Cleveland_Clinic_Host: Welcome to our Online Health Chat with Daniel Alam, MD.
Daniel Alam, MD, is the Head of the Section of Facial Plastic and Reconstructive Surgery in the Head & Neck Institute of Cleveland Clinic. He was recruited to join the Staff of Cleveland Clinic in 2002. His practice encompasses the entire range of facial plastic surgery. The Section of Facial Aesthetic Surgery, under his leadership, has developed six new surgical procedures over the last five years, including new minimally invasive cosmetic procedures.
The team of world-class ear, nose and throat doctors at Cleveland Clinic’s Head and Neck Institute has been recognized nationally and internationally as vanguards, pioneers and leaders in this multidisciplinary field. Dr. Alam focuses his practice on facial plastic surgery, from minimally invasive cosmetic procedures to complex microvascular reconstructions of major facial injuries or cancer resections.
During the next hour, Dr. Alam will answer your questions on many facial cosmetic procedures, including facelifts, eyelid and brow lifts, necklifts, otoplasty, rhinoplasty, injectables and more.
Welcome Dr. Alam and thank you for being here with us today. Before we get started with questions that people have submitted, let's discuss about the basics of facial cosmetic surgery.
Speaker_-_Dr__Daniel_Alam: Plastic surgery is an issue of balance. Consider that our face ages in thirds: The upper third is the upper eyelid, forehead creases and brow position. The middle third is the lower eyelid area, nose, position of the cheek and sagging around the mouth. The lower third is from the corner of the mouth to the jowls and the neck.
Achieving an optimal outcome in a patient involves reestablishing this balance. Most patients come to a plastic surgeon because a particular part of their face bothers them. Often this portion of the face has aged prematurely when compared to the surrounding areas.
Improving appearance involves bringing one particular area back into balance with the rest of the face. One of the most common concerns voiced by patients is whether they will look like "a plastic surgery patient" with an abnormal wind-swept and pulled look about them.
If the procedure is done appropriately, the opposite should occur. Bringing the face back to balance should allow for a more natural appearance. The abnormal wind-swept appearance from facial cosmetic surgery is a type of undesirable surgical outcome usually due to over aggressively treating one area without considering the face as a whole. Often a patient is better served having smaller procedures done to each of the facial areas instead of an aggressive procedure done to one area alone (for example: an aggressive face lift without considering the eyes.)
Hamm: What is the best treatment for lines around your eyes (crows feet)?
Speaker_-_Dr__Daniel_Alam: The best treatment is Botox because these lines develop due to excess activity of the muscles around the eye. This is a non-surgical procedure performed in the physician’s office without any significant recovery time.
tmer: I am particularly interested in Botox and an eye lid lift.
Speaker_-_Dr__Daniel_Alam: Eye lid lifts are effective to help open your eyes up. The benefit that most people report is that they appear less tired. The eye lid lift is also good for extra upper eyelid skin and the loss of the normal crease in the upper eyelid. If the brow is sagged, then a brow lift is necessary. Botox is good for crow's feet and vertical lines between the brows.
horvatm1: How much time off is needed for a blepharoplasty? (eye surgery) Is it covered by insurance if it is medically necessary? When is it considered medically necessary?
Speaker_-_Dr__Daniel_Alam: Blepharoplasty is covered by insurance if the amount of excess skin or sagging of the eyelid affects one's vision. This is assessed by a visual field test. After consulting with your plastic surgeon, if this is likely a visual field test will be scheduled and pre-authorization is obtained from insurance.
MJ: I am 35 years old and interested in a brow lift first. Do you recommend it for someone of my age or should I wait a few more years? Also, what is the recovery time and is the procedure a costly one?
Speaker_-_Dr__Daniel_Alam: In general, age is less important than actual severity. There are patients that are 35 that may need and brow lift and there are individuals that are 60 and may not need one. Our faces age differently between individuals and within different regions of our face.
Recovery depends on the method of treatment. An endoscopic brow lift is usually less than one week. Upper eyelids alone is approximately 3-5 days. Again, cost is variable- probably $2000-$4000 for those procedures.
Frances: I have these little bumps on my upper and lower eyelids. They look a little bit like pimples, but they aren't. They have been there for over a year. Do surgeons take things like these off? They bother me.
Speaker_-_Dr__Daniel_Alam: Yes - we can remove them. They are often related to small deposits of fat/cholesterol in the upper skin layer. They can be removed in an office setting with minimal downtime.
CS: Since I'm going to hit 55 this year and starting to look older I was considering a "tightening" of the skin on my face. Since I have never had plastic surgery before what would this entail? How long would I have to be off work, would I be bruised? Thank you.
Speaker_-_Dr__Daniel_Alam: This depends primarily on the amount and extent of the surgical procedures that would be necessary to give you your desired outcome. Facelift procedures now vary across a wide range with recovery as short as a few days to as long as a few weeks.
It is no longer one procedure for all patients.
If you have minimal aging, a min-lift type procedure could be accomplished at less cost and with less recovery time.
The costs also vary based on the extent of surgery that is necessary. Often the discussion with a plastic surgeon is optimizing these factors for the individual patient. Busy individuals with active careers may opt for a less invasive but less dramatic procedure to reduce post-surgical down time.
collinwood: I am a 51 year old female and would like to know an approximate cost for Otoplasty (ear) and also nose size reduction (rhinoplasty.) Thank you, Ilona.
Speaker_-_Dr__Daniel_Alam: Otoplasty in general varies depending on whether it is a congental problem, or if it is just large size ears. If you are just referring to large size ears, the cost is around a couple thousand. The rhinoplasty is based on the amount of work that needs to be down - from $1000-$5000. If a nose only has a bump that needs to be trimmed down it would be less cost than a large amount of cartilage.
DLH: I received lacerations to my forehead, right eye and top lip at the age of 9 due to a car accident. I had plastic surgery at age 21 to remove the excess skin on my forehead. I am 54 years old and would like to have cosmetic surgery to at least the lip area which is affecting my speech. Do you feel that this would be a practical thing to do at my age?
Speaker_-_Dr__Daniel_Alam: Post-traumatic deformities particularly those affecting function can be fixed at any age and are often covered by medical insurance. If you are otherwise healthy and can undergo a surgical procedure then the important thing is the balance how the scar deformity affects your quality of life versus the recovery and temporary discomfort associated with the surgery. With our average life expectancy in this country extending well into the 80's, 54 years is still pretty young!
Neck Lifts and Jowls
WG: How long does a neck lift last? What are the risks? I have jowls can they be fixed along with a neck lift?
Speaker_-_Dr__Daniel_Alam: The amount of time a procedure lasts is probably not the appropriate way to think about it. These procedures turn back the clock but the individual still continues to age. As we get older, this process becomes more rapid.
For example, if a neck lift can return your neck contour to the way it appeared 10 years ago, in 5-7 years it will likely return to what it looks like now.
This varies with factors like general health, stress, smoking & nutrition.
Jowls can be addressed with a neck lift. Aging in the mid-face (like deep furrows between the nose and lips) usually needs a specific mid-face lift or a face-lift.
GC: Is the string draw neck lift used to tighten skin beneficial or and safe for African Americans? Is it possible to have your hairline above the forehead adjusted to bring the hairline forward, reducing the size of the forehead? Thank you.
Speaker_-_Dr__Daniel_Alam: There are a number of different minimally invasive techniques for addressing the neck and it’s aging. String or suture based techniques work well for patients who have sagging but minimal excess skin. Patients with excess skin will require the skin to be removed.. This is usually done behind the ear in a traditional neck lift approach.
While thread lifts are ideal for certain patients, they are very ineffective for others.
Certain African Americans have a tendency to form prominent scars or keloids. This is the only risk for these procedures that varies between ethnicities. If the individual has had surgery previously without a tendency for forming these scars, it is unlikely it will be an issue with plastic surgery.
StEl: I've heard 20 minute surgeries for jowls? Is that correct? What does it involve?
Speaker_-_Dr__Daniel_Alam: This type of surgery does exist, but is primarily utilized in patients who exclusively have sagging muscle and no extra skin. If this is done in patients with extra skin it can give a tethered abnormal appearance to the neck.
Bel: I am a woman of 65 years and would like to get rid of my wrinkles, but am afraid of undergoing surgery with anesthesia due to a coated brain aneurysm (08/1985) and stroke # 1 (10/2007). Could I have Botox, Restylane, Perlane, etc.? I had eyelid lift a few years ago.
Speaker_-_Dr__Daniel_Alam: This brings up questions regarding other medical problems and plastic surgery. The most common serious adverse events that occur during these procedures are unrelated to the surgery themselves and relate to anesthetic or medical complications in the patient.
For individuals with medical issues like heart disease, COPD, diabetes, plastic surgery can often be performed safely but it is imperative that these patients have these procedures done in the appropriate setting with the appropriate medical and anesthesia teams involved.
Many surgeons in private practice operate in small surgical centers without anesthesiologists present. This can be somewhat risky in a frail medical population.
In terms of your specific questions, Botox, Restylane or Perlane fillers would be safe. A surgical procedure would require a clearance form your primary medical doctor and other physicians who care for you.
T_H_: Does the problem with facial hair fall under this category you will be talking about? Do you work with facial blotches, like dark circles under the eye with some sagging, and dark blotches on dark skin completion? I have tried some topical creams, including going to CCF Dermatology only to be told my skin will peel, and using steroid only not work. Your comment would be most appreciated.
Speaker_-_Dr__Daniel_Alam: Treatment for facial hair or irregular skin complexion usually involves some form of skin resurfacing or laser treatment. These may be problematic in patients with darker complexions because of the risk of pigment irregularities after the treatment.
The other alternative is certain creams which it seems you have previously tried.
A complete answer to this question would require an individual evaluation of your skin type and the severity of the problems you describe.
Dark circles under the eye are often related to shadowing of light and certain surgical procedures which improve the contour of the eye lid and the bagginess can help with this even in patients whose skin complexion precludes resurfacing procedures.
Monica: I have facial scaring from acne blemishes. Is this something that facial plastic surgeon may remove?
Speaker_-_Dr__Daniel_Alam: Facial scarring that is broad across the face is generally best addressed by resurfacing techniques such as chemical peels or laser resurfacing. These procedures do not eliminate the scarring but instead make the skin texture smoother. These are procedures that a plastic surgeon can do. The procedures may be done in either the office or an operating room depending on the depth of the treatment.
Taylor: I have heard of Moh's surgery for skin cancer treatment. Do they (you) use this type of surgery for facial reconstruction? Can you explain what this is, and how it might differ from other types of plastic surgery? Thanks.
Speaker_-_Dr__Daniel_Alam: Moh's surgery is a technique for removing skin cancers with the smallest possible area of tissue excised. This results in a surgical wound that requires closure as would any other skin cancer removal.
The primary advantage of the Moh's procedure is keeping the area of tissue that is removed small. It is particularly useful for cancers on the face where smaller scars are much better camouflaged.
Typically a dermatologist performs the Moh's surgery to remove the tumor and then a plastic surgeon closes the site.
Eileen: Have there been any studies that indicate that plastic surgery has emotional or psychological benefits? I mean this not in terms of reconstruction done in the event of an accident or fire or something, but in general. Does this type of surgery lift your spirits as well as your skin?
Speaker_-_Dr__Daniel_Alam: This is a good question. Plastic surgery does not solve emotional or psychological difficulties that an individual may be facing. That is not to say that it cannot have a positive impact in the psychological health of an individual. Often a physical deformity or the process of aging itself can make people less social and reduce their self esteem. In this patient population, surgery can offer them a jump start to help get back into their life.
This is a different scenario then a patient who is depressed or concerned for other reasons who may think that surgery will help resolve these other issues in their life. Often these patients temporarily "feel better" after their surgery, but this is short-lived and many actually become more depressed when they realize that their problems extend beyond the simple solution.
A thorough discussion about motivations for why one would like to have plastic surgery is important to have with one's plastic surgeon. Often this discussion will help determine if surgery is the right thing to do.
Rachel: Is there some way to treat the broken blood vessels that sometimes occur in the nose area?
Speaker_-_Dr__Daniel_Alam: These can be treated with a special laser that causes these vessels to disappear. This procedure can be performed in the office with minimal recovery.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Alam is now over. Thank you again Dr. Alam, for taking the time to answer our questions today.
Speaker_-_Dr__Daniel_Alam: I would like to add one more thing to remember. Successful facial plastic surgery is a result of good rapport between patient and surgeon. Confidence, based on realistic expectations and exacting medical expertise, develops in the consulting stages before surgery is performed. Your surgeon can answer specific questions about your specific needs. As with all facial plastic surgery, good health and realistic expectations are prerequisites.
This has been a great forum today. Thank you for asking me to chat.
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