About Face

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About Face

The Possibilities

Chapter One The Facial Assessment Balance and Proportion The Possibilities

The thing to remember as you learn more about the facial assessment, and about some of the corrective procedures outlines in this book, is that the art of facial cosmetic surgery is essentially the art of disguise. It’s not so much that I can actually “change” your face, but that I can minimize the problems of aging, disfiguration and balance, so that the overall effect is more pleasing. And I can only change what you give me to work with, which is your own face. I’ve had patients come in and give me the photograph of a model from a magazine, demanding a similar nose to hers, or his, and it can’t be cone, unless they’ve got that kind of nose to start with.

A good example of the kind of disguise I’m talking about, or visual illusion, is when a patient with deep acne scarring comes tome. First I do a facial assessment under direct, fluorescent lighting, to see exactly where the light catches the edges of the scars to cast shadows. My surgical approach will be to minimize those areas by planing them down, or using other methods, so that light playing on the face is reflected more evenly and the skin appears to be smoother. If it is warranted and the patient agrees. I might take the imaginative step of recommending eyelid surgery and/or a brow-lift, so that when the patient is fully healed, the troublesome skin seems less evident and the expressive eyes are suddenly more noticeable.

Once we’ve agreed on the area of chief concern, be it a bump on the nose or something else, then I’ll start to educate the patient with regard to the balance we seek. I point out the options, and the routes we might take. For example, if I notice, during assessment of the nose, that the patient has a deep line between the eyebrows at the top of the nose due to frowning, I might suggest a collagen injection to smooth it out. Or if I see that the patient’s main problem is that natural aging has caused the forehead to drop, I can suggest we lift it - partly because it will enhance the nose job, and partly because, as I have said, I strive for balance in a face as much as possible. As a patient, however, you should know that you don’t have to follow all of your surgeon’s suggestions. There is always the option of doing nothing at all.

Sometimes the options I suggest are dictated by the patient’s age and heredity. For example, I have a couple of simple techniques to test for loose skin that has lost its elasticity around the eyes. These techniques tell me if surgery will make a difference to the patient’s appearance. First I’ll ask the patient to tilt her head forward, so that she is looking up into a mirror. Loose skin and fatty deposits under the eyes become immediately more apparent this way, and I’ll pull gently on the skin with a tiny pair or forceps or my fingers to illustrate exactly what I am talking about. With the patient’s head upright, I’ll take the same forceps and pull on the skin above the eyes to check again for looseness. Usually, the excessive skin or “draping” of upper lids is due to age but sometimes heredity is the cause and it can appear in a patient’s twenties.

This kind of facial assessment also allows me to take special note of the way a patient reacts to my use of the forceps. Most are a little jumpy at first, naturally, but is a nervous reaction persists, I have cause for concern. One of the elements of facial cosmetic surgery that sets it apart from other types of surgery is that it is elective, meaning the patient has voluntarily sought it out. This should mean that there is less apprehension and reluctance on the part of the patient.

It is important that facila cosmetic surgery patients are comfortable with touching, because many of the procedures are performed under a local anesthetic and with intravenous sedation. I can’t have someone flinching on the operating table just because I’m working close to the eye or have moved in close to the face. And, during some procedures, I rely on what the touch of my fingers tells me; often I am operating underneath the skin, so that I have to feel for results rather than look for them. This would be the case, for example, with a liposuction of the neck. Finally, a patient must be comfortable with touching for the follow-up procedures. Sometimes I have to remove stitches. Often I’ll palpate the area I’ve worked on - touch it and move it around gently with my fingers - to check the healing process. If you’re squeamish about having your face touched, you are not a good candidate for this kind of surgery.

Another consideration during an assessment is the age of a patient, which can influence both the procedures and the results of surgery. I might be looking for slack skin that needs reduction in an older patient, but with regard to Rhinoplasty (surgery for the nose) and otoplasty (surgery for flyaway ears), youth is an important consideration. Otoplasty can be done any time after a child reaches four years of age, but there are other factors to take into account. For one, I have to use a general anesthetic on young patients; they can’t be expected to lie quietly on an operating table. For another, the follow-up procedure with otoplasty requires that the patient wear a light, around-the-ear hairband for about two weeks after surgery, and some young children are not able to do this.

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