Most patients seeking facelifts say that coworkers or family members tell them “they look tired” all the time. They then proceed to pull upward on their neck or lower cheeks mimicking the effect they want from surgery. To make a point, I sometimes cover my face and ask what color my eyes are. They always get it right (my eyes are brown). I then ask whether I have bands in my neck (I have one). Invariably they say they didn’t notice.

So, what’s the point I’m trying to make?

People make judgments about how old your face looks from your eyes, not your neck or jowls. There is a famous study where the picture of a woman was put on a screen. A subject looks at the picture. Behind the screen there is a camera that tracks the eye movements of the subject looking at the picture of the woman (see image).

On the left, we see the picture of the woman. On the right we see the tracking pattern of the subjects eyes as he looks at the picture. Notice that the vast majority of the subject’s eye movements track back and forth over the woman’s picture eyes. There are a few passes from eye to nose and back to opposite eye, and fewer still to the mouth. There is only one pass around the patients facial contour.

Thus in summary, the experiment illustrated that people notice your eyes first.  This has implications as to surgical choice. If you want to look younger to other people, focus on the eyes. If you don’t care how you look to others, but your jowls really bother you, you may elect to do a lower facelift.

As a surgeon, I have a preference based on anatomical details and experience. Because other people concentrate on your eyes, my first priority in making you look younger is the forehead and midface area. That’s “where the action is”. A forehead lift is done with an endoscope so it has minimal scarring. The mid facelift is done through small incisions inside the mouth. Thus you can have a major impact on the appearance of the face with no visible scars, just a few small incisions hidden within the hairline, and no stretched-out look. As a matter of fact, after a browlift most patients remark that people tell them they look better and  refreshed, but can’t quite put their finger on what was done. 

The lower facelift, in contrast, has the benefit of smoothing out the jowls and improving the neck, but if not done correctly, it can give you a stretched out or “done” look.  Even if done correctly, as I do it, the lower facelift will not change anything about your eyes. Thus if a patient has to choose between the upper facelift and the lower facelift, I usually encourage the upper facelift. 

If the patient insists, of course I will do a lower facelift. Before doing so, I show them pictures of patients who have had only mid facelift and browlifts, as well as pictures of patients who have had lower facelifts only so they can better judge what the want.

Ultimately it is your decision, but I always try my best to guide you thru your decision process. 

Ricardo L Rodriguez, MD

 

In all other branches of medicine, a treating doctor assumes that the patient has some kind of medical problem that the doctor has to fix or make better. If the patient experiences some pain, gets a big scar, or has some side effects, it’s an acceptable tradeoff because it’s for the patient’s benefit to attain good health.

Cosmetic surgery is different because the patient’s body is working right, and the doctor is just trying to make it look better. Our logo at Cosmeticsurg.net is “the Science of Beauty” not only because we apply state of the art techniques to make you look better, but also we search far and wide for techniques to make our surgery safer and with fewer side effects.

When asked before surgery, most patients report fear of pain or scars. However, when surveyed after surgery, most patients cite nausea as their worst experience after surgery. Even the pain pills can cause nausea and some patients find themselves in an unpleasant cycle of nausea and pain. The nausea in itself can be very problematic, as patients need to take fluids after surgery. If they are vomiting, they can get quickly dehydrated. By far the most common causes of admission to the hospital after cosmetic surgery are nausea and vomiting.

Whether it is for breast augmentation, tummy Tuck, facelift, or liposuction, our preparation starts before surgery. We supply the patient with a patch of a drug called “Scopolamine”. It is well known to people who have seasickness. You put the patch behind your ear the night before surgery. Its side effects can be sleepiness and dry mouth, but since most patients at Cosmeticsurg.net have 7:30 AM starts, that are rarely noticed. The patch can stay on for up to 3 days. This has worked so well for us we rarely ever prescribe anti-nausea medications after surgery. We like to leave it on because patients may need to take pain medications, and most pain medications can cause nausea.

Some surgeries such as Facelift and Rhinoplasty do not have much of a pain component after surgery. Others, such as Tummy Tuck, Body Lift, and Breast Augmentation (when done below the muscle) do have a significant pain component.

As a Plastic Surgeon I have a goal of minimal pain surgery, and a strategy to achieve this goal. The perception of pain starts at the moment of injury, whether the patient is awake or under anesthesia. For this reason I inject short and long acting local anesthetic agents after the patient is sedated and before surgery starts. We don’t rush to start, but wait a good 15-30 minutes for the anesthetic to be well set in before we start. Once surgery is over, the effect of the long acting anesthetics will last for 12 to 18 hours. Again, this period is crucial in the perception of pain. If you can blunt pain perception in the first 24 hours, the patient does much better. With less pain medications there will also be less nausea.

Surgeries such as Breast Augmentation, Tummy Tuck, and Body Lift have postoperative pain which can be intensive. My patients who are having these procedures are given the choice to using a “pain pump”. This is a device that has two components. The first is a small catheter, smaller than a drainage tube. It lies in the operated area and is brought out thru a pinhole sized opening in the skin. The catheter connects to a reservoir of local anesthetic, which is pumped continuously into the operated area. There are multiple benefits to this. The patient takes fewer pain medications, because she feels a lot less pain. There is less nausea. The patient gets around better, and breathes better.

After I started using the pain pump, the first thing I noticed was that fresh post operative patients (1-2 days post op) were walking into the office, instead of them calling ahead and asking for a wheelchair to pick them up from the car. Secondly, their skin looked better. At first I thought patients were getting flushed from walking into the office. In reality, I was expecting the pale face of the patient in pain that I was so used to seeing before using the pain pump. Needless to say, the recovery of these patients is improved because they get up and around much sooner. Moreover, the experience is much improved, because both pain and nausea are much improved.

I hope you learned something about some of the issues we deal with as we try to improve your care. We truly are devoted to the concept of “the Science of Beauty”, and this includes all aspects of your care, both before and after surgery.

Ricardo L Rodriguez, MD

When I perform surgery, I routinely combine multiple procedures in the same operative session. For example: brazilian butt lift with tummy tuck, face lift with lip aug---I’m very comfortable with all these combinations and it is fairly common in my practice. However, when it comes to injectables I am just beginning to realize the dramatic opportunities in combining Botox and Facial fillers for a more youthful appearance.

Several months ago I saw a female patient who had a social event coming up and wanted a “quick and easy” surgical procedure with minimal downtime. At the time, I frankly did not offer her anything because I thought what I could deliver with fillers and Botox would only be temporary, and require more money than just an “impulse buy”. Sometime later, a male friend of mine requested something non surgical that would make him look younger without any downtime. Thinking about that last patient I had seen, I offered a combination of fillers (sculptra, Restylane/Juvederm) and Botox. Still uneasy, I tried to explain to him, that for the money, he might as well have surgery. Then, what he said surprised me.

He looked at me straight in the eye and told me that what I had described (fillers with botox) did indeed sound more attractive than surgery. He did not want to experience any downtime at all! Furthermore, he knew he would have to repeat the injections within a year, but that to him, it was still better than surgery. Time IS a big issue for a lot of patients. He wanted results now and without any downtime. So, I performed the combination of injections and he is very happy with his results.

Which brings me to today’s subject: The Liquid Facelift. I first heard about it from Heidi Rebuck, a Juvederm and Botox rep. “The Liquid Facelift” is basically what I did with my male patient, using a filler with Botox, but I think these pictures of “The Liquid Facelift” are worth a thousand words.

Basically, the patient in the photo (courtesy of Allergan) had Botox to forehead and “crow’s feet” wrinkles around the eyes, with tissue fillers to the lips, nasolabial folds (folds that go from side of nostrils towards the corners of the mouth), and possibly under the eyes. The change is dramatic and substantial.

This experience has made me reevaluate how I listen to patient’s requests. As a result I am much more inclined to offer these “temporary solutions”, as they are indeed perfect for a lot of people. As a matter of fact, most women do approach temporary beauty solutions as a matter of course. Think of hairdos, facial creams, even sun tanning, none of which are “long lasting”, yet essential to good appearance.

The Liquid Facelift, takes “non-invasive” beauty treatments to an entirely new level. I am very excited about it and you would do well looking into it.

Ricardo L Rodriguez, MD

 

I have already spoken on the subject of the browlift, but a picture is worth a thousand words.

Many young women come to my office when they start noticing a little bit of “extra skin” on their eyelids. They have heard about eyelifts (blepharoplasty), and how easily it can be performed- under local anesthesia, in the office, in 1 to 2 hours. Naturally, they are very interested.

While I am not against eyelifts, I counsel patients to think very carefully about it, because eyelifts can have undesirable effects, such as a “crowded” look around the eyes that is not necessarily youthful. Look at the two pictures above, the picture to the left is before eyelift surgery and the one further down and to the right is after eyelift surgery. The red arrow on the left eye is the same size in both pictures. What you will notice is that the distance between the brow and the eyelid shortened markedly in the after surgery picture. This creates a more “crowded” look around the eyes, certainly not the more open look of youth.

There is a reason for this. When your eyes try to focus, you “squint” your eyes, or squeeze your eyelids closer to focus better. Since the eyelid muscles are connected to the tissues of the brow, gradually the brow attachments to the brow bone relax, and gravity brings the brow down. This bunches up the skin above the eyelashes. But this is not “excess” skin, it is only bunched up because the brow came down. The eyelashes feel the weight of the “excess” skin pushing down and send the brain a signal to lift the brows in order to get the “excess” skin out of the way. This is how you get forehead wrinkles. It comes from years of lifting the brow to get the skin out the way.

If you cut away the “excess” skin with an eyelift, the brow no longer needs to be lifted so it relaxes and drops again. That is why the distance between the brow and the eyelid is shorter in these 'after eyelift' surgery pictures. That is also why some patients complain after surgery that “not enough skin was taken off”. What happened is not that the surgeon took too little skin off, but that the brow dropped some and now skin is bunching up again.

At this point, if you cut more skin off, you run the danger of the eyelids not closing properly, allowing the tear film to dry too fast, and irritating the eyes. This is called “dry eye syndrome”.As we can see, the problem is not “excess” eyelid skin, but brow position.

In order to refresh the eye to a natural position, the brow needs to be lifted. This will have the effect of lifting the upper eyelids. For this reason I prefer an endoscopic brow lift. Scars are minimal, recovery time is minimal (7 days), and it has a better result. In my next post I will address endoscopic brow lift.

Ricardo L Rodriguez, MD

Board Certified Plastic Surgeon

I went to see Dr. Rodriguez on Sept 25th for Lip Advanta Implants and Sculptra . I was greeted by the nicest staff and made to feel very comfortable. I was more then briefed on every option that i asked about to ensure a confident choice in procedure. After my procedure I was a bit terrified by the immediate effects of surgery (swelling),but the entire staff assured me that the swelling was completely normal. Now, 3 days later, the swelling has went away and I LOVE my new lips. I also can see a drastic difference around my smile lines from the Sculptra even after my first treatment. I have two more treatments for the Sculptra and im excited to see Dr. Rodriguez, Kelly and the rest of his staff soon!