Why a Chin Implant is a Nose Job's Best Friend

Correction of a receding chin is frequently performed simultaneously with other facial procedures such as face and neck lifting, neck sculpture or nasal cosmetic surgery. Occasionally it is a stand-alone procedure. People have chin augmentation when their chin is receding; that is, it doesn't project as far forward as it should be in harmony with the other facial structures.

The standard for judging just how far forward the chin should be, when looking at the profile, is that the front of the chin should come as far forward as a vertical line drop from the upper and lower lips. Using two mirrors, to see your profile, will tell you that.

Our experience for nearly 40 years is that approximately 20% of patients whose profile would benefit from rhinoplasty would also be well-served with a chin implant. There are circumstances where there are limitations on how much the forward projection of the nose can be reduced and in such cases where typically the chin is also receding, increasing the chin projection can take attention away from the over-protruding nose. Hence, the chin implants bails out the nose, and is a nose job's best friend.

The decision to have the procedure must follow some analysis and thought on the part of the patient and the surgeon. In my opinion, the means to understand what the outcome would be and predict the patient's satisfaction is computer imaging, whereby the predicted result is shown on the computer screen. This allows the patient to compare side by side their existing profile with the anticipated result.

How do people look on the front view following chin augmentation? There is less impact than that upon the profile. However, most of today's pre-formed implants are wrap around, U-shaped, such that they not only increase chin forward projection, but also give a little bit of wideness and fullness to the front part of the jaw area.

Remember that profile analysis must include whether or not the angle between the neck and the jaw is satisfactory because that has an impact on how strong the chin line looks. Again, this is best appreciated when computer imaging is performed for the patient's benefit.

The surgical procedure itself is quite straight forward. FDA-approved, medical grade silicone-plastic, pre-formed implants come in a large variety of sizes and shapes to match the patient's specific architecture. They are inserted through either the mouth, in the groove between the lower lip and front teeth, or through a thin horizontal incision hidden under the chin. The surface stitches are generally removed within one week. Healing is rapid and most people look quite satisfactory within seven days. Generally, there is very little bruising because the implant is placed underneath the muscle, far from the skin surface.

The chin surgery is done under local anesthesia with sedation or general anesthesia; both techniques affording no pain and no awareness. Operating time is less than one hour.

Initially, due to swelling, the implant may appear slightly inappropriately large, but within that seven to ten-day period after surgery, the swelling has gone down significantly, and the end result can be appreciated.

While the implant is secured in place by the surgeon, using either metallic screws or stitches, it takes the body six weeks to develop a firm fibrous "capsule around the implant to secure its position against the chin bone. This fixation is permanent.

Patients need to understand that there may be some temporary numbness of the lower lip and chin, but that typically only lasts a matter of a couple of weeks. Likewise, there may be some stiffness in function of the lower lip, but that only lasts a day or two as the immediate postoperative swelling goes down.

There are a few complications or untoward side effects. Occasionally, the implant might slip and require removal and replacement, not unlike the situation with respect to breast implants. Should the end-result not please the patient, the existing implant can be removed and a differently sized or shaped substitute placed. Infection is very rare, as well as "rejection" of the implant material.

Robert Kotler, MD, FACS

Related Topics:

• WebMD Video: Chin Implants for Men
• WebMD Video: Botox for Men

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Does Cosmetic Surgery Need More Government Oversight?

"California lawmakers want increased oversight of doctors performing cosmetic procedures in outpatient facilities." -Los Angeles Times

California Assembly Bill 2968 was generated by the death of Donda West, 58 year old mother of Kanye West.

Donda - according to the L.A. County Coroner - did not die from any operating room slip-up, nor from a specific error under anesthesia. But there still lingers a question as to how well Mrs. West's state of health was evaluated, well before surgery.

Common sense and sound medical practice suggests that patients, of any age, should have "medical clearance". Medical clearance is a history and physical plus appropriate laboratory, x-ray and electrocardiogram testing as a basic means of evaluating suitability for - and the risk of - both the operation itself and the anesthesia. Sometimes, additional consultation with other specialists, such as cardiologists, is called for. In Mrs. West's case, we know that she had significant risk factors such as family history of heart disease, borderline diabetes, obesity, high blood pressure and other factors that made her higher risk than might be acceptable.

What seemed to be lacking in the West case is what we doctors call clinical judgment; just plain old medical common sense. Whether the patient is a celebrity or not, a cosmetic surgeon's first obligation is to ponder whether or not the operation is "too risky". As we teach our trainees, "Think before cutting."

Despite these good intentions of legislators, there are only so many laws that can be put into place to regulate medical practice, already the most overseen and highly -regulated of all professions.

It is naive and unrealistic to propose yet another law intended to control thought processes and decision-making.

Related Topics:

• Is Cosmetic Surgery Right for You?
• Cosmetic Surgery - Important Considerations

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Spring Allergies: How a Nose Specialist Deals with His - and His Patients'

Photo Credit: SpooSpa

Ah, springtime. Trees, grasses and other plants return. The world looks green and better. Except for those of us with inhalant allergies. The lining tissues of the nasal passages swell, the nose becomes stuffy. This gives rise to the pressure sensation, headache, difficulty breathing, itching, sneezing, post-nasal drip, coughing and sometimes even loss of taste, due to temporary loss of smell.

While allergies are rarely "cured" (they represent a mismatch with the environment), relief of symptoms is the goal. And, while some people have long-standing breathing problems because of a deviated nasal septum or nasal fracture, even they can obtain relief when further burdened by an allergic attack.

The following treatment plan has been effective, for me and my patients, to relieve the burdensome nasal symptoms.

I use two nasal spray medications. First, Afrin, or Otrivin, well-known, non-prescription spray-mists, which shrink the lining of the nose and provide almost instantaneous relief from the blockage and pressure sensations. This drug, a cousin of adrenaline, shrinks the internal nose's blood vessels, which are dilated maximally as part of the body's reaction to the inhaled allergens. Typically, I will spray four sprays into each nasal passage, wait four minutes, and then again install four sprays into each nasal passage. It is important to allow that four-minute waiting period, since the initial sprays will shrink only the swollen front portion of the nasal interior. Following the pause, the second round of sprays will then gain access to the back portion of the nasal passages.

While it is easy to fall in love with the effectiveness of these sprays, the user is reminded that after five to seven days, there comes the "rebound effect", whereby the internal nose becomes intolerant to the spray that now does less and less. Some unfortunates become habituated to its use. I once had a physician-patient who had become so hooked, he sported an Afrin-containing holster on his belt!

The second medication is a prescription cortisone nasal spray. Brand-names include Flonase, Nasalide, Nasacort, Vancenase, Beconase, Nasonex. The mission of these sprays is to blunt the biochemical reaction that the offending invisible allergic particle has incited, causing the swelling of the tissues. These sprays are designed for long-term use; there is no tolerance developed. However, there is a several day "ramp-up" before the medicine reaches peak effect, hence the wisdom of utilizing, temporarily, the immediate-action oxymetrazolamine to provide relief until the steroid spray kicks in.

Non-prescription decongestant nasal sprays last eight to twelve hours; the prescription cortisone nasal sprays typically last twelve hours. For the first week of treatment while waiting for the cortisone to take effect, as both sprays are being used, I use the decongestant first. One half-hour later, the steroid spray, now entering an unblocked nose has room to work its magic.

Incidentally, the same program works for the common cold. In that case, the nasal tissues become swollen because of the reaction to the cold-causing virus.

Related Topics:

• 100 Worst Spring Allergy Cities
• Treating Nasal Allergies: Your Day-to-Day Game Plan

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Mommy Makeover Book Misses the Mark

People have been asking about some new book that apparently advises high-anxiety mothers planning a Mommy Makeover cosmetic surgery. The book purports how Mom should explain and justify the surgical experience -- including the immediate and not glamorous post-operative appearance -- to her ostensibly worried 4-7 year old youngsters.

Frankly, I see this as an inane book in search of a need. Of the six billion people on earth, the book's potential readership might fit into the local school auditorium. Do parents really require scripting to explain their decision and then the temporary bruising and swelling? Cannot the average parent, in their own words, better allay any anxiety or answer questions posed by the little ones?

Is a how-to book necessary for every occurrence in life?

Has there ever been a book-for-kiddies delivering scripts on how to explain the also-temporary bloating and swollen ankles of pregnancy? Or, spoon-feeding advice on handling an irritable Mommy during menopause? Or, why Mom can't trampoline with the kiddies one day after her bunionectomy?

Have we no confidence in the innate common sense and sensibility of today's parents? Are we all thought to be that stupid and lacking adequate communication skills?

In all fairness, I have not had a chance to read the entire book because, right now, it lives only in its pre-publication promotion and PR phase. So, currently, we must rely on the news media to deliver the book's message and purported wisdom. Perhaps there will be a better book than the press releases suggest; I hope so.

However, given limited budgets and bookshelf space, perhaps parents should think first of books that teach universal life lessons, broaden awareness, stimulate imagination, expand vocabulary and teach tolerance and respect. Think the Dr. Seuss series. Or, for old-fashioned, real-life practicality, Everyone Poops (My Body Science). After all, the pool of 4-7 year olds -- nervously grappling with how to understand their Mommy's makeover sojourn -- is rather miniscule. But, every kid needs a running start in mastering the essential basic life skills.

Related Topics:

• Body Image and Your Kids
• The Mother-Daughter Weight Connection

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Priscilla Presley and Silicone

"Priscilla Presley is the victim of botched cosmetic procedures."

From (TMZ):

Priscilla, whose face looks ... strange on "Dancing with the Stars," went to Dr. Daniel Serrano around 2003. Serrano was a good-looking doc from Argentina who hooked into Hollywood's social A-list and started giving them what he claimed were miracle injections that worked better than Botox.

In fact, Serrano was injecting industrial, low-grade silicone similar to what's used to lubricate auto parts in Argentina into the faces of these women.

Another celebrity falls into the hands of the wrong doctor for cosmetic surgery. So much for fame and fortune immunizing against bad selection of professionals.

If these people - presumably with savvy connections - and living in the world's epicenter of cosmetic surgery, Beverly Hills, can't pick the right doctor, or at least one with a CA medical license, what about the less sophisticated of America?

My latest book, The Essential Cosmetic Surgery Companion, a unique workbook, really makes it easy to avoid doing dumb things. It even has links to the Federation of State Medical Boards to facilitate checking that the doctor working out of his patients' homes (a huge RED FLAG) has a valid medical license.

It's sad that the great accomplishments of modern cosmetic surgery are tainted by crooks, charlatans and grifters. But, in this world, medical or otherwise, it is "Buyer Beware!"

Related Topics:

• Get Savvy Before Cosmetic Surgery
• Cosmetic Procedures: Botox

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Florida Teen's Cosmetic Surgery Death Explained

Since yesterday, there have been many reports and comments about the Florida teenager who died during  breast augmentation surgery.  Some report highlights:

• Malignant hyperthermia, the cause of death, is hereditary and thus any patient undergoing GENERAL anesthesia should be asked: "Family history of problems with anesthesia?" If so, there is a diagnostic test available


• MH, very rare, but reversible if detected early and treated aggressively. Every anesthesia specialist and surgeon should know the management.


• An accredited, licensed or certified surgical facility, whether hospital, outpatient surgery center or office facility is required to have the specific antidote, a drug called Dantrolene, on the premises for emergency use.

What we know, so far, is that the 18-year old Florida patient developed the very rare complication of general anesthesia, malignant hyperthermia, literally "dangerous elevated temperature". But the temperature, per se, is not the only, nor typically the first, sign of this acute erroneous error of muscle metabolism. It is merely the most striking sign because few other elements of surgery or anesthesia will generate a high temperature in the middle of an operation.

While the patient's pre-disposition is hereditary, because of the condition's rarity, few patients can report a family history. Therefore, unless suspected, the condition arises without warning during surgery.

Here are the classical signs of malignant hyperthermia:

1. Sudden and otherwise unexplainable RAPID and STEEP rise in the pulse rate, e.g from 80 to 150 within minutes.


2. Rapid rise in breathing rate.


3. Major temperature elevation, which usually follows the above. Can rise to 106 F or more.

Think in terms of a marathon runner. The muscles are working overtime and the body attempts to self- regulate by automatically increasing heart and breathing rate and the temperature rises to "cool down" the body.

In malignant hyperthermia, the muscles are working overtime but not carrying the patient anywhere.

The immediate treatment is well-established. The general anesthestic agent, is "turned off"; 100% oxygen is driven into the lungs. To stop the muscles' hyper-metabolism, a drug, Dantrolene -- specifically used for malignant hyperthermia -- is given intravenously. The body is cooled by packing in ice and the patient is transported to a hospital intensive care unit.

The key to successful treatment and saving the patient's life is early recognition by the surgeon and anesthesia specialist. Because most anesthesiologists have not seen a case in their careers, they must carry a high index of suspicion when the computerized monitors' warning lights and bells suddenly go off for no apparent reason.

Appreciation to Kevin Tehrani, MD, Chief of Anesthesia at the Summit Surgery Center, Beverly Hills, CA., for his input. In preparing this, I consulted with Dr. Tehrani whom I recalled had successfully treated a case of malignant hyperthermia at the USC-LA County Hospital.

Related Topics:

• Guide to Breast Enlargement Surgery
  
• Breast Implant Safety
  

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Peels, Lasers and Microdermabrasion? Which is Best?

What is the difference between the non-surgical skin treatments: peels, lasers and microdermabrasion? How do you select the best one for aging skin?

With over 100 treatments now available, it is daunting to know what is best for your skin.

"Light" Chemical Peeling Agents

Alpha-hydroxy Acids: These mild peeling agents act as a deep exfoliant removing the dead cells from the skin surface and accelerating the maturation of the remaining cells. The aim is to make the skin smoother to the touch and more lustrous in appearance. The most commonly used alpha-hydroxy acids are lactic acid, glycolic acid and citric acid. Alpha-hydroxy acids (in concentrations of less than 10 percent) are used in cosmetic preparations; in concentrations of 10-70 percent, as skin peeling agents. In antiquity, women bathed themselves in sour milk in the hope of softening and smoothing the skin. Perhaps they understood intuitively that sour milk contains lactic acid, now used for, the same purpose.

Medium Strength Chemical Peels

The most common medium strength agent is trichloroacetic acid ("TCA"). Typically used in concentrations between 20 percent and 50 percent, TCA, a strong acid, destroys the epidermis (the outer layer of skin) and penetrates into the dermis (deeper skin). As a result, it stimulates the formation of new, fresh skin that is richer in collagen and elastic fibers, and is more taut with fewer wrinkles. Trichloroacetic acid has been used by experienced practitioners for many years. Because of the strength of this chemical and the possibility of complications, TCA skin peels should be performed only by experienced dermatologists and cosmetic surgeons. Anesthesia may be required for patient comfort and safety. This process of skin rejuvenation may take five to seven days of "down time" after which the skin is red. Cosmetics are required until the red color fades. When red, the skin is extremely sensitive to the effects of the sun and, therefore, a comprehensive skin program emphasizing sun protection is mandatory.

The "Heavy Hitters"

Deep Phenol Peels

"Phenol peels," the so-called "heavy weights" of skin rejuvenation, have a long and successful history. They have been performed in the U.S. as a mainstream procedure since the early 1960's.

Phenol is an acid-like chemical that, when mixed with other agents, becomes a potent prescription, resurfacing the skin by removing wrinkles, crow's feet, age spots and other superficial skin imperfections. Experienced practitioners regard phenol formulations as the standard against which all other skin resurfacing procedures must be measured.

Because of its ability to penetrate to the deeper layers, there may be some permanent lightening of the skin.

Laser Peels

• Nd:YAG (Neodynium) laser: penetrates below the outer layer of skin, stimulating fresh collagen without causing a destruction of the outer-most layers. This translates into a shorter healing time. But this procedure, because it is less intense, requires maintenance treatments and has not lasted as long as the other laser treatments, and may not last as long as other laser treatments.
• Carbon Dioxide (CO2) laser: The first widely utilized skin laser, introduced in 1995. Strongest, most invasive laser. Less popular today because of high percentage of over treatments (think complications) and undertreats (think disappointed patients).
• Fraxel Laser: Less invasive, faster healing. Good for improving sun damaged skin, spider veins, age spots and some acne scars.

Skin Rejuvenation Technology

• Titan®: Light flashes purportedly restructures the dermis to tighten the skin without surface changes.
• Thermage®: Radio frequency technology. Superheats the skin and claims to thereby tighten the skin by strengthening the collagen. Little down time, but reports of a very high percentage of disappointed patients.
• Plasma Energy New: Claims resurfacing of the skin to "reduce wrinkles and improve skin tone and texture". Further evaluation is needed.
• Intense Pulse Light (IPL): Flashes of light to reduce spider veins, pigmentation, also employed against acne. Has been well accepted with very low complication rate.
• Microdermabrasion: Gentle sandblasting to smooth the lines and lighten age spots and other signs of skin damage. A minimal treatment.

Note: This list is not intended to be all-inclusive. I have chosen a variety of the more popular and/or promising treatments so that one may understand the variety in procedures and technology available today.

Related Topics:

• WebMD Video: Peel Away Wrinkles
• Age-Fighting Skin Treatments for Men

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