Introduction
Cleveland_Clinic_Host: Today, join us as Dr. P. Daniel Knott discusses the latest techniques for many facial cosmetic surgery procedures. To make an appointment with Dr. P. Daniel Knott, or any of the other specialists in the Head and Neck Institute at Cleveland Clinic, please call 216.444.6691 or visit us online at clevelandclinic.org/renewyou.
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. Dr. Knott will be available to answer your questions at 12 noon (EST) today.
Cleveland_Clinic_Host: Dr. P. Daniel Knott, is a staff physician in the division of facial plastic and reconstructive surgery in the Head and Neck Institute Department Plastic Surgery at Cleveland Clinic. Dr. Knott is board-certified by the American Board of Otolaryngology/Head and Neck Surgery. He received his medical degree from the University of California, San Diego School of Medicine, La Jolla. He completed his internship in general surgery and residency in otolaryngology/head and neck surgery at Cleveland Clinic, as well as a fellowship in facial plastic and reconstructive surgery at UCLA Medical Center, Los Angeles, CA. Dr. Knott’s awards and honors include first runner up for the 2007 Jack Anderson Award for the highest board score on the American Board of Facial Plastic and Reconstructive Surgery annual board examination; winner of the 2007 Robert Maxwell Byers Award for the best clinical research project from the American Head and Neck Surgery Society; and winner of the 2008 Ben Shuster Memorial Prize for most outstanding research project in the field of facial plastic surgery.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. P. Daniel Knott. We are thrilled to have him here today for this chat. Let’s begin with some of the numerous questions we have received.
Considering Facial Cosmetic Surgery
scarlett: At what age do you start doing cosmetic facial enhancements?
Speaker_-_Dr__P__Daniel_Knott: This is a very difficult question. I perform nose jobs as early as the age of 17. Scar revisions and laser surgery can be performed at any age. I don’t recommend a face lift until the late 40’s or early 50’s. Other lasers, injections, botox, implants are usually for people in their 30’s and 40’s. I think that rejuvenative eye surgery is excellent for appropriate patients in their 40’s.
scarlett: At what age can you do it without a parental consent? Is it 18?
Speaker_-_Dr__P__Daniel_Knott: Correct. A patient can give permission when he/she becomes a legal adult, which occurs at the age of 18. That being said, I prefer to avoid situations when surgery is going to lead to conflicts in a family.
How to Choose a Surgeon
vonnie: How do I know which doctor I should go to? Should I talk to more than one and then make a decision?
Speaker_-_Dr__P__Daniel_Knott: You should make certain that your surgeon is well trained and has completed a fellowship at a reputable institution. That information should be readily available and the surgeon should be happy to provide you with that information. Board certification is critical. Also, you should check that your surgeon is well published and stays on top of the latest developments in the field. I usually recommend more than one opinion. It is important that you like and trust your surgeon. I believe that a good relationship between doctor and patient is key to an outstanding result.
Blepharoplasty: Eyelid Procedures
Jordan: My left eye appears to be much smaller. It looks like it is a lazy eye. Would you go with an eyelid procedure or a brow lift?
Speaker_-_Dr__P__Daniel_Knott: It is simple to treat asymmetric eyelids, but a true lazy eye requires surgery on the eyeball which is more complicated. You would probably need to see an ophthalmologist before thinking about surgery. Brow lifting can be performed if the brows need to be rejuvenated.
Rhinoplasty: Nose Reshaping
worriedme: I had rhinoplasty about 6 months ago. It was itching recently, and I began kind of picking at it and rubbing it. How bad is this and how will it affect the healing process?
Speaker_-_Dr__P__Daniel_Knott: It shouldn’t affect anything if it healed well for the first 6 months. The nose after a rhinoplasty stays minimally swollen for up to 1 year, but all of the structural elements are well healed by 6 months, so you should not be overly concerned.
kandi: How painful is it to have rhinoplasty? How long is the healing process?
Speaker_-_Dr__P__Daniel_Knott: This is a difficult question to answer. It all depends on the parts of the nose that need to be addressed. At worst, if you require an open approach and bone cuts to make the nose somewhat smaller and more fine in appearance, patients usually use narcotic pain medication for 4-6 days. They can have black and blue eyes for 10 days, and they usually wear a splint for 1 week. The nose looks mildly swollen for 2 weeks, and after that, only good friends or family members can tell that the nose is swollen. After 1 month, only the patient can tell the nose is mildly swollen, and it heals completely after another several months.
Berger: My 16 year old son seems to have little cartilage in his nose. He has a wide nose and when he rubs it, it seems to go all over the place. Is there something that can be done for this in the future? Definitely not at 16.
Speaker_-_Dr__P__Daniel_Knott: There is usually abundant cartilage in the septum (the wall between the nostrils) or in the ears. I use these sources of cartilage when I have to reinforce a nose with additional cartilage. A rhinoplasty may be safely performed in a patient after the age of 16-17. You usually want to wait until the face has achieved full growth before performing a rhinoplasty, and this of course varies with each patient.
godard17_2: After an endoscopic resection of a malignant neoplasm (esthesioneuroblastoma/ethmoid sinus) in 2004, I have been cancer free for 5 years. My question is: would a rhinoplasty bring a higher chance of recidivism?
Speaker_-_Dr__P__Daniel_Knott: A rhinoplasty would in no way increase the possibility of a recurrence of sinus cancer.
richarl1: From start to finish, what is the average recovery time for a rhinoplasty? And does it differ among men and women?
Speaker_-_Dr__P__Daniel_Knott: The recovery time completely depends on the approach used for the rhinoplasty. An approach using an incision only inside the nose has much faster healing and much less swelling. People's noses will usually look normal in 2-3 weeks. Rhinoplasty using external incisions will be swollen longer and should look normal after 4-5 weeks. Men usually experience a little bit more bleeding during the surgery, but recovery should be the same.
Necklift
calicos: Are these facial lifts in-and-out procedures or is there a hospital stay involved?
Speaker_-_Dr__P__Daniel_Knott: I recommend that a nurse stay with you for the first night. That can be arranged with an overnight hospital stay, or at a hotel or at your home for the first night. I see all of my face lift patients the day after surgery.
Rhytidectomy: Facelift
Proctor: How does a face or neck lift done when a person is 50 change as they age? Are further surgeries necessary?
Speaker_-_Dr__P__Daniel_Knott: If performed correctly, a facelift should make a person look 10-15 years younger. The face will then age normally after the surgery, but the patient will continue to look younger. Ideally, no other surgeries should be necessary, but a tuck-up in the neck may be required after 6-8 years.
liz: How much does it cost?
Speaker_-_Dr__P__Daniel_Knott: The cost depends upon the procedure. Eyelid surgery costs between $3,000-$6,000. A Facelift procedure usually requires around $8,000-$10,000. Rhinoplasty is approximately $5,000. There is a discount for every additional procedure you have done, as long as it is done at the same time.
Harper: Jowl (excess fat) removal – outpatient? Recovery time?
Speaker_-_Dr__P__Daniel_Knott: Usually the jowls are best treated with a face lift. Occasionally I can access them through a limited neck lifting incision. There is an important nerve that passes close by, so the surgeon needs to be careful in this region. Simple liposuction may work on men and women under the age of 40, but attempted on people older than this can lead to a “deflated” look which I avoid.
gary: You see many stories of bad facial surgeries on TV and in magazines. What causes this, having a bad surgery or having too many surgeries?
Speaker_-_Dr__P__Daniel_Knott: One should certainly keep the surgeries to a minimum, but appropriate surgeries done well should make one look younger and more vital. My personal approach is to help patients look 10-15 years younger and to rediscover their former “look”. I don’t want to change someone’s appearance.
brownie: I’ve read something recently about the liquid facelift. Can you describe the procedure and do you recommend it, and for what areas of the fact?
Speaker_-_Dr__P__Daniel_Knott: The two issues that affect faces over time are descent of the soft tissues and soft tissue atrophy (“droopiness and loss of volume”). A face lift treats the tissues that have fallen over time, but does relatively little to treat atrophy. A liquid face lift uses a variety of soft tissue fillers to restore lost volume. When used in the appropriate patients, these injections can provide remarkable results. I use fillers exclusively for the lips. They can also provide remarkable results around the eyes.
lanna40: I am now 40. If I have face work done now, how long does it last? What will it look like in 10, 20 or even 30 years? Will I need to the face work redone?
Speaker_-_Dr__P__Daniel_Knott: I don’t recommend a face lift for anyone younger than 40. Usually people can get by with some of the minimally invasive procedures until the peri/post-menopausal period in women and the early 50’s in men. Then a well performed face lift in the appropriate patient can provide a very nice and lasting effect for 10-15 years. The neck is often the area that sags first, and may require a “tuck-up” after 4-6 years. If the face looks good after 6 months, it will not look “strange” after 10-20 years. The most important thing is to restore and maintain harmony in the face.
calicos: Are these facial lifts in-and-out procedures or is there a hospital stay involved?
Speaker_-_Dr__P__Daniel_Knott: I recommend that a nurse stay with you for the first night. That can be arranged with an overnight hospital stay, or at a hotel or at your home for the first night. I see all of my face lift patients the day after surgery.
capn: What is the general recovery period for facial surgery?
Speaker_-_Dr__P__Daniel_Knott: Usually a patient can look great after 2 weeks. If a peel is done at the same time, an additional 2 weeks is often required. I usually ask my patients to wear an elastic dressing for 1 week, to prevent any fluid accumulations.
chowdeon: What is the infection rate after this type of work?
Speaker_-_Dr__P__Daniel_Knott: The infection rate is usually less than 1%. I give all of my patients antibiotics before and after the procedure to limit that as much as possible. I have never had an infection after a face lift, and while I have had an infection after a facial implant, I have never had to remove an implant.
lowie: What exactly is a ‘mini’ facelift, as opposed to what, a full facelift?
Speaker_-_Dr__P__Daniel_Knott: A mini lift usually uses smaller incisions, involves minimal tissue dissection, requires shorter downtime, necessitates less anesthesia, but unfortunately as well it usually provides less rejuvenation and a shorter duration of result.
newtonm: Are all facial implants permanent?
Speaker_-_Dr__P__Daniel_Knott: No. In fact, recent developments have led to reabsorbable implants. I use special implants for cheek lifts that were developed in Los Angeles. These rejuvenate the cheeks beautifully, disappear after 9 months, yet provide long lasting results. No other technique that I know of can equal these special implants.
kamden: How much scarring is there after a facelift?
Speaker_-_Dr__P__Daniel_Knott: The scarring is usually minimal, if the incisions are planned well and the surgery is performed well. I have had to redo many facelifts to “clean up” work that was not performed well. As long as not too much tension is placed on the skin closure, the scars should be virtually invisible. The scarring under the skin is actually good, in that it helps the face stay “lifted”.
summer: Are orbital rim implants and cheek implants ever done in conjunction with each other? Not necessarily at the same time?
Speaker_-_Dr__P__Daniel_Knott: They certainly can be done at the same time. It depends on the area that needs to be augmented and amount of soft tissue on one’s face. I tend to prefer to use absorbable implants that lift the face, in conjunction with injections to restore lost volume.
Otoplasty: Ear Reshaping
richarl1: At what age can a child have an otoplasty to pin back large ears? Is there an age that is considered too young?
Speaker_-_Dr__P__Daniel_Knott: The ear has achieved 85% of adult size by the age of 5-6. So that is the age I begin to perform otoplasties. For some, children with large ears grow into them with time. Therefore, I feel that age 6 is appropriate for this surgery.
Laser Skin Resurfacing Treatments
ryancharles: What can be done for deep and old acnes scars? I’m tired of having a pitted face!
Speaker_-_Dr__P__Daniel_Knott: That is one of the most difficult problems in facial plastic surgery. I usually recommend laser resurfacing and dermabrasion as primary treatments. If this fails, I can perform a needle treatment called surgiwire for the deepest scars. I have had moderate success with this.
syd411: Does a chemical peel last as long or do as well as a laser for deep wrinkles? Are there any other procedures that work better?
Speaker_-_Dr__P__Daniel_Knott: A chemical peel and a laser should last the same amount of time, depending on the depth of the laser or the chemical peel. The laser treatments usually provide the aesthetic surgeon with greater control and a finer ability to feather and contour the final appearance.
Botox®
Bryn_t: Can Botox injections prevent wrinkles in young population?
Speaker_-_Dr__P__Daniel_Knott: Yes. If used early enough, they can completely prevent the formation of wrinkles. This is commonly done in Los Angeles.
Injectable Fillers
rose: What is Restylane®?
Speaker_-_Dr__P__Daniel_Knott: Restylane is hyaluronic acid. This is protein-free, soft tissue filler, which is temporary, lasting approximately 4 months. This is material we all already have in our skin. It is usually injected superficially.
denise: I periodically get Botox® and Juvéderm® injections from my dermatologist. If I make an appointment with a plastic surgeon to discuss surgery options, is it better for the surgeon to assess my face without the presence of fillers and injectables? During a consultation, can (or will) a plastic surgeon advise me of what surgical options he (or she) would be most appropriate, or beneficial for my face? I would also be interested in which procedures require the least amount of "down time" i.e. recovery time.
Speaker_-_Dr__P__Daniel_Knott: As long as you tell the plastic surgeon when and which fillers have been used, it shouldn't matter if you have them in your face at the time of the consultation. A reputable plastic surgeon should always inform you what the most appropriate procedure for you is, if any, and should accurately inform you what to expect. I always tell my patients what the down time will be so they can schedule their lives accordingly.
Closing
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. P. Daniel Knott is now over. Thank you again for taking the time to answer our questions about the numerous options for facial cosmetic procedures.
Speaker_-_Dr__P__Daniel_Knott: I really enjoyed this opportunity to speak with you today. I should be very happy to answer any more of your questions, either by phone or consultation. I look forward to helping you in any way I can.
More Information
- For more information about facial plastic surgery and our surgeons at Cleveland Clinic Head & Neck Instituteand to download our free guide, you may visit clevelandclinic.org/renewyou
- To make an appointment with Dr. Knott, or any of the other specialists in our Head & Neck Institute Dept. of Plastic Surgery, please call 216.444.6691 or visit the web site at clevelandclinic.org/headandneck
- A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult
- If you need more information, click here to contact us, chat online or call the Center for consumer Health Information at 216.44.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!
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This chatt occurred June 5, 2009
