Are there different shapes or styles of Asian Blepharoplasty?

Posted on June 25, 2024 by Donald B. Yoo, M.D.

Asian blepharoplasty refers to upper eyelid surgery in Asian patients, and encompasses a wide range of anatomies and aesthetic goals. Sometimes called double eyelid surgery, the procedure has the ability to create a supratarsal crease or upper eyelid fold in patients without a native fold, increase the height and depth of a pre-existing fold, and/or alter the shape and size of the supratarsal fold. In addition, the upper eyelid fold may be created by using three small incisions and permanent sutures (DST or double-suture with twist), or with an incision along the entire upper eyelid crease (incisional upper blepharoplasty).

DST Asian eyelid surgery works best in younger patients without excess skin or fat in the upper eyelids that needs to be addressed. It also works best in patients with thinner skin, as the resulting fold will look more natural during dynamic movement than a patient with thicker skin. The rate of crease failure, or the upper eyelid fold unraveling, for suture only blepharoplasty is quite high at 10-15%. This failure rate also increases slightly with increasing age, as patients who undergo surgery may have a beautifully formed upper eyelid crease initially, but may see the crease weaken or even disappear completely with aging.

During incisional upper blepharoplasty the scar design and placement becomes crucial for the best results. The optimal scar placement will follow the newly created supratarsal crease or upper eyelid fold so that when the eyes are open the slight overhang of skin along the crease will completely hide the scar. In traditional blepharoplasty or upper eyelid lift the scar may extend into the lateral periorbital area (crow’s feet) where it can be hidden within a wrinkle, however in Asian patients and with patients with Fitzpatrick IV-VI skin types this results in a highly visible scar.

Before and after Asian eyelid surgery to create a higher and brighter appearing upper eyelid crease.

During Asian eyelid surgery once excess skin is addressed, excess fat may be repositioned within the upper eyelid sulcus to create a more youthful appearance, and any protruding fat may be excised. Supratarsal fixiation (anchoring) sutures are then used to set the height and shape of the upper eyelid crease, which fall into two general categories. An infold or tapered crease will have the medial aspect of the fold taper and meet the medial corner of the eyes, while an outfold or parallel crease will see the upper eyelid crease run nearly parallel with the eyelid margin and maintaining space between the margin and upper eyelid crease even towards the medial aspect of the eye. The appropriate shape will depend on personal preference, but should be guided by facial harmony relative to a patient’s unique facial features and proportions.

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What are the limitations of a nonsurgical nose job?

Posted on June 21, 2024 by Donald B. Yoo, M.D.

Nonsurgical rhinoplasty, or liquid nose job, refers to the use of dermal fillers to change the shape of the nose. The past few decades have seen a rapid evolution in the development and application of facial fillers that offer safe, effective, and longer lasting results.

Though difficult to fathom now, the first injectable filler was actually paraffin wax. It predictably caused a number of serious complications, including delayed chronic granuloma formation, and its use abandoned. Silicone injections followed soon after, also with severe complications including scarring and granuloma formation, leading to a ban on its use by the U.S. FDA. While Silikon 1000 is a medical-grade silicone that is FDA approved for injection to treat retinal detachment, but some unscrupulous surgeons continue to inject silicone in delicate areas such as the nose, where irreversible injury in the form of scarring, fibrosis and granuloma formation occurs frequently.

A huge leap forward occurred with the development of bovine collagen for use as a dermal filler, and the FDA approved it for cosmetic injection in 1981. While an improvement on the previously available materials such as silicone and wax, the effects of bovine collagen were very short-lived – on the order of ~3 months. Also the cow origin of the protein led to a theoretical risk of allergic reaction that had to be tested for prior to injection, and monitored carefully after treatment.

Hyaluronic acid fillers ushered in the modern era of cosmetic filler injections with the FDA approval of Restylane in 2003. Hyaluronic acid occurs naturally in our skin and joints, conferring the characteristic elasticity and ability to retain water. Since it naturally occurs in our body, hyaluronic acid fillers also possess an extremely low theoretical risk of allergic reactions, and thus immunogenic testing is not required. Its stable composition, which allows it to be stored at room temperature and also last many times longer than bovine collagen once injected, has provided a seismic shift in the way surgeons perform cosmetic filler injections.

Advancements continue to improve upon the favorable characteristics of hyaluronic acid fillers for specific anatomic areas. A full armamentarium of facial fillers, from those with high cohesivity and resistance to deformation, to extremely soft and silky fillers. For nonsurgical rhinoplasty, the mainstay of safe and effective treatment remains hyaluronic acid fillers that have a high G prime and high cohesivity such as Restylane, Restylane Lyft and Juvederm Voluma. The cost of nonsurgical rhinoplasty typically differs depending on the type of filler used, in addition to the skill and experience of the surgeon performing the liquid nose job.

So what are the limitations? Nonsurgical rhinoplasty works great for issues that can be addressed and improved by adding volume. Surgeons can easily address minor asymmetries caused by depressions or lack of volume, augment the nasal dorsum or bridge in patients lacking height, camouflage mild to moderate dorsal humps by adding volume and height to the radix, slightly increase tip projection and definition, and create minor changes to the tip rotation either rotating or counter-rotating the tip. Within these parameters surgeons can enhance the shape of the nose fairly significantly, in the appropriately selected patients.

Before and after nonsurgical rhinoplasty to raise the starting point of the nose, straighten and augment the bridge, and refine the tip of the nose.

Nonsurgical nose job does not make a tall nose shorter, de-project a nasal tip that sticks out too far, reduce the width and flare of nostrils, reduce the width of wide nasal bones, straighten a deviated septum, or reduce excess volume in the tip of the nose. Especially in patients with thicker skin, changes to the tip of the nose may be limited given the mismatch between strong thick skin vs. weak underlying cartilaginous support. Detailed evaluation by a nonsurgical nose job specialist, followed by comprehensive discussion of the expected results, risks and limitations, will ensure the highest chance of the best and most beautiful result.

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What is the cost of nonsurgical rhinoplasty?

Posted on June 12, 2024 by admin
Before and after nonsurgical rhinoplasty with Restylane

Pricing and cost for nonsurgical nose jobs typically comes down to the experience, skill-level and geographic location of the provider. The reversible nature of using hyaluronic acid filler for the procedure does provide a level of safety; however, given the delicate nature of the nasal vasculature, the safest and most effective results will come from a provider with mastery of the anatomy. Cost for nonsurgical rhinoplasty in the Los Angeles and Beverly Hills area will typically range between $800 and $3000 per session, with each treatment’s effect lasting 9-18 months on average. Pricing in general is commensurate with the training, expertise and skill-level of the provider.

Bruising and swelling are the most common possible complications, with swelling typically resolving within the first week and bruising occurring in ~20% of patients. When bruising or ecchymosis does occur, it will resolve within the first 1-2 weeks, and often is easy to conceal with makeup. Avoiding NSAIDs like Ibuprofen, aspirin and other foods and medications such as alcohol prior to the treatment can help to minimize the risks of bruising and swelling. Predictably, the best nonsurgical rhinoplasty will not be the cheapest nonsurgical rhinoplasty.

More significant complications have been reported in the literature, including vascular compromise resulting in skin necrosis and sloughing of skin, to the even more catastrophic complication of blindness. These complications can occur with filler injections of any kind, but due to the delicate nature of the blood supply of the nose, occlusion or blockage of any of these small blood vessels can create a disastrous complication. The best way to avoid these catastrophic complications is to seek out a rhinoplasty surgeon experienced and skilled in nonsurgical rhinoplasty.

Some irresponsible surgeons and practitioners have resorted back to injecting silicone and other permanent or semi-permanent fillers into the nose, ignoring the decades of well-documented experience in the medical literature dealing with the complications and failures of permanent and semi-permanent facial filler injections. Scarring, fibrosis, granuloma formation, chronic inflammation, and cosmetic deformity are all common long-term complications from these types of injections. When you see any surgeon advertising this kind of nonsurgical rhinoplasty, turn the other way and run.

The price of nonsurgical rhinoplasty represents a cost savings compared to surgical nose job in the short term. For patients ok with a temporary change, and a result that is limited in scale and scope relative to a surgical rhinoplasty, then nonsurgical nose job can be a great way to “try out” how a change in nose shape feels. Long-term filler injections, even when performed by experienced and skilled surgeons, can result in deleterious effects to the nasal anatomy as well, so for patients seeking a more significant change, patients seeking changes to the nasal tip and nostrils, and patients seeking a permanent change, surgical rhinoplasty may prove the best option long-term.

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Are there specific rhinoplasty techniques that predispose a patient to needing a revision rhinoplasty in the future? Part 2

Posted on June 10, 2024 by admin
Silicone implant placed during previous Asian rhinoplasty

I touched on a few techniques that predispose you to having a revision nose job surgery later on in life in my previous blog post, and today I’ll touch on a few techniques in augmentation rhinoplasty that may have the same unintended consequence. Augmentation rhinoplasty encompasses revision rhinoplasty cases requiring added height or projection to the nasal dorsum and/or nasal tip, as well as any ethnic rhinoplasty such as Asian rhinoplasty, African American rhinoplasty that require the same.

Surgeons through the generations have described many different approaches and techniques for dorsal augmention during nose job surgery. Throughout history surgeons made use of materials we would definitely consider weird by today’s standards, like ivory, jade, wax, and even animal bone. A small advancement came in the 1970s with the advent of the silicone nasal implant. Especially with Asian rhinoplasty surgeons in Taiwan, Korea and Japan, silicone implants for the dorsum and L-shaped silicone implants to project the tip in addition to the dorsum became all the rage. This technique dominated the surgical scene for decades, and only began to wane in popularity towards the 2010s and onwards as the patients who had had previous nose jobs with silicone implants began showing the long term effects of having a silicone implant.

Synthetic implants such as silicone, Goretex and Medpor implants never integrate into the nose, and therefore create a gradual but predictable thinning and weakening of the overlying skin envelope. With trauma, or even aging, can precipitate a break in the skin and ulceration of the skin covering the implant. Even barring such a catastrophic event, smaller issues such as contour irregularities, implant mobility, and aesthetically unappealing nasal shape frequently result from a silicone nasal implant that has been in place for an extended period of time.

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Are there specific rhinoplasty techniques that predispose a patient to needing a revision rhinoplasty in the future?

Posted on June 4, 2024 by admin
Before and After rhinoplasty and alarplasty
Before and after rhinoplasty with rib cartilage and alarplasty to add refinement and balance to the nose.

Surgeons have attempted to rebuild and reshape the nose in myriad ways throughout the ages. The earliest forms of rhinoplasty trace back to the rudimentary Indian forehead flaps, followed by French lateral cheek flaps. Attempts at augmenting the nose using non-autologous and and autologous materials followed, with varying degrees of success. Dr. Gary Burget and Dr. Fred Menick made a significant advancement in the way to conceptualize rhinoplasty and nasal surgery by publishing on the nasal subunit principle of nasal reconstruction. In this seminal book on rhinoplasty they described the fundamentals to accurately assess and analyze a nose in terms of form and function.

An interesting, and certainly prescient, observation by Dr. Burget remains, “No sooner has the result been created on the operating table than it begins to change.” The 4th dimension of time presents perhaps the biggest variable and challenge to every rhinoplasty surgeon, and for every patient undergoing nose job surgery. Dr. Burget’s sentiment hints at the intrinsic variability between the shape of the nose the operating surgeon creates, and the shape of the nose that ultimately persists. It stands to reason, then, that some techniques and maneuvers in rhinoplasty present a higher chance of permanence and withstanding changes through time, while some surgical techniques and approaches may suffer from more susceptibility to changes and distortions with time and aging.

While an exhaustive list might be excessive for this format, I’ll highlight some techniques here:

  • Transdomal or dome binding sutures
    • While these remain the workhorse of tip-narrowing in many primary rhinoplasty cases, they remain a double-edged sword in that they can cause the tip cartilage (lower lateral cartilage) to twist and turn over time, creating bossa and contour irregularities especially in thin-skinned patients. These suture techniques work best when used in combination with techniques to stabilize tip rotation and projection, and when tightened conservatively. Aggressive narrowing of the nasal tip with transdomal or interdomal sutures creates concavity and weakness along the lateral crura which manifests in weakening of the alar rims over time, and a resultant “pinched” nose appearance.
  • Dorsal hump reduction without middle vault reconstitution
    • Nasal bones comprise the upper third of the nasal dorsum or bridge, and the upper lateral cartilages with the dorsal septum, comprise the middle third of the dorsum, also referred to as the middle vault. In patients with bumps on the bridge of the nose, or dorsal humps, the hump is reduced by removing some portion of bone and cartilage to eliminate the convexity along the profile, typically for a straighter profile. This represents one of the most fundamental rhinoplasty maneuvers, and may be easily executed by rhinoplasty surgeons of all experience levels. Unfortunately, some nose job surgeons will overlook one critical nuance of nasal hump reduction, which is the preservation or restoration of the connection between the nasal bones and dorsal septum (keystone area) as well as the attachments of the upper lateral cartilages to the dorsal septum. When a surgeon removes bone and cartilage from the dorsum of the nose, these attachments frequently become disrupted and weakened. Over time the upper lateral cartilages may descend and narrow, creating internal nasal valve collapse, or the dreaded inverted-V deformity in severe cases. When a surgeon disrupts the keystone area the nasal dorsum or bridge can become discontinuous as the septum and nasal bones separate over time, creating a dip along the bridge or a saddle-nose deformity

Two techniques rooted in rhinoplasty fundamentals, but with definite nuances to consider for a successful surgery outcome.

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What does BB laser do?

Posted on May 23, 2024 by admin

The BB laser (beauty balm or blemish balm laser) takes its name from the now ubiquitous BB cream that became extremely popular in Korea beginning in the 1980s, and continued to soar in popularity as it came to be introduced to the U.S. and the West in the 2000s. The allure of beauty balm cream remains its ability to correct minor pigment irregularities of the skin while simultaneously moisturizing and protecting it from further injury. The BB laser is a non-ablative 1927 nm Thulium Fractional Laser that has shown impressive results for brightening skin by addressing many common dyschromias and pigmentary issues in the skin with powerful yet precise energy dellivery to the epidermal basal layer.

Mechanism of Action of BB Laser
Mechanism of Action of BB Laser

By preserving the outer layer of skin (stratum corneum) while ablating the deeper layer containing the pigment molecules and melanocytes, downtime is drastically reduced while improving skin brightness, skin texture, and removing pigmentation to create a more even skin tone. Though many patients experience minimal discomfort and will tolerate the laser treatment well without topical numbing, it may also be performed after application of topical anesthetic for 20-30 minutes. Mild pink or redness, and in some cases mild scabs or crusts may form initially. Use of gentle cleansers and moisturizers for the first week after treatment, along with strict avoidance of excess sun exposure is important. Results will be evident as soon as a week after treatment, and will continue to improve over 6-8 weeks.

BB LASER
Learn more at HALO Beverly Hills

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How long has rib cartilage been used from rhinoplasty?

Posted on May 23, 2024 by admin

Somewhat surprisingly, the use of costal cartilage and rib cartilage in rhinoplasty and revision rhinoplasty has existed for more than a century. In an article published in Paris in 1904, French rhinoplasty surgeons describe harvesting rib cartilage and using it to repair the framework of a cartilage depleted nose during a reconstructive rhinoplasty. They obviously lacked the sophistication and precision of modern surgical techniques to harvest the cartilage in a minimally invasive manner, but nonetheless it is remarkable that they possessed the foresight to attempt such a surgery with the primitive instruments they had available to them despite facing incredibly high morbidity and the risk of disastrous complications.

Following the initial description, due to the complexity and inherent risks of harvesting rib cartilage, the use of costal cartilage for rhinoplasty surgery was largely limited to small subsets of reconstructive plastic surgery, and did not become widely utilized in the realm of cosmetic rhinoplasty surgery. Rhinoplasty surgeons such as Eugene Tardy, Jack Gunter, and later by Dean Toriumi, expanded the uses and indications of costal and rib cartilage in nose job surgery and began using it as the primary graft material in revision rhinoplasty cases where septal cartilage was not available, or insufficient. The acceptance of costal cartilage for use as a graft material in nose job surgery was gradual for the first 80-90 years since its inception, but in the last few decades has exploded to become the gold standard in revision rhinoplasty, and also in primary rhinoplasty cases where additional support or volume is needed. Korean plastic surgeons abroad, and plastic surgeons such as Donald Yoo and Charles Lee in Beverly Hills, California, have helped to spread awareness and widespread adoption of the use of autologous rib cartilage in primary rhinoplasty cases such as Asian rhinoplasty.

https://www.donyoomd.com/services-asian-rhinoplasty.php

Autologous costal cartilage and rib cartilage have proven to be reliable, permanent graft materials for use in nose job surgery that integrates seamlessly with the natural nasal framework. Autologous rib cartilage (cartilage from your own body) has the distinct advantage of being viable, living tissue and is intrinsically 100% immunocompatible with your nose, meaning there is no risk of rejection or resorption due to an immune response. Costal cartilage used as grafts obtains a blood supply from the nose, and becomes a permanent part of the nasal framework.

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What’s the best technique to augment the dorsum in Asian rhinoplasty or Asian nose job surgery?

Posted on May 18, 2024 by admin

The bridge of the nose, or the nasal dorsum, represents a subtle yet visually impactful component of the nose and of the face as a whole. The width, height and shape of the dorsum has an effect on the appearance of the balance of the face and especially in terms of the projection of the mid-face and cheeks, the appearance of the eyes and the area between them, and the side profile and oblique facial proportions. In Asian nose job surgery the dorsum of the nose is often low or wide, or a combination of both. Bone comprises the upper third of the bridge, while there exists an important “keystone” area where the bone interfaces with cartilage along the middle-third of the bridge. Critically, any surgical approach to augment the dorsum must preserve this connection, but also become integrated with it so as to provide a bridge that is solid and does not move, just as the original bone and cartilage do not. Any material that is placed on top of the natural bone and cartilage, but does not integrate with it, will be predisposed to migration and eventually extrusion through the skin.

The best material then, for creating a permanent change to the shape of the nose is material that will integrate and become 100-percent a part of your nose, and the only material that will do this is tissue from your own body. For this reason, the best Asian rhinoplasty surgeons have spurned the use of synthetic materials such as silicone, Goretex and Medpor in favor of cartilage from the ears or from the ribs. Depending on the amount of augmentation, and the concomitant changes to the shape of the nose with respect to the tip and ala desired, ear cartilage or costal cartilage may offer the superior option. For the greatest degree of tip-refinement and augmentation, rib cartilage offers the benefit of a plentiful volume of strong, straight cartilage to provide structural grafting.

Asian Nose Job with rib cartilage and DCF

When using rib or costal cartilage in Asian nose job surgery, rhinoplasty surgeons may opt to carve a single piece of rib cartilage (en bloc rib cartilage) use diced cartilage which is glued together (diced cartilage glue or DCG) or dice the cartilage it and use fascia as a wrapping to create the desired shape (diced cartilage fascia or DCF). En bloc rib cartilage has the risk of warping and migration, as it is difficult for the solid block of cartilage to precisely adhere to the underlying bone and cartilage of a natural bridge. Contour irregularities are also not uncommon given the challenge of carving a solid piece of cartilage to mimic the smooth contours of a natural nose bridge. DCG eliminates the risk of warping, as the cartilage is diced. It also has a higher chance of incorporating with the underlying nasal dorsum, as the diced cartilage can easily accomodate the shape of the underlying nasal framework. However, given the tissue glue used in between pieces of diced cartilage, cobble-stone contour irregularities may result, and given the un-contained nature of the diced cartilage, the surgeon has less control with regards to where the cartilage ultimately resides along the dorsum. The DCF technique is also not without downside, as it is the most technically demanding to create a precise result, and also requires the most time in surgery to perform, as well has results in the longest recovery time to the patient. Fascia provides an exact shape for the diced cartilage to congeal and solidify into, while allowing the diced cartilage to become tightly packed to itself without the need for any tissue adhesives in between the pieces of cartilage. When performed masterfully, a nasal dorsum constructed from diced cartilage fascia will look and feel exactly like a natural nose bridge.

Learn more: https://www.donyoomd.com/services-asian-rhinoplasty.php

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What is the hardest plastic surgery?

Posted on May 17, 2024 by admin

Plastic surgery encompasses a wide gamut of surgical procedures from complex microvascular reconstructions to delicate cosmetic eyelid surgeries. As with all surgeries, plastic surgery requires a mastery of the anatomy and a profound understanding of the form and function of its component parts, but one distinct aspect that is somewhat unique to cosmetic plastic surgery is the way in which artistry and a keen aesthetic eye must accompany technical prowess for a surgery to be truly successful. Even in a highly complex and demanding surgery such as using tissue from a patient’s forearm to reconstruct a portion of a patient’s tongue that has been resected, there are certainly some judgements that have to be made with regard to appearance, but very much secondary to function. In this way the surgery becomes almost algorithmic, with success predicated more on the completion of each requisite step rather than a more holistic assessment of the outcome that places utmost emphasis on the beauty of the result.

For this reason, many plastic surgeons consider rhinoplasty to be the most challenging plastic surgery procedure. The nose has multiple core functions that must be preserved, and sometimes enhanced, during surgery including breathing, smelling, and contributing to the tonality of your voice. In addition to the critical functions the nose represents the central facial feature and must be cohesive and balanced with the rest of the face to optimize facial harmony. Perhaps the most challenging aspect, however, is to create a shape that is aesthetically pleasing not only when judged by “textbook” measures and standards of beauty, but to create a shape to the nose that blends and enhances the face when you as the patient look at it. As everyone has their own standard of beauty, influenced by personal bias, rhinoplasty surgeons have the task of understanding and incorporating their patients aesthetic ideals and biases to create the closest shape surgically possible with their unique anatomy, and the limitations this presents.

see more: https://www.donyoomd.com/gallery-surgical-rhinoplasty.php

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What is Rejuran?

Posted on May 16, 2024 by admin

Rejuran is a recent K-beauty import that has taken the Korean aesthetic surgery market by storm as it is a novel filler product manufactured from purified polydeoxyribnucleotides (PDRN) that have been shown to promote wound healing by stimulating tissue repair. PDRN has been extracted from multiple sources, such as human placentas, but in the case of Rejuran it is extracted from salmon semen. Yes, you read right, salmon semen. While it may sound a bit extreme, this purified PDRN has been shown in several studies to accelerate the would healing process by influencing cellular growth pathways, such as initiating intracellular signaling through G-protein coupled receptors, which promotes anti-inflammatory effects and stimulates cellular repair.

PDRN has been applied to the clinical setting to help promote more rapid wound healing in the case of diabetic foot ulcers, and now more recently as a skin boosting treatment in cosmetic plastic surgery. The same anti-inflammatory and cellular proliferation effects are harnessed to provide quicker recovery from energy-based and laser-based skin toning and tightening treatments, and as a way to create a “boost” of skin recovery from accumulated damage from exposure to UV radiation from the sun and environmental toxins. Skin appears rehydrated and restored, for a more youthful appearance.

Learn more: https://www.halobeverlyhills.com/services/rejuran/

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