids for enhancement of a patients appearance or to improve a patients visual ﬁeld function. The latter is covered by some insurance carriers but, requires preoperative evaluations and testing such as, visual ﬁeld testing of the eyes. Consult with your plastic surgeon to see if this procedure could be a covered service by your insurance carrier.

Eyelid surgery can correct puffy eyes and excessive upper eyelid skin. It does not remove crows feet, dark circles under the eyes or a sagging/droopy brow. Blepharoplasty can be done alone, or in conjunction with other facial surgery procedures such as a facelift or browlift.

The best candidates for eyelid surgery are men and women who are healthy, psychologically stable, and realistic in their expectations. Most are 45 years of age or older. But if droopy, baggy eyelids run in your family, you may decide to have eyelid surgery at a younger age. Some medical conditions make blepharoplasty more risky. They include thyroid problems such as hypothyroidism and Graves’ disease, dry eye or lack of sufﬁcient tears, high blood pressure or cardiovascular disease, and diabetes. Adetached retina or glaucoma is also reason for caution.

Your evaluation before surgery should include determination if you have upper eyelid ptosis/drooping, ectropion/inverted lower eyelids, ectropion/everted/sagging lower eyelids or other eyelid disorders. Often these conditions are corrected in conjunction with your Blepharoplasty or Eyelid Surgery. Make sure to avoid blood thinners before and immediately after your surgery.

Blepharoplasty usually takes one to two hours, depending on the extent of the surgery. In a typical procedure, the surgeon makes incisions following the natural lines of your eyelids. The incisions may extend into the crow’s feet or laugh lines at the outer corners of your eyes. The surgeon separates the skin from underlying fatty tissue and muscle, removes excess fat, and often trims sagging skin and muscle. Sometimes, if you have a pocket of fat beneath your lower eyelids but don’t need to have any skin removed, your surgeon may perform a transconjunctival blepharoplasty. In this procedure the incision is made inside your lower eyelid in the conjunctiva leaving no visible scar. It is usually performed on younger patients.

After your surgery anticipate swelling. Cool compresses assist in decreasing the swelling for the ﬁrst 3 to 4 days. After this point luke warm compresses are more helpful and soothing. You should be able to read or watch television within two or three days. You won’t be able to wear contact lenses for about two weeks. Most patients feel ready to go out in public (and back to work) in a week to 10 days. Even then you still may have some bruising. You may be sensitive to sunlight, wind, and other irritants for several months, so you should consider wearing sunglasses. Avoid strenuous activities for about three weeks.

Healing is a gradual process, and your scars may remain slightly pink for several months or more after surgery. Eventually, though, they’ll fade. The positive results of your eyelid surgery-the more alert and youthful look-can last for years. For many patients, these results are permanent.
Eyelid Ectropin
Lower eyelid ectropin refers to an outwardly turned or sagging lower eyelid. Often the conjunctiva or pinky part of the lower eyelid is grossly visible. This sagging can leave the eyeball or globe exposed resulting in a dry crusty eye. This chronic exposure and dryness of the eye ball can lead to possible corneal injury and loss of vision.

Surgical correction is dependent upon the cause of the ectropin. Your occuplastic or reconstructive surgeon will review the various causes and available corrections for lower eyelid ectropin. The procedure is usually an outpatient procedure. The ﬁnal result may take several months to see but, your symptoms are usually corrected expeditiously after the surgery.
Eyelid Entropin
Eyelid entropion refers to an inward rotation of the eyelid. The lashes can often rub up against the eyeball or globe. This can result in irritation, redness and sensitivity to wind and light. Patients often complain they feel something in their eye. Left untreated damage to the cornea of the eye may occur.

Correction of eyelid ectropin varies upon the etiology and extent of the condition. Evaluation by your oculoplastic or reconstructive surgeon will determine which surgical procedure is best for you. Most corrections are performed as outpatient procedures. Recover is often quick and symptoms are usually improved in short order.
Eyelid Ptosis
Eyelid ptosis refers to drooping of the upper eyelid resulting in what is often referred to as a lazy eye. Causes of the condition can be varied. Check with your oculoplastic or reconstructive surgeon to determine the exact etiology of your eyelid ptosis prior to surgical intervention.

Eyelid ptosis repair will raise one or both droopy upper eyelids to restore an alert appearance and possibly improve you visual fields or peripheral vision. Some insurance companies may cover the costs of ptosis surgery when eyelid drooping significantly impairs visual fields. Visual field testing is the first step in making this determination. Ask your oculoplastic or reconstructive surgeon for the steps required to get your eyelid ptosis repair pre-approved through your insurance carrier. Correction is usually an outpatient day surgery procedure. Recover is quick, but the final result can take about several months to achieve visually.
Otoplasty
Do you have prominent or protruding ears? Are they asymmetrical? This most likely a condition called Otapostasis or Apostasis Otum. Your condition can be improved or corrected to a more aesthetically appearing appearance by a surgery called an Ear Pinning or Otoplasty. Make sure to write down your concerns about your ears such as asymmetry, wide ear lobules, etc,

Prominent ears often have certain anatomical components that are missing or more pronounced than in other individuals. The first and most common anatomical variant is a loss of the Antihelical Fold. This lack of a crease and fold in front of the edge of an ear causes the upper ear to appear rotated forward. The second most common anatomical feature in the prominent ear patient is a Large Chonchal Bowl. This large choncha again rotates the entire ear outward and forward. Last but not least consider accessing your ear lobes. Some patients even have over rotated or prominent ear lobes. Pre-operative asymmetry is often the rule rather than an exception in the prominent ear patient. Each anatomical component/ variant should be addressed to produce the appealing post operative result.

Otoplasty surgery usually is not exceptionally painful. Recovery is often quick. Often a gentle soft headband may be required. Avoid any possibility of activities or trauma that might disrupt your ears surgery. Full physical activity can usually be resumed within 3 to 4 weeks following your otoplasty.
Nose Refinement/Rhinoplasty
Rhinoplasty entails surgery to reshape the nose. It is one of the most common of all plastic surgery procedures. Rhinoplasty can reduce or increase the size of your nose, change the shape of the tip or the bridge, narrow the span of the nostrils, or change the angle between your nose and your upper lip. It may also correct a birth defect or injury, or help relieve some breathing problems. Rhinoplasty can enhance your appearance and improve your selfconﬁdence, but it won’t necessarily change your looks to match your ideal, or cause other people to treat you differently. Before you decide to have surgery, think carefully about your expectations and discuss them with your plastic surgeon.

The best candidates for rhinoplasty are people who are looking for improvement, not perfection, in the way their nose look. Rhinoplasty can be performed to meet aesthetic goals or for reconstructive purposes-to correct birth defects or breathing problems. Age is a consideration. Many surgeons prefer not to operate on teenagers until after they’ve completed their growth spurt-around 14 or 15 for girls, a bit later for boys. It’s important to consider teenagers’ social and emotional adjustment. The surgery should not be performed because it is what their parents really want.

There are open and closed techniques for Rhinoplasty surgery. When an “open” technique is used, or when the procedure calls for the narrowing of ﬂared nostrils, the small scars on the base of the nose are usually not very visible. When planning your surgery good communication between you and your plastic surgeon is essential. In your initial consultation, the surgeon will ask what you’d like your nose to look like, evaluate the structure of your nose and face, and discuss the possibilities with you. Factors that can inﬂuence the procedure include the structure of your nasal bones and cartilage, the shape of your face, the thickness of your skin, your age, and your expectations. Be sure to tell your surgeon if you’ve had any previous nose surgery or an injury to your nose, even if it was many years ago. You should also inform your surgeon if you have any allergies or breathing difﬁculties; if you’re taking any medications, vitamins, or recreational drugs; and if you smoke.

The duration of a rhinoplasty depends upon the extent of the procedure but, usually takes an hour or two. During surgery the skin of the nose is separated from its supporting framework of bone and cartilage, which is then sculpted to the desired shape. The nature of the sculpting will depend on your problem and your surgeon’s preferred technique. Finally, the skin is re draped over the new framework. When the surgery is complete, a splint will be applied to help your nose maintain its new shape. Nasal packs or soft plastic splints also may be placed in your nostrils to stabilize the septum, the dividing wall between the air passages.

After your surgery a little bleeding is common during the ﬁrst few days following surgery, and you may continue to feel some stufﬁness for several weeks. Your surgeon will probably ask you not to blow your nose for a week or so, while the tissues heal. Most rhinoplasty patients are up and about within two days, and able to return to school or sedentary work a week or so following surgery. It will be several weeks, however, before you’re entirely up to speed. Your surgeon will give you more speciﬁc guidelines for gradually resuming your normal activities. They’re likely to include these suggestions: Avoid strenuous activity (jogging, swimming, bending, sexual relations-any activity that increases your blood pressure) for two to three weeks. Avoid hitting or rubbing your nose, or getting it sunburned, for eight weeks. Be gentle when washing your face and hair or using cosmetics. You can wear contact lenses as soon as you feel like it, but glasses are another story. Once the splint is off, they’ll have to be taped to your forehead or propped on your cheeks for another six to seven weeks, until your nose is completely healed.

In the days following surgery, when your face is bruised and swollen, it’s easy to forget that you will be looking better. In fact, many patients feel depressed for a while after plastic surgery-it’s quite normal and understandable. Rest assured that this stage will pass. Day by day, your nose will begin to look better and your spirits will improve. Within a week or two, you’ll no longer look as if you’ve just had surgery. Still, healing is a slow and gradual process. Some subtle swelling may be present for months, especially in the tip. The ﬁnal results of rhinoplasty may not be apparent for a year or more.

In the meantime, you might experience some unexpected reactions from family and friends. They may say they don’t see a major difference in your nose. Or they may act resentful, especially if you’ve changed something they view as a family or ethnic trait. If that happens, try to keep in mind why you decided to have this surgery in the ﬁrst place. If you’ve met your goals, then your surgery is a success.
Endoscopic Brow Lift
A forehead lift or “browlift” is a procedure that restores a more youthful area above the eyes. The procedure corrects drooping brows and improves the horizontal lines and furrows that can make a person appear angry, sad or tired. In a forehead lift, the muscles and tissues that cause the furrowing or drooping are removed or altered to smooth the forehead, raise the eyebrows and minimize frown lines. In the newer surgical method, an endoscope, a viewing instrument that allows the procedure to be performed with minimal incisions is utilized.

A forehead lift is most commonly performed in the 40 to 60 age. Prior to this age Botox is commonly utilized with or without fillers to correct aging issues. A forehead lift is often performed in conjunction with a facelift to provide a smoother overall look to the face. Eyelid surgery (blepharoplasty) may also be performed at the same time as a forehead lift, especially if a patient has significant skin overhang in the upper eyelids. Sometimes, patients who believe they need upper-eyelid surgery find that a forehead lift better meets their surgical goals and needs.

For a better understanding of how a forehead lift might change your appearance, look into a mirror and place the palms of your hands at the outer edges of your eyes, above your eyebrows. Gently draw the skin up to raise the brow and the forehead area. That is approximately what a forehead lift would do.

Your surgeon can help you decide which surgical approach will best achieve your cosmetic goals: the classic or “open” method, or the endoscopic forehead lift. This is often determined by the height of your forehead pre operatively. Make sure you understand the technique that your surgeon recommends and why he or she feels it is best for you.
Facelift/Rhytidectomy
As people age, the effects of gravity, exposure to the sun, and the stresses of daily life can be seen in components of their faces. Deep creases form between the nose and mouth; the jawline grows slack and jowly; folds and fat deposits appear around the neck. A facelift (technically known as rhytidectomy) can’t stop this aging process. What it can do is “set back the clock,” improving the most visible signs of aging by removing excess fat, tightening underlying muscles, and redraping the skin of your face and neck. A facelift can be done alone, but is commonly done in conjunction with other procedures such as a forehead lift, eyelid surgery, fat grafting or nose reshaping.

When considering a facelift write down the your three most important concerns, such as, my neck, these creases next to my mouth or my check bones have dropped. Before you decide to have surgery, think carefully about your expectations and discuss them with your surgeon. Next, be aware that a facelift is for anatomical facial improvement. It will not help with most fine wrinkles or skin discolorations. Laser resurfacing or tissue fillers may be required to correct these issues.

The best candidate for a facelift is a man or woman whose face and neck have begun to sag, and whose bone structure is strong and well-defined. Most patients are in their forties to sixties. Facelifts can be done successfully on people in their seventies or eighties as well. Facelifts are very individualized procedures and often involve several components. Divide your face into three parts. The first is from the eyebrows up the, the eyes and nose and finally from the checks down. The last area is the anatomical are usually addressed by a face lift. In your initial consultation the surgeon will evaluate your face, including the skin and underlying bone, and discuss your goals for the surgery.

Be sure to tell your surgeon if you smoke or are taking any drugs or medications, especially aspirin or other drugs that affect clotting. Smoking can contribute to many complications that can occur with facelifts. Bleeding resulting in a clot under your skin or a hematoma is one of the most common complications of a facelift.

There are many types of facelifts available from short scar to deep plane techniques. Discus with your plastic surgeon which technique will result in achieving your goals and the best long term result. Often combined procedures, such as facelift, liposuction of the neck and a blepharoplasty are performed.

After surgery in the beginning, your face may look and feel rather strange. Your features may be distorted from the swelling, your facial movements may be slightly stiff and you’ll probably be self-conscious about your scars. Some bruising may persist for two or three weeks, and you may tire easily. It’s not surprising that some patients are disappointed and depressed at first. By the third week, you’ll should begin to look and feel much better. Most patients are back at work about ten days to two weeks after surgery. Remember, cover or special camouflage makeup can mask most bruising that remains.

The chances are excellent that you’ll be happy with your facelift. Especially if you realize that the results may not be immediately apparent. You’ll have some scars from your facelift, but they’re usually can be hidden by your hair or in the natural creases of your face and ears. Having a facelift doesn’t stop the clock. Your face will continue to age with time, and you may want to repeat the procedure one or more times — perhaps five or ten years down the line. It is important to maintain your facial skin during this time. Consider a basic skin care program. Consult your plastic surgeon as to which program will best fit your skin type to maintain the results of your facelift over time.
Laser Skin Resurfacing
In laser resurfacing, sometimes called “laser peel,” a type of carbon dioxide (CO2) laser is used to remove areas of damaged or wrinkled skin, layer by layer. The procedure is most commonly used to minimize the appearance of ﬁne lines, especially around the mouth and the eyes. However, it is also effective in treating facial scars or areas of uneven pigmentation. Laser resurfacing may be performed on the whole face or in speciﬁc regions. Often, the procedure is done in conjunction with another cosmetic operation, such as a facelift or eyelid surgery. Laser resurfacing is still a very new procedure. However, it has been shown that in some cases, this surgical method produces less bleeding, bruising and post-operative discomfort than is typically seen with other resurfacing methods.

The “weekend” skin peel or micro-laser peel is also performed with the laser. Often a fractioned laser technique is utilized. It is an intra-epidermal laser peel that can precisely ablate the outermost layers of the skin. The procedure can be individually tailored to the nature of the condition to be corrected. Skin conditions such as: wrinkles, scars, acne scars, keratosis, or pigmentary problems can be successfully treated with the fractioned laser technique. If you are looking for more than microdermabrasion or light chemical peels, and have shorter time for a prolonged healing process, then the microlaser peel might be a good choice. Anticipate increased costs as compared to microdermabrasion or a light chemical peel.

Laser resurfacing is performed using a beam of laser energy which vaporizes the upper layers of damaged skin at speciﬁc and controlled depth of penetration. It’s clear that laser resurfacing may offer a number of advantages over other resurfacing methods: precision, little (if any) bleeding and less postoperative discomfort. However, laser resurfacing isn’t for everyone. In some cases, an alternative skin resurfacing treatment, such as dermabrasion or chemical peel, may still be a better choice for you. Remember no matter which procedure you choose preoperative treatment with retinoids, antibiotics or antiviral agents may be required. Consult with your plastic surgeon prior to your procedure.

All resurfacing treatments work essentially the same way. First, the outer layers of damaged skin are stripped away. Then, as new cells form during the healing process, a smoother, tighter, younger-looking skin surface appears. Laser resurfacing is a new method being used by plastic surgeons to remove damaged or wrinkled skin. It’s also important to consider the length of recovery when choosing among the skin-resurfacing alternatives. The more aggressive the resurfacing procedure is, the more prolonged the recovery is likely to be. “Light” resurfacing procedures, such as superﬁcial chemical peels or superﬁcial laser resurfacing, offer shorter recovery times. However, these lighter procedures may need to be repeated multiple times to achieve results comparable to those achieved with more aggressive/deeper techniques.

In many cases, facial wrinkles form in localized areas, such as near the eyes or around the mouth. The laser can be precisely controlled so that only these speciﬁc areas are targeted. Patients with olive skin, brown skin or black skin may be at increased risk for pigmentation changes no matter what type of resurfacing method is recommended. Your plastic surgeon will evaluate your skin characteristics and make recommendations accordingly.

Remember, having laser resurfacing can help enhance your appearance and your selfconﬁdence, but it won’t completely remove all facial ﬂaws or prevent you from aging. Lines that occur as a result of natural movements of the face – smiling, squinting, blinking, talking, chewing – will inevitably recur. Your plastic surgeon can suggest ways to help you preserve your results by protecting yourself from sun exposure or using skin care maintenance treatments, such as medicated facial creams. Before you decide to have laser resurfacing, think carefully about your expectations and discuss them with your plastic surgeon.
Forehead & Browlift
A forehead lift or “browlift” is a procedure that restores a more youthful area above the eyes. The procedure corrects drooping brows and improves the horizontal lines and furrows that can make a person appear angry, sad or tired. In a forehead lift, the muscles and tissues that cause the furrowing or drooping are removed or altered to smooth the forehead, raise the eyebrows and minimize frown lines. In the newer surgical method, an endoscope, a viewing instrument that allows the procedure to be performed with minimal incisions is utilized.

A forehead lift is most commonly performed in the 40 to 60 age. Prior to this age Botox is commonly utilized with or without fillers to correct aging issues. A forehead lift is often performed in conjunction with a facelift to provide a smoother overall look to the face. Eyelid surgery (blepharoplasty) may also be performed at the same time as a forehead lift, especially if a patient has significant skin overhang in the upper eyelids. Sometimes, patients who believe they need upper-eyelid surgery find that a forehead lift better meets their surgical goals and needs.

For a better understanding of how a forehead lift might change your appearance, look into a mirror and place the palms of your hands at the outer edges of your eyes, above your eyebrows. Gently draw the skin up to raise the brow and the forehead area. That is approximately what a forehead lift would do.

Your surgeon can help you decide which surgical approach will best achieve your cosmetic goals: the classic or “open” method, or the endoscopic forehead lift. This is often determined by the height of your forehead pre operatively. Make sure you understand the technique that your surgeon recommends and why he or she feels it is best for you.
Fat Grafting/Stem Cell Facelift
Fat grafting has been attempted for decades but, with recent advancements in technology has become a common adjuvant procedure in plastic surgery procedures. Fat is harvested, processed and the re-injected into desired body area. Absorption rates for the fat depend upon multiple factors but can average between 20% and 40%. Therefore, overcorrection is often required to augment an area.

With weight loss and age fat is often absorbed or lost from critical areas of the human body. These areas can now be corrected by fat grafting. Donor sites include the abdomen, buttox and back. Common areas that are injected with fat grafting include the face, post traumatic depressions, buttox, etc. Research is being conducted on the long term effects of fat grafting to the breast.

Fat grafts have long been known to be a great source of stem cells. Therefore, when fat is injected into the face to enhance the appearance of a patient it has gotten the acronym of a Stem Cell Face Lift. This procedure can be conducted on its own or in combination with other types of facial rejuvenation procedures. Results can be dramatic as facial volume is restored and the face/neck are lifted.

>Fat grafting must be done by a surgeon very familiar with the processing and distribution of the fat. These techniques can vary depending on the desired location of the fat grafting. Discus these issues with your plastic surgeon. Remember, the fat graft stays with you for a long time after your surgery.
Facial Scars
Scars whether they are caused by accidents or by surgery are unpredictable. The way a scar develops depends as much on how your body heals as it does on the original injury or on the surgeon’s skills. Many variables can affect the severity of scarring, including the size and depth of the wound, the blood supply to the area, the thickness and color of your skin, post injury infections and the direction of the scar. How much the appearance of a scar bothers you is, of course, a personal matter.

If your skin is cut there is a very high probability you will scar. There are three common types of scars that patients do not like. A widened or depressed scar, the hypertrophic scar and the keloid. Widened or depressed scars are more common over anatomical points that bend like elbows, knees and the trunk. A hypertrophic scar is a scar that rises up within the conﬁnes of the scar and then with treatment ﬂattens out. Hypertrophic scars respond to treatment frequently. A keloid is a scar that grows into normal tissue. Keloids are very difﬁcult to treat often requiring multi-modality therapy like steroid shots, surgery and radiation. Complete resolution of a keloid even following multi-modality therapy may occur on one third of the time.

While no scar can be removed completely, plastic surgeons can often improve the appearance of a scar, making it less obvious through the injection or application of certain medications or through surgical procedures known as scar revisions.

Many scars that appear large and unattractive at ﬁrst may become less noticeable with the passage of time. Some can be treated with steroids to relieve symptoms such as tenderness and itching. For these reasons, many plastic surgeons recommend waiting as long as 6 months to a year or more after an injury or surgery before you decide to have scar revision. If you’re bothered by a scar, your ﬁrst step should be to consult a board-certiﬁed plastic surgeon. Be frank in discussing your expectations with the surgeon, and make sure they’re realistic. Insurance usually doesn’t cover cosmetic procedures. Check your policy or call your carrier to be sure.

Keloids are thick, itchy clusters of scar tissue that grow beyond the edges of the wound or incision. Keloids occur when the body continues to produce the tough, ﬁbrous protein known as collagen after a wound has healed. Keloids can appear anywhere on the body, but they’re most common over the chest, on the earlobes, and on the shoulders. They occur more often in dark-skinned people than in those who are fair complected. The tendency to develop keloids lessens with age. Keloids are often treated by injecting a steroid medication directly into the scar tissue to reduce redness, itching, and burning. In some cases, this will also shrink the keloid. If steroid treatment is inadequate, the keloid can be cut out. Immediate post operative radiation therapy to the area is helpful to prevent recurrence of the keloid. No matter what approach is taken, keloids have a stubborn tendency to recur, sometimes even larger than before. It is important to follow-up after treatment as additional steroid injections may be required. Or you may be asked to wear a pressure garment over the area for as long as a year. Even so, the keloid may return, requiring repeated procedures.

Hypertrophic scars are often confused with keloids, since both tend to be thick, red, and raised. Hypertrophic scars, however, remain within the boundaries of the original incision or wound and do not grow out into the surrounding tissues. They often improve on their own though it may take a year or more or with the help of topical steroid applications or injections. If a conservative approach doesn’t appear to be effective, hypertrophic scars can often be improved surgically. The plastic surgeon will remove excess scar tissue, and may reposition the incision so that it heals in a less visible pattern or area.

Deep burns or other injuries resulting in the loss of a large area of skin may form a scar that pulls the edges of the skin together, a process called contraction. There is often a loss of range of motion associated with a contracture. The resulting contracture may affect the adjacent muscles and tendons, restricting normal movement. Correcting a contracture usually involves cutting out the scar and replacing it with a skin graft or a ﬂap. In some cases a procedure known as Z-pasty may be used to lengthen the scar area. And new techniques, such as tissue expansion, are playing an increasingly important role in burn contracture treatment. If the contracture has existed for some time, you may need physical therapy after surgery to restore full function.

Because of its location, a facial scar is frequently considered a cosmetic problem, whether or not it is hypertrophic. There are several ways to make a facial scar less noticeable. Often it is simply cutting out a widened or depressed scar and leaving a thinner, less noticeable scar. If the scar lies across the natural skin creases (or “lines of relaxation”) the surgeon may be able to reposition it Some facial scars can be softened using a technique called resurfacing,often done with a laser or mechanical device.

Z-plasty is a surgical technique used to reposition and lengthens a scar. It can also relieve the tension caused by contracture. Not all scars lend themselves to Z-plasty. While Z-plasty can make some scars less obvious, it won’t make them disappear. A portion of the scar will still remain outside the lines of relaxation.

Skin grafts and ﬂaps are more serious than other forms of scar surgery. They are usually performed when severe scaring is present following burns or trauma. They’re more likely to be performed in a hospital as inpatient procedures, using general anesthesia. The treated area may take several weeks or months to heal, and a support garment or bandage may be necessary for up to a year.

Grafting involves the transfer of skin from a healthy part of the body (the donor site) to cover the injured area. The graft is said to “take” when new blood vessels and scar tissue form in the injured area. In addition, all grafts leave some scarring at the donor and recipient sites.

Flap surgery is a complex procedure in which skin, along with the underlying fat, blood vessels, and sometimes the muscle, is moved from a healthy part of the body to the injured site. In some ﬂaps, the blood supply remains attached at one end to the donor site; in others, the blood vessels in the ﬂap are reattached to vessels at the new site using microvascular surgery.

Skin grafting and ﬂap surgery can greatly improve the function of a scarred area. The cosmetic results may be less satisfactory, since the transferred skin may not precisely match the color and texture of the surrounding skin area. In general, ﬂap surgery produces better cosmetic results than skin grafts in most patients.
Skin Cancer Care
Skin cancer is the most common form of cancer in the United States. More than 550,000 new cases are reported each year and the incidence is rising faster than any other type of cancer. While skin cancers can be found on any part of the body, about 80 percent appear on the face, head, neck or back where they can be disﬁguring as well as dangerous.

The primary cause of skin cancer is ultraviolet radiation most often from the sun, but also from artiﬁcial sources like tanning booths. In fact, researchers believe that our quest for the perfect tan, an increase in outdoor activities, and the thinning of the earth’s protective ozone layer are behind the alarming rise we’re now seeing in skin cancers. Anyone can get skin cancer-no matter what your skin type, race or age, no matter where you live or what you do. But your risk is greater if…
- Your skin is fair and freckles easily.
- You have light-colored hair and eyes.
- You have a large number of moles, or moles of unusual size or shape.
- You have a family history of skin cancer or a personal history of blistering sunburn.
- You spend a lot of time working or playing outdoors directly in the sun without protection.
- You live closer to the equator, at a higher altitude, or in any place that gets intense, year-round sunshine.
- You received therapeutic radiation treatments for adolescent acne.
By far the most common type of skin cancer is basal cell carcinoma. Fortunately, it’s also the least dangerous kind. It tends to grow slowly, and rarely spreads beyond its original site. Though basal cell carcinoma is seldom life-threatening, if left untreated it can grow deep beneath the skin and into the underlying tissue and bone, causing serious damage and disﬁgurement. Squamous cell carcinoma is the next most common kind of skin cancer, frequently appearing on the lips, face, or ears. It sometimes spreads to distant sites, including lymph nodes and internal organs. Squamous cell carcinoma can become life threatening if it’s not treated and should not be ignored. A third form of skin cancer, malignant melanoma, is the least common, but its incidence is increasing rapidly, especially in the Sunbelt states. Malignant melanoma is the most dangerous type of skin cancer. Also, it is one of the most dangerous cancers known to the human race. If discovered early enough, it can be completely cured. If it’s not treated quickly, however, malignant melanoma may spread throughout the body and is often deadly. Make sure you seek evaluation for these conditions by someone who treats skin cancers on a regular basis like your plastic surgeon. Skin cancer surgery represents the most common reconstructive surgical procedures performed by plastic surgeons.

Malignant melanoma is usually signaled by a change in the size, shape, contouring or color of an existing mole, or as a new growth on normal skin. Watch for the “ABCDE” warning signs of melanoma:

-Asymmetry – a growth with unmatched halves
-Border irregularity – ragged or blurred edges
-Color – a mottled appearance, with shades of tan, brown, and black, sometimes mixed with red, white, or blue
-Diameter – a growth more than 6 millimeters across (about the size of a pencil eraser), or any unusual increase in size.
-Evaluation – Seek evaluation by a specialist that deals with skin cancer on a regular basis and is familiar with current techniques of treatment of these cancers.

If all these variables sound confusing, the most important thing to remember is this:
Get to know your skin and examine it regularly, from the top of your head to the soles of your feet. (Don’t forget your back.) If you notice any unusual changes on any part of your body, have a plastic surgeon check it out.

Two other common types of skin growths are moles and keratoses. Moles are clusters of heavily pigmented skin cells, either ﬂat or raised above the skin surface. While most pose no danger, some-particularly large moles present at birth, or those with mottled colors and poorly deﬁned borders-may develop into malignant melanoma and should be removed. Moles are frequently removed for cosmetic reasons. Solar or actinic keratoses are rough, red or brown, scaly patches on the skin. They are usually found on areas exposed to the sun, and sometimes develop into skin cancer. Often they are ablated by cryotherapy or topical agents like 5-FU.

Skin cancer is diagnosed by removing all or part of the growth and examining its cells under a microscope often called a biopsy. It can be treated by a number of methods, depending on the type of cancer, its stage of growth, and its location on your body. Most skin cancers are removed surgically, by a plastic surgeon or a dermatologist. If the cancer is small, the procedure can be done quickly and easily, in an outpatient facility or the physician’s ofﬁce, using local anesthesia. If the cancer is larger or in a critical area then surgery may be required were the margins of resection are determined at the time of the surgery. Other possible treatments for skin cancer include cryosurgery (freezing the cancer cells), radiation therapy (using x-rays), topical chemotherapy (anti-cancer drugs applied to the skin), and Mohs surgery, a special procedure in which the cancer is shaved off one layer at a time. Mohs surgery is performed only by specially trained physicians and often requires a reconstructive procedure as follow-up. By far the most common method of removing skin cancers involves removal with checking the margin of resection and closure with a skin graft or ﬂap. Typically, this procedure is done under local anesthesia with some IV sedation.

All of the treatments mentioned above, when chosen carefully and appropriately, have good cure rates for most basal cell and squamous cell cancers You should discuss these choices with your plastic surgeon before beginning treatment. The different techniques used in treating skin cancers can be life saving, but they may leave a patient with less than pleasing cosmetic or functional results. Depending on the location and severity of the cancer, the consequences may range from a small but unsightly scar to permanent changes in facial structures such as your nose, ear, or lip. In such cases, no matter who performs the initial treatment, the plastic surgeon can be an essential part of the treatment team to prevent permanent disﬁgurement.

After you’ve been treated for skin cancer, your plastic surgeon will often schedule regular follow-up visits to make sure the cancer hasn’t recurred and you are not developing new lesions. Your physician, however, can’t prevent a recurrence. It’s up to you to reduce your risks by changing old habits and developing new ones.
- Avoid prolonged exposure to the sun, especially between 10 a.m. And 2 p.m. and during the summer months. Remember, ultraviolet rays pass right through water and clouds, and reﬂect off sand and snow.
- When you do go out for an extended period of time, wear protective clothing such as wide brimmed hats and long sleeves.
- On any exposed skin, use a sunscreen with an SPF (sun protection factor) of at least 15. Reapply it frequently, especially after you’ve been swimming or sweating.
- Finally, examine your skin regularly. If you ﬁnd anything suspicious, consult a plastic surgeon or a dermatologist as soon as possible.
Facial Rejuvenation
Facial Rejuvenation refers to combining multiple Cosmetic Surgical procedures to the
face in one setting. Often with Facial Rejuvenation procedures like Face Lifts, Eye Lifts, Brow lifts, etc,. are done in conjunction to produce a much more youthful appearance. Consider bring in a set of old photographs for Dr. Culbertson to review & determine what features made you more attractive at a younger age ( i.e. tight jaw line, prominent check bones, elevated brow position, etc.) The goal should be to try and turn back the clock.

As we age loss of facial volume with sagging of facial structures is very common. Besides the various lifts done with Facial Rejuvenation Fat Grafting to the face has become a mainstay for the surgical procedure. The increased volume provided with the addition of fat to the face can assist in restoring a more youthful appearance. Some examples of Fat Grafting with Facial Rejuvenation performed by Dr. Culbertson can be found here: https://garyculbertson.com/facial-plastic-surgery-before-and-after/. Many patients choose Facial Rejuvenation rather than a solitary Face or Eye Lift. Facial procedures combined in one setting can you a take a bit longer to recover. Consider allowing appropriate time before you go out into the public.