Dr. Terence Davidson is currently a professor of surgery, the associate dean for Continuing Education in the School of Medicine and chief of the Section of Head and Neck Surgery at the VA Medical Center in San Diego. Dr. Davidson received his undergraduate training at the University of California, Riverside. He went to medical school at the University of California, Los Angeles, where he also did his first year of general surgery. He did four years of head and neck surgery at the University of California, San Diego and following this he did a one year fellowship through the American Academy of Facial Plastic and Reconstructive Surgery with Dr. Richard Webster in Boston, Massachusetts. In 1976, he joined the faculty at the University of California, San Diego.

Dr. Davidson is a member of the American Academy of Facial Plastic and Reconstructive Surgery, the American Academy of Otolaryngology-Head and Neck Surgery and is a Fellow of the American College of Surgeons. Dr. Davidson has written 2 books, three monographs and 15 book chapters, 125 scientific articles and has produced almost 125 hours of videotapes in facial plastic and reconstructive surgery.

Dr. Davidson's primary interests lie in facial plastic and reconstructive surgery. He is actively involved in clinical research to improve the surgical techniques for local control of head and neck cancer. Dr. Davidson is recognized for his knowledge and contributions in the treatment of skin cancer and is one of the few head and neck surgeons skilled in the techniques of MOHS chemosurgery.

Dr. Davidson is an active member of the American Academy of Facial Plastic and Reconstructive Surgery and has played a major role in producing a series of videotapes called "The San Diego Classics in Soft Tissue and Reconstructive Surgery." These videotapes are distributed by the American Academy of Facial Plastic and Reconstructive Surgery throughout the world. They are a major contribution in all residency programs in soft tissue and facial plastic surgery. Dr. Davidson's interest in television and education has resulted in his appointment as associate dean for Continuing Education. His most recent contribution is constructing the Website for the American Academy of Facial Plastic and Reconstructive Surgery.

Dr. Davidson's interests outside of medicine lie primarily in outdoor activities and when not on-call, he is most likely to be found hiking through the mountains, four-wheeling through the desert, or gardening.

In today's society, a premium is placed on personal appearance. The desire of men and women to improve their appearance is not solely self indulgence, but may be a factor in business and social relationships. Facial plastic surgery is a potential means to these ends as a realistic aspiration, and not merely a manifestation of personal vanity. Our goal is to provide modern, expertly performed, facial plastic surgery at a reasonable cost.

Medical photographs are taken before and after most facial surgery. These are used to illustrate and document changes from surgery and, with the permission of the patient, are used to demonstrate techniques and results to scientific and other audiences.

Results of surgeries are generally predictable, but do vary from individual to individual. Factors which influence the outcome of surgery include individual healing, personal health, psychological well being, and care of the incision sites. Aging is not stopped following surgery, nor are all one's ills corrected by surgery. Surgery can improve your appearance, it can change the way you feel about yourself and when properly planned and properly performed, should have a successful outcome.

The university is an exciting place wherein the most expert physicians in the country get together to learn, to do research, and to treat patients. The majority of major medical advances have been born and developed in university centers. This is the place where all physicians receive their initial medical training, and much of their postgraduate training as well. Traditionally, the university serves primarily as a tertiary referral center for patients with complex, difficult-to-diagnose or difficult-to-manage diseases. Many patients have recognized the tremendous expertise available at the university for all of their medical care. Most of us in medicine enjoy taking care of people, and we're just as happy to take care of healthy people with normal medical problems as we are to take care of the very sick with much more severe problems.

Many people are concerned that because UCSD is a teaching hospital, and because it is interested in research that they will be used as "guinea pigs." This is not true. If your doctor is interested in performing any kind of research that involves you, it is required by law that you be informed of this, and that you sign a special consent form clearly describing what will happen to you and what risks you might be taking. It is true that all of us at the university continue to ask questions, and for this reason, you will have younger physicians and older, more experienced physicians talking with you and reviewing your medical problems. It is the culmination of all these opinions that results in the care that you receive.

The evaluation is the most important consideration in facial plastic surgery. Every face is different and every patient has different needs. The proper evaluation allows your doctor to learn something about you, the opportunity to learn what you would like changed and how you would like to appear at the end of surgery. Rarely do we ever do the same operation twice. People are so different and their needs are so different that every surgery must be "tailor-fit" for each patient and his or her needs. The same will be true for you. You may think that you're looking a little older, and that what you need is a facelift. But, in fact, it may be that your appearance will not benefit from a facelift; it may be that some of your problems, such as baggy eyes, forehead wrinkles or fat under the chin, would not be corrected by a facelift. The preoperative evaluation is the time for you to communicate with your physician, to tell him what you want, and find out what can be done to help you. It is also your opportunity to meet your doctor and develop a sense that this is someone that you can trust. The preoperative evaluation is a time for you to ask questions and learn about all the important aspects of your surgery. At the end of this evaluation, you are for the first time in a position to answer the following questions:

1. Do I want to have this surgery?
2. Do I like this physician, and do I want this physician to do that surgery?
3. Do I understand and accept the risks and the benefits that this procedure offers?

You may choose to have your surgery awake, sleepy or completely anesthetized. If you have a small problem such as a skin tumor or a small scar that needs to be excised, the cheapest, easiest and safest way to do this is with little or no preoperative medication. If the surgery is more extensive or if you are particularly frightened or nervous about the surgery, you can be medicated with tranquilizers like Valium, and narcotics like Demerol. Any time you take any medication, you incur some risk, for all of these drugs affect your brain and your heart. You also incur some cost, both for the drugs and the extra time involved in giving them to you. We have had a great deal of experience with this kind of premedication, and have found it to be safe.

General anesthesia is used for most cases and for those situations in which a patient wishes to be completely asleep and know nothing about what is happening during surgery. General anesthesia incurs additional risk and additional expense.

Minor procedures are performed in the operating area in the Head and Neck Surgery Clinic. All other procedures are performed in an operating room. If your surgery is to be performed as an outpatient (in other words, if you come in in the morning and go home in the afternoon) then the surgery is normally performed in our Outpatient Surgery Center, under local or general anesthesia. Operating rooms require a tremendous investment in people and equipment and so your surgery costs more when it is performed in the operating room.

The body is in a constant state of change, from the time it is born until the time of death. When one performs an operation on the human body, one alters the normal course of growth and development and it takes the body a long time to successfully incorporate this into its normal development. Every time you make an incision, you leave a small scar. Every time you alter tissue in any way by performing a rhinoplasty, a blepharoplasty, or a facelift, you leave behind some scar tissue. That scar tissue initially goes through an inflammatory phase and finally through a maturation phase. The inflammatory phase lasts for several weeks and it is during this period that most changes are seen. The maturation phase goes on for months, and in many patients for years. During this time, the effects of surgery are less noticeable and the changes are more subtle, but in fact they continue to occur. Many postoperative results continue to change for several months after surgery. Most of the time this long-term healing results in an ever-improving final result.

Every person is uniquely different in the ability to heal; each operation is different in the amount of injury it causes, and in the time required to completely heal. As a general rule, if there is bruising with some color change, such as would be found in a black eye after eyelid or nasal surgery, the blood which causes the color change is reabsorbed over a period of seven to fourteen days. Incisions which initially are red, lose much of that redness in the first six weeks, and from that point on slowly change from a red color to a white color. This change continues for six months to two years, and occasionally even longer. During this time, if the scar has been slightly elevated, it will tend to flatten and occasionally even retract, causing a small indentation. If bones are broken or cut, they normally require six weeks to mend.

The cost for all of these procedures varies depending upon the patient's needs, and the procedures to be done. You should feel free to discuss these costs openly, for you need to understand them before you decide whether or not you can afford this surgery. Generally, we break costs down into five categories. These are preoperative evaluation, surgeon's fee, operating room fee, anesthesia fee, and hospital fees. For most procedures, it is required that a laboratory evaluation be performed. For young, healthy people this may include an examination of the blood. For people with heart or lung disease, or for people over the age of forty, it is often advisable to obtain a chest x-ray and an electrocardiogram (EKG). The surgeon's fee is based upon the complexity of the procedure, the time involved in the procedure and the amount of postoperative care that my be required. The operating room fee is based upon the time spent in the operating room and materials used during your surgery. If you use an anesthesiologist either for general anesthesia or just to monitor your heart, your lungs and the depth of sedation during a local anesthetic, a separate fee is charged by the anesthesiologist both for his/her time and for the medicines used. If time is spent in the hospital recovering, then a separate fee is charged by the hospital for the time spent and for the materials used. All of your postoperative care is included in the initial surgeon's fee; hence you should not receive additional medical bills from the surgeon. If you have complications and require additional operations, hospitalizations or services, you will be required to pay for these.

The complication rate for most elective procedures in facial plastic and reconstructive surgery is low. Major complications from this kind of surgery include severe problems with your heart or lungs, certain kinds of nerve damage, and major bleeding or infection. While all of the above are possible, the chance of these problems occurring is small. There are a variety of much smaller problems which do occur to some extent in many cases. It is common to have a little bit of bleeding from some wounds. There often is a little bit of infection at some of the incision sites; there always is some scar that is left behind. Anytime the skin is cut, nerves are cut as well, and there can be areas of numbness or tingling around the incision sites.

The most common problem in all elective facial surgery is that the patient's expectations are greater than the surgeon's realistic abilities. If it was your expectation that the surgery would turn out perfect and that you would be dramatically improved, you will be dissatisfied. If your expectations for physical improvement are realistic, then there is a very high chance that you will be satisfied.

Several case examples may make this last point clearer. The first is the story of a junior high school student who came in with her mother and asked to have her nose made smaller. After an appropriate consultation and discussion of all the pros and cons, risks and benefits, the surgery was performed. The girl was average in appearance, albeit with a slightly large nose. Postoperatively, her appearance remained average, albeit with a smaller nose than before, and one which perhaps was in better balance with the rest of her face. Nonetheless, the overall general appearance was not remarkably changed. I did not see this young lady for several months postoperatively, and when she finally came in, I asked how she was doing and how she liked her new nose. She had very little to say but her mother commented that prior to the surgery this girl had not had a single date. She had now been elected queen of the Junior Prom and was booked for dates two months in advance. In retrospect, what happened was that following surgery this patient felt substantially better about her own self image; she carried herself in a different manner, and this different mental attitude was perceived by her friends. She literally blossomed into an outgoing, social, popular human being. The surgery was not responsible for this change. The surgery only helped this girl's self esteem. It was her own personality that blossomed and resulted in these changes.

Contrast this with the case of a young man who appeared with a very large, unsightly nose, and requested improvement. Surgery in this case made a dramatic improvement in this young man's appearance, but when he came in several weeks postoperatively and was asked how he liked his nose, he complained bitterly about the changes and said that this made absolutely no difference in his appearance or his well being. He was disappointed that he had ever had the surgery and was disappointed in the surgeon for failing to achieve a reasonable result. After a long discussion, this patient agreed to see a psychiatrist. In fact, what had happened was that this young man was having fairly severe marital difficulties, and he had felt that an improvement in his appearance would result in an improvement in his marriage. When the marriage failed to improve, rather than blaming himself, he chose to blame the surgeon. This is a good example of an unrealistic expectation from facial plastic surgery.

Rhinoplasty is the operation that changes the appearance of the nose. Septoplasty is an operation which rearranges the inside of the nose to improve a patient's breathing. When these two procedures are performed together, the operation is called a septorhinoplasty. Insurance may pay for part or all of a septorhinoplasty if you have some element of nasal airway obstruction due to an anatomical blockage inside your nose or if your nose is obviously crooked or deformed following a traumatic accident. The goals of a septorhinoplasty are 1) to improve the breathing and 2) to improve the appearance. The surgery can be performed under local anesthesia or under general anesthesia. The majority of people in my experience prefer, if they can afford it or if the insurance company is paying for it, to have a general anesthetic. The operation consists of a very complex series of steps designed to straighten the septum, which is a piece of cartilage on the inside of the nose, refine the soft, cartilaginous tip of the nose, and normally to reduce the bony prominence on the upper third of the nose. Occasionally, particularly when a revision rhinoplasty is being performed, the goals will be to build up the tip of the nose and to build up the bony dorsum of the nose as well. Most nasal surgery is performed through small incisions placed inside the nose. At the end of surgery, all of the tissues of the nose must be splinted in place. A cast on the outside of the nose holds the tissues in place. By adjusting the cast, one can mold this dressing to hold the nose in the desired shape.

The chin is just as important in the profile as is the nose. Often in association with rhinoplasty and sometimes just by itself, the profile of the chin can be changed. If the chin protrudes, it can be reduced by drilling away some of the bone under the chin pad or if the teeth do not fit properly, by moving the entire jawbone backwards, thereby improving the occlusion of the teeth and the appearance of the chin. If the chin does not protrude sufficiently to create an aesthetic profile, it can be built up with a small, hard silicone rubber implant. The implant can be placed through a small incision underneath the chin or through an incision inside the mouth. Both techniques have advantages and disadvantages. It is our experience that implants placed from below the chin have a lower infection rate and cause much less discomfort than those placed through the mouth. The major risks with a chin implant are infection, extrusion of the implant, or some displacement of the implant. In fact, in as many as 5% of cases, the implant slips and needs to be removed or adjusted. Interestingly, when the implant is removed, it often leaves some scar tissue and a very improved profile. Another occasional complication with the insertion of chin implants is injury to the nerve that supplies sensation, that is feeling, to the lower lip. This nerve comes out of the bone close to the area where the chin implant must sit. It is sometimes injured, and while there is always some spontaneous recovery, that recovery is never complete.

The chin implant does not take long to insert. When performed alone, it can be done in the office, and when done with a rhinoplasty it is performed at the same time. There will be three small bandage strips over your chin; these come off four days after surgery, the same time that the rhinoplasty dressing comes off. No further dressing is necessary. The small scar under your chin generally heals well, and because of its placement under the chin, is not easily seen.

Otoplasty is the operation that changes the external appearance of the ears. This is most commonly done for what is known as protruding ears. When the ears seem large and stick out from the side of the head, they can be pushed back to lie closer to the head, and therefore not protrude. Most commonly, this surgery is performed in children. Most parents notice that their children's ears protrude very early, and will often seek consultation at the age of one and a half or two years. As a rule, the older the child is and the bigger the child is, the safer the surgery and the easier it is to perform. Around the age of four or five, just before the child enters school, is a safe time. It is a time when the child also desires to have the surgery, and it is a time that the child and the ears are big enough that the surgery is easily performed, and will produce a permanenet result. For children in their preschool years, it is necessary to do this under general anesthesia, and very often the insurance company will pay for this under the clause that this is a congenital deformity. If the child is between eight and twelve years old, the surgery can often be performed under local anesthesia and certainly for young adults, the surgery is most commonly performed under local anesthesia.

Following surgery, there will be a great big dressing around both ears. The dressing is removed at four or five days and can either be replaced with a second dressing or with a headband. You can purchase a headband from most sports stores. They are often used for skiing to keep the ears warm. It is simply an elastic band that fits around the head in such a way that it holds the ears flat against the head. Ideally, this will be worn for an additional week, after which no dressing is needed. For most ears, the only incision is behind the ear and this heals into the crease between the ear and the scalp and normally forms an inconspicuous scar.

The above photos show a boy before and after an otoplasty.

Wrinkling and drooping occurs in the forehead affecting both appearance and vision. The functional problems include: impaired vision and headache. Impaired vision occurs because the forehead droops pushing the eyebrow and then the upperlid downwards and obstructing vision and upward gaze. When this causes a significant visual impairment the condition is called pseudoptosis. Some people find the pseudoptosis annoying and develop a habit of constantly raising their eyebrows. This puts the forehead muscles in spasm and causes pain, a condition which is called asthenopia. Both are readily corrected with forehead surgery.

Aging also affects the forehead with sagging and wrinkling. This is in part a stretching of the skin and in part a result of underlying muscle activity. There are several surgical procedures to improve forehead appearance and function. The simplest is a browlift. Small incisions are placed immediately above the brow or in the first or second wrinkle above the brow. Excess skin is excised, the underlying tissues are tightened and the incisions closed. These surgeries are often performed in association with upper eyelid surgery.

Full forehead lifts are generally performed with incisions either in the hair line or at the back of the head. Endoscopes and endoscopic surgical techniques are now frequently used to limit the incision length and the scar. Excellent results are now possible. The approach is individualized for each patient.

As the eyelids age, the eyebrows sink down, the skin of the upper lids become saggy and overhanging and the skin of the lower lids sags and often bulges. The bulging is caused by fat herniating out from underneath your eyes. All of these problems can be corrected. The eyebrows are lifted by making an incision either in the temple or some place in the middle of your forehead in a wrinkle where the scar will be less visible when it heals. The excess skin of the upper eyelids is easily removed and the scars lie in the natural creases of your upper eyelids. The lower eyelids are the most difficult to correct, for if one pulls the skin too tightly, one can create some deformity in the shape of the eye. Often it is not possible to correct all of the lower eyelid deformities entirely, and one must either accept an incomplete correction or some change in the eye shape. The surgery also exposes the fat that is pushing out, creating the bulging in the lower eyelid, and this fat is either removed or sewn back underneath the eye where it belongs. Eyelid surgery and brow surgery can be performed in the office. There is a very light dressing over the eyes, and if you will hold gentle pressure either with gauze sponges or with a little ice pack, you can very much decrease the postoperative swelling and discoloration.

The dressing is removed from the eyes three to five days following surgery, and the sutures are normally taken out at that time. All of the incisions should heal inconspicuously, although often the upper eyelid excision, if it extends past the outside of the eye, will take longer to heal. The lower eyelid incision where it, too, extends to the side beyond the eye, also takes longer to heal and very often you will be advised to keep some tape across this incision for three to six weeks after surgery. The discoloration should be gone in seven to ten days, and everything should be fairly well healed in three to four weeks. Beginning at about one week after surgery, you can put makeup on your eyes. Many people wear sunglasses while their eyes heal. This is fine and does not affect healing for the final result.

Facelift or cheek-neck lift is the operation that pulls up the skin around your mouth, the jowels around your chin and the excess skin of your neck. If there are platysmal bands cording your neck, these are treated at the same time. The incision for facelift begins in the hair of your temple and courses down in front of your ear, around behind your ear, and finally into the hair behind your ear. The skin in this ear is dissected away from the muscles, and other structures of your face. It is then pulled upwards, and sometimes a little bit backwards. The muscles of your face are then tightened with sutures, and the cords in your neck are treated at the same time. Any excess fat in your neck and beneath your jawbone and on your face is trimmed, and then the skin incisions are closed. This operation can be performed under general anesthesia or under local anesthesia.

The most common complication in facelift surgery is bleeding. The local anesthesia reduces the risk. After surgery, a large dressing will be placed around your face. Most patients who have friends or relatives to care for them choose to go home. The dressing is changed the following day, and a much lighter dressing is put on. That dressing comes off three to four days later. The sutures around the ear are all dissolvable and come out by themselves. There are staples used to close the incisions in the temple and behind the ear, and these come out ten days after surgery. Since the skin and muscles of your neck and face have been stretched into a new position, it is important not to stretch them in the first seven to ten days. You should be very careful not to turn your head and pull these muscles. Some patients are more comfortable wearing a cervical collar; others are more comfortable just remembering not to turn the head. You should not drive a car for a week after this surgery, and you should not do any vigorous exercise such as laundry, major housecleaning, dance or other exercises. Exercise can be started again two to three weeks after surgery, and should be started slowly. The swelling and the discoloration from this surgery disappears in seven to fourteen days. One can put on makeup after the second dressing is removed and one can wash one's hair after that dressing is removed as well. Ideally, one would get a hairstyle consultation and a makeup consultation about three weeks after surgery, and if you are not knowledgeable about current ideas in skin care, you should seek this information as well.

Facelift surgery does not stop the aging process, it merely backs it up a little bit. For these reasons, the face continues to age and the sagging can recur. In some people, his happens in a short period of time such as six months to a year and in others, there are no appreciative changes following surgery for the next five to ten years. If properly done, the facelift procedure can be repeated as frequently as an individual desires. Many older movie stars, who wish to maintain their youthful appearance, will have a repeat facelift as often as once a year. Most people who just wish to keep a little ahead of the aging process will have one or two facelifts performed in their life, generally separated by at least five to ten years.

Figure 12A	Figure 13A	Figure 14A
Figure 12B	Figure 13B	Figure 14B

Figures 12,13 and 14 show a man and a woman before and after a facelift.

If you have a double chin with excess skin, fat or muscle cording beneath your chin, then the facelift will not adequately correct this area. To take care of this problem properly, a separate incision is made underneath your chin. The fat in this region can be removed either surgically, or by a new technique called liposuction, and the muscles that cause the bands in this area can be cut or sutured together. This procedure is often performed in conjunction with a standard cheek-neck lift, but if one's deformities are restricted to this region, the submental can be performed alone.

Liposuction is a technique for removing fat. The surgery has been developed to a point where it is effective and safe. It is much simpler than other surgical means of fat removal. Liposuction is performed by making a short incision in the skin, and then inserting a small suction cannula through the incision. The cannula is connected to a suction machine and as the cannula is moved back and forth through the areas containing fat, the fat from these regions is removed. The technique is most effective in the head and neck for decreasing the mounding that occurs on the cheek around the nose and mouth. It is also effective in removing some of the fat in the jowling area that occurs under the chin. Liposuction will not correct saggy skin problems, and is most effective in those individuals with good skin tone.

Liposuction is a very exciting new concept in facial plastic surgery. If you feel that you have areas of fat collection, it is a technique in which you should be extremely interested.

None of the above-mentioned procedures improve the very fine wrinkling that can occur on your face, about your eyes and about your mouth. It is not possible to pull the skin tightly enough to pull these fine wrinkles smooth. The proper way of smoothing these fine wrinkles is with dermabrasion, chemical peel or LASER resurfacing. Some surgeons prefer dermabrasion, others prefer a chemical peel and others prefer the LASER. They both have the same risks and, in good hands, seem to have very similar outcomes. My own preference is to use a chemical peel, for I feel this gives the best result and lasts longer. Chemical peel is normally performed in the office, and it consists simply of painting onto your face a solution containing phenol. The phenol burns your skin very much the way the sun would burn your skin, but it burns it more deeply, and when the skin heals, it scars, contracts, and pulls the fine wrinkles smooth. A chemical peel can be very uncomfortable for the first two or three days after it is performed, and very often narcotics are necessary to treat this pain. The procedure is almost always performed under local anesthesia, generally in the clinic. After surgery, you will be given ointment and you can apply this to your face. Some people find this makes their face more comfortable; others prefer not to use it. The face initially will form some crusts and ooze a bit, but beginning around the fifth to seventh day, this superficial crusting should be gone, and the skin takes on a very bright red color. This red color dissipates over the next three to six weeks and beginning a week or two after surgery, can be covered very effectively with makeup. The effect of a chemical peel can be very dramatic, and it is particularly useful for the fine wrinkles that occur about the mouth. The one problem with a chemical peel is that it thins the skin and increases the skin's risk for sun damage. Therefore, chemical peel is generally performed on people older than forty years of age, and is only performed on people who are willing to significantly reduce their sun exposure, wear hats and always use sunscreens when out in the sun. The risks from chemical peeling include changes in the texture of the skin, occasionally scarring and in 5-10% of cases, there can be some change in the color of the skin. It can either become lighter in color, or occasionally even form areas that are pigmented. The risk for these changes is much higher in people whose skin is naturally pigmented and so dermabrasion and chemical peel should only be performed in fair skinned individuals.

New treatments. There are many new treatment modifications for fine wrinkles. Patients can perform their own chemical peelings by placing weak peeling solutions glycolic acid, retenoic acid, alphahydroxy acid and others onto their skin once or twice a day. Some of these peeling solutions require a prescription. Many are available as over the counter cosmetics or medications at cosmetic stores.

Used on a regular basis these are very effective for slow steady improvement of facial wrinkles. Deeper wrinkles and faster cures require stronger chemical peels, be they performed with trichloroacetic acid or in some advanced cases, phenol.

The latest development is the use of LASERs to resurface the skin. The LASER changes the skin similiarly to a chemical peel. Many taught this as superior to chemical peels and it may well be. It will take years to prove that LASER are more effective and that there are no long term risks such as the induction of cancer.

One of the other complaints in aging is the development of pigmented skin. There are a number of bleaching agents currently available which will lighten and even abolish these pigmented spots. The chemicals used are hydroquinones. They can be purchased in weaker concentrations as over the counter medications and in higher concentrations as prescription items.

Results in aging face surgery are variable. The two following case examples demonstrate some of the principles.

The first is a man whose problems focused about this eyes. They were certainly droopy and gave him an older appearance, but in fact had also become a hindrance to his vision. His eyebrows and eyelids drooped so much that when he looked up, it was difficult for him to see things much above his forehead. A blepharoplasty and browlift were performed. You see here pictures be fore surgery and a year after surgery (Figures 12A,B and 13A,B).

The next patient is a woman who desired a facelift. This was performed. In Figures 14A and 14B, you can see pictures before surgery and after surgery. This woman took particularly good care of her skin, and I am sure this contributed significantly to the dramatic improvement in her appearance.

Skin cancer is an epidemic disease in this country. The majority of skin cancer occurs about the face, neck and the back of the hands, and is caused primarily by the ultraviolet radiation in sunlight. Skin cancers can be recognized as any change in the skin and can appear as a flaky, scaling area, as an itch, as a non-healing sore or as a tumor growth. If you have any areas about which you are suspicious, you should show them to your physician. There are many ways of treating skin cancer, and they should be individualized for the person and for the tumor. Some very superficial tumors can be treated by applying a medicine called 5-fluorouracil to the skin, but most tumors need to be treated by some surgical technique. In the past, tumors were treated with radiation or with freezing, but these techniques have not been as successful, have not created cosmetically acceptable results and are infrequently used today. The best treatment for skin cancer, therefore, is a surgical removal with a reconstruction at the time of surgery. The overall cure rate for skin cancer is 90 to 95%. There is a small group of cancers that recur, and these tumors are locally much more aggressive. These tumors must be removed, and the margins examined by a technique called Mohs chemosurgery. The cure rate for this kind of aggressive skin cancer is only 50%, but using the technique of Mohs, the cure rate is improved to 90%. This may require multiple excisions, but when the tumor is finally totally removed, the area can be safely reconstructed.

The most important thing you should know about skin cancer is its prevention. Prevention consists of keeping the ultraviolet radiation away from the skin. This can be done by avoiding sun exposure, by wearing hats and sunglasses, and by wearing sunscreens. Sunscreens filter the ultraviolet rays that cause skin cancer and cause aging, but they do not adversely affect one's ability to suntan. Therefore, anytime you are in the sunglight you should wear a sunscreen.

Scars are ubiquitous in our society, and may be caused by accidents or by various operations. All scars should initially be allowed to heal for a period of six to twelve months, and then if their appearance is not acceptable, should be seen by a facial plastic surgeon skilled in scar revision. Almost any facial scar can be improved to some degree. No scar can be totally removed. There will never be a perfect result in scar revision, but almost always there will be some degree of improvement. Every scar is different, and the techniques necessary for improvement will vary from scar to scar, and from patient to patient. Some scars can merely be excised and resutured, but most scars will require an excision in some sort of irregular pattern. Excising the scar with an irregular pattern camouflages the scar.

Most scar revisions are performed under local anesthesia and most of these are done in the office. Normally, a light dressing is placed over the operated area, and this is removed three to four days after surgery. If sutures need to be removed, they too are removed around the third or fourth postoperative day. You will be encouraged to wear antitension taping across the incision, for this will greatly improve the final result. Somewhere between three and twelve months after surgery when things are healed, an additional procedure needs to be performed. This is called dermabrasion, and this sands the area of the scar smooth, so that it sits at the same level as does the surrounding normal tissue. This too causes some reddening; the reddening and the healing will now progress over the next six to twelve months, and somewhere between twelve and twenty-four months after the dermabrasion, the scar will finally be improved. One must be patient with scar revisions, for improvements do not occur rapidly, and with many scars, multiple procedures are necessary to obtain the best final result.

The major risk with scar revision is that the patient is not pleased with the final result, and this is most commonly caused by expectations far greater than are reasonably possible. Other complications include bleeding, infection, changes in pigmentation and numbness or tingling.

Figure 15	Figure 16	Figure 17

Figure 15 shows a woman who has been involved in a serious automobile accident. She has many cuts, abrasion and even some tissue loss. Figures 16 and 17 show her appearance several years later after multiple scar revisions.

Many men and some women lose the hair on their head anywhere between the ages of eighteen and fifty. There are a variety of techniques available for refurbishing the scalp. The oldest technique is called hair transplantation, and involves taking a series of small, circular punch grafts from the back of the head in areas where hair did not bald and putting these in the front of the scalp. The hair from these little transplant plugs grows and with proper grooming, gives an improved appearance. There are problems to this kind of hair transplantation and these include the fact that it takes several operations to get a reasonable result. The result is rarely perfect, and it requires a period of anywhere from a year to two years before the hair grows out fully enough to be combed and properly styled.

There are new surgical techniques that are available, and these include scalp reduction and the Juri flap. Scalp reduction is a very simple technique. One simply excises the bald scalp and in a series of operations, removes as much of the bald scalp as possible and stretches the hair-bearing scalp over the top of the head.

The Juri flap is a technique developed in Argentina, but has now been utilized in the United States and seems to be reliable. The technique takes a strip of hair-bearing scalp from the side of the head, lifts it up and places it across the front of the scalp. The defect left on the side is closed by simply performing a facelift procedure on the side of the head. If one wishes to spend the time and money, one can have a similar flap performed about three months later on the opposite side and then undergo a series of scalp reductions and in many patients, completely cover the head with hair-bearing scalp. The biggest problem with hair replacement surgery is patient limitations. Not everyone is a good candidate for this kind of surgery, i.e., not everyone will get a nice result because the density of the hair, or the amount of hair that is left, is insufficient.

There are new developments in medicine which are now reported to the public long before they have proven benefit. This is particularly common in facial plastic surgery where both cosmetic surgeons and instrument companies try and promote new technologies to increase their share of the market.

LASERs are touted as a tool which is superior to scalpels and scissors.

Endoscopes are the latest method of looking under tissues and using smaller incisions more safely. Each of these techniques and tools improves our ability to perform facial plastic and reconstructive surgery.

We, at the University of California, San Diego are fully aware of the advantages of LASERs and endoscopes. We use them daily, but disapprove of the marketing, commercialization, and the promotional materials shown in the newspapers, televisions and public interest magazines. A few specifics are mentioned.

While it is true that LASERs can make incisions that bleed less than those made by scalpels and scissors, the LASER causes some tissue damage and therefore the incision takes longer to heal and the scar is never as "good." There are, however, occasions in which LASERs provides sufficient advantage that they are routinely employed. Hemangiomas are small blood vessel tumors which are often better vaporized with LASERs than resected with excisions. Certain operations for snoring and vocal cord tumors are better performed with the LASER. The same is true with some nasal and ear work. The newest use of a LASER is to rid the face of wrinkles. This is called LASER resurfacing. At the time of the writing of this book, this is a brand new technique. The LASER companies have promoted this, but long-term results are not yet available.

The initial impressions show LASER to be as good for resurfacing as is achieved with chemical peels. The patient's skin remains reddened for 3-6 months, and the heeling process is substantially longer than with dermabrasion and a chemical peels. At this point, no one knows whether the long-term result has any advantage over dermabrasion and a chemical peels. We know nothing about the fate of the skin and whether this predisposes to early aging, skin cancer or any other typed deformity.

You are encouraged to ask about LASERs, but are also encouraged to focus more on the choice of procedures then on the exact tools which will be used.

Endoscopes provide opportunity to make smaller incisions and for some situations such as the forehead lift they do have benefit. The surgery takes longer, it has different risks, it costs more and to date no one has shown that the results are as good, let alone better. Ask about endoscopes, ask about anything you have heard or read about, but do not let good judgement be ruined by Madison Avenue advertisement.

Throughout this pamphlet we have continually referred to risks and complications with facial plastic surgery. Even in the very best of hands with the best of care, complications do occur. The following information is excerpted from the surgical experience at UCLA between 1972 and 1974. Under the categories of facelift, otoplasty, chin implant, nose surgery and blepharoplasty surgery, the different kinds of complications are listed and the percentage of cases in which these occurred are also listed. These complications occurred in a training program and, it is hoped, are less likely in our hands with the techniques and equipment available to us in the 1990's.

Nonetheless, these complications do occur, and the following statistics will give you some idea about the kinds of complications that occur, and how frequently they might occur.

FROM Smith, et al. Risk of Facial Plastic Surgery in an Otolaryngology Program. Archives of Otolaryngology, 104:137-139, 1978.

Ophthalmologists, otolaryngologists-head and neck surgeons, dermatologists, general plastic surgeons, and a variety of other physicians do facial plastic surgeries. It is our opinion that facial plastic surgeons trained in otolaryngology-head and neck surgery training programs are most familiar with the anatomy and diseases of the head and neck, and if they have received training in facial plastic surgery, are the most skilled for this type of work.

The best surgical results depend upon both the doctor and the patient. The following instructions are important to follow. Write down questions you may have so they can be discussed prior to any surgical procedure. It is important that we know about any medical problems and medicines you are using. Aspirin and non steroidal antiinflammatory agents (Motrin, ibuprofen etc.) can cause bleeding and bruising, and so should be avoided two weeks before surgery, and one week after surgery. Please refer to our Aspirin Caution Sheet for further details.