6 months after open rhinoplasty and all natural tissue rhinoplasty. Note the open columella and nostril narrowing scars are barely visible on the nostril view.
Before and After Open Rhinoplasty
Before and After Open Rhinoplasty
Before and After Open Rhinoplasty
Before and After Open Rhinoplasty
Before and After Lower Eyelid Surgery
Before and After Lower Eyelid Surgery
Before Surgery
Surgery Day (Day 0)
Healing Photos (Day 1)
Healing Photos (Day 7)
Healing Photos (Day 30)
Healing Photos (Day 60)
Before and After Non Surgical Nose Job
Before and After Non Surgical Nose Job
Before and After Non Surgical Nose Job
Before and After Non Surgical Nose Job
The prominent jaw angle can be due to enlarged muscle, bone or a combination of the two. Surgical correction is tailored to correcting the aspect of the jaw angle that contributes most to the problem.
A natural appearing curved shape is easier to obtain through this behind-ear approach
Traditional Approach
In a recent survey, 60% of Asian plastic surgeons perform the jaw angle reduction operation through an intraoral approach. An incision is made along the back of the cheek and a portion of the masseter muscle is shaved off. The outer portion of the bone is then chipped off. This approach is best for narrowing the frontal view of patients. The change is subtle and very natural. The bone contour remains curved. When the primary problem is the appearance of the jaw angle from a side view, then the contour of the bone must be changed. This means that rather than thinning the muscle and chipping off the outer portion of the jaw bone, the full thickness of the jaw angle bone should be removed.
Traditionally, this is done through the intraoral approach. Unfortunately, the surgeon’s view is not very good and most of the surgery must be done by feel. This reduces the accuracy of the procedure. In situations where the patient requires full thickness bone removal, an incision hidden around the ear gives direct access and direct view of the bone to be removed. A more substantial amount of bone an be removed. There is also the added benefit that the recovery time is much shorter, since swelling stays confined to the neck area, which is more easily hidden compared to intra oral approach. I offer jaw angle reduction by either route, depending on patient preference.
In most cases I would recommend the posterior approach due to the direct access to bone, the quicker recovery time, and a more substantial improvement in the contour of the bone.
Asian rhinoplasty using all natural tissue (without silicone or gortex foreign implants)
No need for rib grafts (in most cases) or skull bone grafts! Recent advances in Asian nasal surgery have developed that allow all natural tissue to be used consistently to build up the tip and bridge of the Asian nose without resorting to the use of foreign body implants such as gortex or silicone.
Prior to the development of this new technique, an all natural Asian rhinoplasty required obtaining a large piece of cartilage from the rib or a piece of rigid bone from the skull. These were the places with material large enough to build up the bridge.
Needless to say, patients were resistant to having major surgery in order to build up the bridge. For that reason, silicone and gortex implants became the standard materials for nasal bridge augmentation. In the mid-1980’s, thin tissue (temporalis fascia) from just under the scalp, near the ear, was used to build up the bridge (Sheen).
This was useful for very small augmentations, typically in Caucasian patients. For greater augmentation, ear cartilage was rolled into a cigar shape and then wrapped in fascia. However, irregular contour was a frequent problem. In the late 1990’s and early to mid-2000’s, rib cartilage became a popular way to build up the bridge of the nose.
The main problems encountered were the tendency of rib cartilage to warp in one direction or another, as well as patient resistance to having a relatively large operation . In the latter 1990’s, ear cartilage was used to build up the bridge by dicing it into small pieces and placing it along the bridge of the nose. By dicing the cartilage into very fine cubes, there was no longer problems with irregular shape or warpage.
Initially, cartilage was wrapped in a Surgicel ®, a material that may cause the cartilage to resorb (Erol). The issue of cartilage resorption was solved by taking diced cartilage and wrapping it in the thin scalp tissue (temporalis fascia) to lay along the bridge (Daniel). In our clinic, we offer the following:
Nasal surgery using silicone or gortex nasal implant with cartilage to the tip under IV sedation. The advantage of this procedure is shorter surgery time and fewer necessary incisions. Nasal surgery using all natural tissue under IV or general anesthesia directed by a board certified physician anesthesiologist.
The advantage is all natural tissue, but a slightly longer anesthesia time. Our facility has on- site certification approved by the state of California to ensure patient safety.
[Special thanks to Dr. Daniel].
Before and After Asian Rhinoplasty Front View
Before and After Asian Rhinoplasty Side View
Before and After Asian Rhinoplasty Oblique View
Before and After Asian Rhinoplasty Nostril View
Before and After Asian Rhinoplasty Front View
Before and After Asian Rhinoplasty Side View
Before and After Asian Rhinoplasty Oblique View
Before and After an All Natural Rhinoplasty - NO RIB needed
Before and After an All Natural Rhinoplasty - NO RIB needed
Before and After an All Natural Rhinoplasty - NO RIB needed
All Asian double eyelid incision surgeries are not the same.
Every surgeon has his/her preferred technique. In the case of Asian double eyelid surgery, I prefer a technique called the “Anchor” procedure. This technique is in contrast to the more commonly performed “classical” technique.
In the classic technique, after the surgeon marks a crease at the proposed height and shape, the skin in incised to reach the levator (“lifting”) muscle and attaching the skin to this muscle. The area below the crease is typically left undisturbed. The advantage of this type of procedure is the quicker recovery time due to the less invasive nature of the operation.
There are several shortcomings to this classic technique.
1. Small preexisting folds are not corrected.
Because the area below the incision is not altered, any small preexisting folds will remain (picture below).
2. A symmetric result is more difficult to obtain.
In the classic technique, the skin is fixed to a dynamic structure, the levator aponeurosis, which is the mobile structure responsible for lifting the eyelid. As you can imagine, each eyelid crease has a higher probability of asymmetry when each eyelid crease is being secured to a dynamic structure.
A more symmetric result can be obtained if the fold is placed to a firm, immobile structure that can be measured precisely with a ruler measured in fractions of a millimeter. The ideal static structure for securing the crease is the cartilage that gives support to the eyelid along the lower margin (the “tarsal plate”). This structure also lies below the level of the crease and is not easily accessible if the surgery is limited to the area above the incision.
Note the preexisting fold and mild drooping of the eyelid, with the patient’s left eye more droopy than the right eye. One month after anchor eyelid surgery, the prior crease is removed and the fold is made more symmetric. At six months, the fold is expected to be about 20% smaller.
3. Loss of the crease can occur on occasion even with an incision technique.
In the classic technique, the crease is created by placing a suture from the skin edge to the underlying dynamic structure (levator aponeurosis), which results in a limited surface area to which the skin crease can stick down. Sometimes permanent nylon sutures are used to secure the skin. This can sometimes create a “tugging” sensation that patients find unsettling. In other cases, absorbable sutures are used to hold the skin long enough for scar formation to occur, which then yields a crease. However, because the area of dissection is limited, the “sticky” area of scar formation is also limited. The results is a less secure fold than if a larger “sticky” surface area is used to form the fold. This larger sticky surface area is, again, the cartilaginous “tarsal plate”, which is an area avoided in the classic technique.
Prior double eyelid surgery with loss of crease
3 month photo with crease permanence using Anchor technique
The incision scar after anchor technique.
Patients at higher risk for fold failure include those with very deep set eyes, large surgical size double eyelid fold, prominent medial epicanthal fold and thick eyelid skin.
4. Difficulty in converting suture technique to an incision technique.
As patients get older and there is more skin sag, many patients who were satisfied with their prior suture procedure request an open procedure to remove the sagging skin and excess fat. In other cases, weakness in the levator muscle requires conversion to an open technique to correct the drooping eyelid. Patients who have had the modern suture method asian double eyelid surgery such as the double suture and twisting (DST) technique or their variants (popular in Asia) requesting conversion to an incision technique will require surgical treatment in the sub-crease/ or tarsal area that is not treated by the classic technique. Surgeons not familiar with surgery in this area will frequently refuse surgery on these patients.
Anchor technique is ideal for reoperation after suture eyelid surgery.
Flowers’ Anchor blepharoplasty.
The “anchor” incision surgery is an advance Asian eyelid technique developed by eyelid expert plastic surgeon Robert Flowers to address the shortcomings of the classical technique. As can be surmised, the anchor technique focuses on surgery in the area below the incision (in front of the tarsal plate). The advantages of the anchor technique include 1). Higher probability of a symmetric result, due to fixation of the crease to a static, unmoving cartilage structure rather than a moving, dynamic structure; 2) creation of a smooth, wrinkle free area below the surgical crease by removing any preexisting multiple smaller creases; 3) Lower probability of crease failure after surgery due to the larger “sticky” surface area to which the fold can adhere; and 4) maximum flexibility in corrective surgeries such as conversion of suture techniques to an incision technique.
Case demonstrating anchor incision double eyelid surgery – two year follow up
20 year old woman with a two year follow up. This patient underwent incision surgery double eyelid surgery with inner corner correction (medial epicanthoplasty).
Result of incision eyelid with inner corner crease surgery at 16 days.
23 year old who underwent incision eyelid surgery with medial epicanthoplasty (inner fold correction). Example of results at 16 days after surgery.
Case to demonstrate the difference between a “dynamic” vs. “static” crease.
27 year old patient with prior incision eyelid surgery. She had a “dynamic” fold crease surgery and no treatment of the inner fold of skin (epicanthus). She wanted removal of the extra pre-existing fold (represented as a double line along the inner corner) in addition to removal of the inner corner skin. This was performed by using an “anchor” or static type asian double eyelid surgery. The redundant double line along the inner corner was removed, as was the inner fold (epicanthoplasty). The result is a clean platform which allows a precise, symmetric crease for easier makeup placement.
Case to demonstrate a creation of a large fold and indication for epicanthoplasty (inner fold correction). How to get a symmetric upper eyelid crease.
27 year old patient requesting a larger fold. In this case, an inner fold correction (medial epicanthoplasty) is required to achieve a larger, symmetric crease. In the preoperative photo, note that the her right eyebrow is lower than the left. This is common in 80% of patients. A symmetric crease required removal of more skin from the side with the lower brow. Photo at three weeks after surgery.
Uneven eyelid size due to right eyelid droop (ptosis).
Presurgery photo – note the smaller right eyelid size and the left eyebrow retraction.
Swelling seen at 4 days after surgery.
Up to 25% of patients have significant unevenness of the upper eyelid, where one side is smaller than the other. Frequently, this indicates weakness in the muscle which opens the eyelid. In this patient, the patient’s right eyelid does not open as widely as the left. The muscle must be corrected at the time of surgery to prevent significantly worse unevenness which will otherwise result after surgery. Patients with weak eyelid muscles are not candidates for the DST suture technique.
Some surgeons prefer to repair the muscle at an initial surgery, then return several months later for the crease surgery. I prefer to do both steps at the same time in most cases.
Ptosis can be difficult to diagnose prior to surgery. Some helpful clues as to whether one has ptosis include uneven double eyelid creases, uneven eyebrows, or significantly wrinkled forehead (in the younger patient).
Here are some examples of nostril narrowing photographs.
In this case, the primary correction was for the excessive wideness of the nostrils. The first post operative pictures are taken at 5 days, the later pictures at 6 months.
In this case, the tip was raised using a cartilage graft and the nostrils were narrowed. The two procedures in conjunction with each other amplify the improvement. The shape of the nostril is improved as well narrowed.
In this case, the nostril was not narrowed, but the shape was improved by removing a small wedge of tissue at the base, along with raising the tip using a cartilage graft. The incisions hide quite well in the groove between the nostril and face.
