When I see a patient for facial improvement, which is almost all I do, I spend time with her. We discuss her face. I examine it, both visually and by touch. I tug and pull and slide the skin to understand what the materials will let me do and how it will look.
In my practice, I see many patients who have seen many plastic surgeons, as they should before getting surgery or other treatments. It's shocking how many people who have seen other doctors tell me that in their other consultations, the doctors didn't touch their faces at all. They simply looked at the patient from across a desk. No one can tell how a face will respond to treatment just by sight. The face is very deceptive. There are some configurations that look like they would be amenable to treatment, but when the face is actually examined by touch, it is apparent that a completely different treatment is necessary. In my opinion, not physically examining the patient disqualifies the doctor immediately.
Whenever a service is sought and money exchanged, there is a potential tension. Cosmetic treatments on the face, whether surgical or non-surgical, are a luxury item which the patient pays for herself, since insurance does not cover them. The incomes of cosmetic surgeons are related to how many procedures they do, so one shouldn’t be surprised that treatments are suggested more than they are discouraged. It is not uncommon to hear a lovely 35-year-old patient relate that she went to see a few doctors about her upper eyelids and was told that she "needed" her face lifted, her nose done and a breast augmentation...as an emergency.
Because patients seeking consultation have insecurities about their appearance, they can easily be manipulated. I am not suggesting that this is universal or even frequent, but high-pressure sales tactics work the best on vulnerable people. Even though most doctors are ethical, if you feel that you are being pressured or manipulated, you might consider finding a new doctor.
I do my best to address what the patients' concerns are, and to suggest minimal ways of treatment before more invasive ways. I've been looking at faces a long time, so if I think there are ways to make a big difference with minimal procedures, that's what I will suggest. As many of my patients will attest, if I don’t think they need something, I will tell them so. I don’t do procedures on people who don’t need them.
If we decide that surgery is the best option for you, I will see you 2 -3 weeks before your surgery at your Pre-Operative appointment. For out of town patients, we can make other arrangements if necessary. During this appointment I will take before and after photos, surgical/treatment consents are explained and signed, and we may have you go upstairs to the lab to have blood drawn and a urine analysis done.
We will go over your procedure(s) in great detail to review and finalize the course of action as well as discuss any questions, comments or concerns. Your pre- and post-operative care will be discussed and you'll be given prescriptions for medication(s) if indicated. We will discuss medications you are currently taking, and which ones you should stop taking before surgery. (There is more information below about this.) The pre-operative appointment is typically 1-2 hours in length and allows for any questions or concerns not previously discussed at the consultation
I want you to have all of your questions answered thoroughly so that you have a clear understanding of the procedure and what is to be expected prior to surgery, immediately after surgery and for the post-operative recovery time. You may be required to have a physical exam, EKG and medical clearance from your primary physician.
IMPORTANT MEDICATION NOTICE FOR SURGICAL PATIENTS
If you are taking aspirin or any other drugs that increase the risk of bleeding, it is imperative that you discontinue the use of these products 2 weeks prior to and 2 weeks after surgery. Any prescription medications that you take should be discussed with your family physician to determine the blood thinning risk and if you are able to temporarily discontinue taking them.
All other over the counter medications, diet, herbal and homeopathic supplements should be discontinued 2 weeks prior to and 2 weeks after surgery. This includes vitamins, fish oils, etc. If you have any questions please call us to go over your concerns. For aches, pain, fever, or other general discomfort, Tylenol products are ok.
Before any surgical procedure I will have seen you at least twice, more if you have questions. In the big scheme of things, facelift surgery is not like removing a pancreas or spleen, but above all surgery needs to be safe, and so people over 50 need to get a note from their doctors and a relatively recent EKG as well as some standard blood work. This is not necessary for small procedures like lid surgery. By tradition, people are encouraged to refrain from aspirin for a few weeks before surgery as it is believed to keep blood from clotting.
Many plastic surgeons do all their surgery under general anesthesia, in other words you are completely asleep with a breathing tube in your throat. I have always thought that this was too much anesthesia. Not that general anesthesia is not safe — it is — but these are typically 31/2 to 41/2 hour procedures and patients can cough when they wake up from general anesthesia and the tube is removed. This is not a good thing after a facelift because it can cause bleeding, and also the incidence of pulmonary embolism (clots in the lung) is higher. There is more nausea and vomiting after general anesthesia as well.
I do almost all of my facial cases with local anesthesia and sedation. The sedation is similar to what is given in a colonoscopy, in other words you are not aware and won’t remember anything. Skillful local anesthesia means that you don’t feel anything because your face and neck are numb. . If you are not feeling pain only a small amount of sedation is necessary to keep you asleep and there is no tube to make your throat sore the next day. Well done it is an elegant and very comfortable way to do surgery. Again, the key is well administered local anesthesia. if the whole face and neck are well blocked and numb there is nothing to hurt and with a low level of medications you can be kept asleep for hours breathing on your own. During surgery you have the same monitoring by an anesthesia professional as you would have in a hospital.
Typically I have patients stay a night (more if they want) with an aftercare nurse. You will go to her house which is set up for aftercare. I will see you the next day and remove the dressings. Most family members or friends have never taken care of a facelift patient before and have no idea what to expect. I have been working with our aftercare group for 20 years; they are invaluable. They know what to look for and what to call me about. Immediate complications from facelifts are rare but need to be attended to right away. She also makes great scrambled eggs in the morning.
Your ride can pick you up then after I see you in the morning.
Recovery is fairly routine. In my practice, I rarely use drains anymore, I place a bulky head dressing on for the first night which comes off the next day. I like to hover over my patients and I always see them the next day and sometimes a few times in the first week, depending on how they are doing. In almost all cases, sutures are removed on the seventh day and almost everyone is able to return to social activity at the end of two weeks. People who like to work out may do so at three weeks if they have common sense enough to listen to their bodies and not overdo it. Patients who are obsessive exercisers are told that their faces will fall off if they go back to maximum exercise too soon.
There is a huge variation in how pts perceive pain, most of my patients report that though the facelift is uncomfortable, it doesn’t really hurt. About 25% of patients don’t use anything stronger than Tylenol. The rest are comfortable with Vicodin. If lower lid surgery has been done you will have some eye drops to take. Ice is helpful for the first 24 hours and longer if you like how it feels. I am a fan of using elastic chin straps on the neck for a month or so after surgery, mainly at night. The patients love the feeling of support and the gentle compression helps the neck get loose supple faster.
It takes months and months for all the swelling to go away after surgery. 80% goes away after the first 6 weeks, and most of that in the first two. ALL the swelling can take 6 months or more. This is actually a good thing, a little swelling is a beautiful thing — it puffs out some of the fine lines and smaller wrinkles that the facelift does not improve. They do come back as the swelling resolves. Unfortunately.
The neck in particular gets tight early on, this is a natural consequence of wound healing in an area that is constantly moving. The chin strap helps that improve. I frequently put micro doses of a dilute steroid into the neck to help it soften quicker.
Policy on Redo Surgery
There are certain things that occur after surgery that are not in the power of the surgeon to control; if, for example, a breast implant gets hard or if neck skin stretches after a facelift.
Because things like this don't come up much, I am pretty easy going about my personal charge to touch them up, which are decided on a case-by-case basis. But procedures like this have to be performed in an operating room, which I don't control, or may include anesthesia service, which I don't control either. So regardless there will be a charge for this overhead.
In addition, I have to be able to see the problem and think that I can make it better — sometimes people have complaints about things that I can't see. If I can't see it, I can't fix it.
In the event I think I could have done something better, I will touch it up with no additional cost at all. This comes up once every few years.