McKinnon Plastic Surgery

Procedures commonly performed by Dr. Mckinnon Facelift (including neck lift and fat removal and grafting) Blepharoplasty (including eyelid repositioning) Rhinoplasty/Septoplasty Breast Augmentation Breast Reduction Mastopexy Otoplasty (ear reshaping, repositioning) Genioplasty (chin reshaping, repositioning) Browlift Abdominoplasty Facial bone alteration (reduction, augmentation) Liposuction Thigh and buttocks lift Dermabrasion Skin chemical peel Laser treatment of veins, red spots Mole excision Scar revision Lip augmentation (fat graft, injectibles) Botox Our Range of Cosmetic Surgeries Brow Lift The primary purpose of brow lifting is to restore a youthful look to the upper... Abdominoplasty Abdominoplasty (tummy tuck) is a procedure for reducing skin and improving muscular laxity of the... Liposuction Liposuction is surgery and its results (good or bad) are usually permanent, given that the patient maintains... Facelift A bilateral facelift should aim to rejuvenate the face and neck, without changing the patient’s... Blepharoplasty The goal of a Blepharoplasty is to rejuvenate the eyelids. The strategy to achieve this... Rhinoplasty The main goal of a nose is to look normally human and to function as... Breast Augmentation Augmentation of the breast can be achieved with either autogenous tissue or implants. Most patients prefer... Genioplasty The genion is the anterior point of the chin. Chin problems can include: under-projection, over-projection,... Mastopexy Mastopexy is essentially a tightening of the breast skin by excision. It can be highly...

A bilateral facelift should aim to rejuvenate the face and neck, without changing the patient’s original appearance. The most reliable strategy to achieve this goal is by surgically elevating the skin of the face and neck and repositioning it. By contrast, attempts to achieve a natural, lasting facelift by tension- producing sutures have not and cannot give comparable results to actual surgery. The techniques of surgical facelift continue to undergo small nuances of change, but patients should have as their first priority a safe and highly reliable result. I perform facelifting in the hospital outpatient setting or in the accredited surgi-center. Most patients are given a choice of anesthetic, and most choose conscious sedation (intravenous narcotic and sedative drugs) combined with locally injected anesthetic. It is an outpatient procedure that can be done alone or in combination with browlift, blepharoplasty, etc. in a healthy patient. Aside from eyelid aging effects, the most common early signs of facial aging are the central face and neck (the jowls, deepnasolabial folds and “turkey neck”). A facelift should surely, then, concentrate on improvement of these areas. A “mini-lift”, by comparison, cannot provide lasting benefit to the central facial changes of aging. Normal facial fat moves down and medial during aging, and it also diminishes in volume. A facelift should re-establish the existing fat to its youthful position over the cheekbones and mandible, and also restore lost fat in some instances with fat grafts. The face and neck may deserve different emphasis, but I carefully discuss individual needs and preferences with each patient. Dressings and drains are removed in the office 2 days after facelifting. Swelling and some bruising is expected, as well as temporary facial numbness and mild to moderate discomfort. All sutures are removed by approximately 1 week. Most patients are doing normal work, limited exercise and some social activities after two weeks. Completion of all healing and recovery continues for 6-12 months. Incisions usually heal rapidly and scars are highly concealed. Complications after facelifting are and should be extremely rare, as it should be with any elective, aesthetic operation. A history of smoking is the biggest risk factor. A lengthy consultation and examination will cover the goals, strategy and risks of the procedure(s) being considered. Patients are invited to return to have a follow-up discussion (without charge), or to confer with other patients who have undergone the procedure. A well informed patient with a natural looking result is the best goal.

The main goal of a nose is to look normally human and to function as an inhaler and exhaler of air. The goals of Rhinoplasty are to improve the appearance and to improve and/or preserve the function of the nose. Any kind of problem of the external and internal nose, including even its absence, can be called Rhinoplasty. It is common that the nasal bones and major cartilage, the septum, need surgical alteration. Septoplasty can be performed independently or as part of a Rhinoplasty. Septoplasty is usually a purely functional procedure and should be considered as a non-cosmetic procedure by insurance companies. Rhinoplasty for cosmetic or aesthetic improvement is not usually a covered insurance procedure in the U.S. I perform Rhinoplasty as an outpatient procedure in the hospital or in the accredited surgery center. The anesthetic is commonly by conscious sedation and local injection of anesthetic, but could also be under general anesthesia. Most elective Rhinoplasties can be completed within 1 hour in my hands. The key point a prospective patient should know is that what separates one surgeon from another is not so much their operative ability, but their diagnostic acumen and judgment with each unique patient. All surgery requires skill, experience and judgment, but among elective, cosmetic procedures, Rhinoplasty probably demands the most of these talents. Some surgeons, either due to their training or their uncertainty, perform Rhinoplasty through an “open” technique (an incision through the skin) so that they expose the internal cartilages and bone of the nose. I am of the opinion that this approach is rarely, if ever, required to perform precise Rhinoplasty, that it actually can distort what the real end result will look like, and that the external scar has been a problem in some cases. Rhinoplasty by me is done through internal, mucosal incisions. Maneuvers to reshape, excise or add to cartilages are done so under direct vision. A natural appearing nose with no sign of surgery is the usual and intended result. Rhinoplasty consultation and examination includes a lengthy discussion of the patient’s history, perception of their problem and their goals. Our discussion also includes the patient’s ethnicity and how their goals may be influenced by it. Persians, Indians, Chinese, Poles, Italians and Africans do have quite different issues with their noses that deserve individual attention. Finally a detailed diagnosis and plan of surgery, if indicated, is presented for consideration. A second office visit is encouraged.Rhinoplasty may include augmentation of the nose with grafts, usually of the patient’s own cartilage, bone or fat. I do not recommend placing artificial implants into the nose due to their risk of infection, extrusion, displacement and scarring. Rhinoplasty should also take into account the harmony or disharmony with other facial features, especially the chin. Rhinoplasty and alteration of the chin (by intra-oral incision) is often performed simultaneously. Chin surgery (Genioplasty) is done under general anesthesia (see Genioplasty).

Augmentation of the breast can be achieved with either autogenous tissue or implants. Most patients prefer augmentation with implants, either filled with saline or liquid silicone. Implants have vastly improved since their introduction in the 1960’s, but they remain a foreign material inside the body, and they still entail risks, including surgical hemorrhage, infection, scar formation, displacement, spontaneous rupture, diminished breast sensation and lactation, ptosis of the breast and repeat operation. Recent studies have revealed that implants with textured surfaces may cause a lymphoma (ALCL) and are no longer recommended. The patient seeking breast augmentation should consider carefully their goals for a lifetime, not just the immediate gratification of a new body image. Future childbirth(s) will invariably change the breast anatomy, as will weight gain, weight loss, menopause and normal aging. Breast disease such as cancer deserves great deliberation regarding reconstruction with the oncologist, general surgeon and plastic surgeon. For women with a congenital breast asymmetry, breast implants can often be part of the solution. The best results of a breast augmentation include: giving the patient natural looking and feeling breasts; breasts that are symmetrical; preservation of normal nipple sensation; normal movement of the breast; and inconspicuous surgical scars. I encourage prospective patients to bring a spouse, dear friend or close adult family member during the consultation. Breast augmentation is not an urgent procedure and should not be hurried. Additional opinions/consultations and time for consideration are worthwhile. It is valuable to let patients “try on†a breast implant inside their bra of different sizes. Finally, breast augmentation is a serious surgery, even though a quite safe one in a modern surgical center and with an experienced surgeon.

Procedures Commonly Performed By Dr. Mckinnon Skin cancer (resection and reconstruction; basal cell, squamous cell, melanoma) Skin tumors Cleft lip and palate (including secondary procedures) Jaw and mouth deformities Craniosynostosis (premature cranial suture closure, “crooked head”) Crouzon Syndrome, Apert’s Syndrome, Saethre-Chotzen Syndrome Treacher Collins Syndrome Hemifacial microsomia Facial deformities/clefts Romberg’s facial atrophy Encephalocele Facial fractures Vascular anomalies/tumors/birthmarks Craniofacial Tumors/Deformities Nasal deformity and reconstruction Ear reconstruction Breast reconstruction (for cancer and asymmetry) Neurofibromatosis (skin and plexiform tumors) (face, skull and body) Facial paralysis Orbital and eyelid tumors (including Graves Disease) Eyelid ptosis, paralysis Scalp and skull deformity/asymmetry Cysts Congenital nevi Lipomas Scars Complications of injected material Neuroma

Individual results may vary. Not all skin lesions deserve a trip to the doctor. If a lesion is growing, if it is clearly unusual to you, if it results in bleeding or skin breakdown, if it is darker in color than one’s normal skin, if it is raised above the skin level, it probably deserves a physician’s examination. Of course, if a lesion such as a mole is disturbing to a patient by its appearance, any dermatologist or plastic surgeon can be consulted for its elective removal, typically as an office procedure. If there is an obvious or biopsy proven skin cancer, I prefer a surgical removal over a treatment with liquid nitrogen (a freezing agent) so that the confirmation of clear margins is achieved. Yes, freezing is quicker but it may also result in a recurrence deep in the skin. I also do not advocate treatment of skin cancers by Radiation. Early Diagnosis & Treatment — Why Surgery Is Often Preferred The vast majority of skin cancers are diagnosed early enough so that Surgery to remove them is usually a minor procedure and can be easily done under local anesthesia as an outpatient. Many of these patients are first seen by their family physician or dermatologist. Dermatologists are excellent diagnostic sources, but they are not trained surgeons. The patient who has an undiagnosed skin lesion that is growing or symptomatic might prefer to seek out a Board Certified Plastic Surgeon to both make a correct diagnosis and perform the surgical procedure to remove it. Often this can be done in a one step procedure, where the surgical specimen can be immediately examined by a Board Certified Pathologist, and the surgeon can finish the reconstruction of the wound with any of a variety of techniques known to plastic surgeons. When I see a new patient in the office with a skin lesion which is suspicious for cancer, we discuss the surgical excision and whether it should be performed in the office or hospital. Many lesions, especially those not on the face, can be cared for by an in-office procedure with local anesthesia. The specimen is marked and sent to the pathologist for confirmation of clear (no tumor) margins. These patients usually return only for suture removal and wound check . For more complex cancers of the face, scalp, neck and ear, the hospital provides all of the surgical necessities, as well as the presence of a Board Certified Pathologist who can give an immediate interpretation of the type of lesion, and whether the borders of the lesion are fully removed. This allows me to simultaneously complete a one stage reconstruction by whatever surgical means is best to achieve the desired result. This also allows the patient to normally return home the same day with the confidence that additional surgery will not be necessary. Follow up for suture removal and wound check takes place usually within seven days at the office. Dermatology vs Plastic Surgery — Differences in Approach By contrast, patients who visit a Dermatologist may frequently experience a separate procedure for biopsy , another procedure for additional biopsies, and one or more additional procedures for a dermatologic attempt at removal of the lesion. Even then, the patient may still require referral to a plastic surgeon for closure of a complex wound. Patients with skin malignancy often ask about the need for MOHS surgery. The long established technique of MOHS chemosurgery (or so-called micrographic surgery) was started by Dr. Frederic Mohs, a general surgeon from Wisconsin. Some dermatologists have adopted this procedure, in large part because it can be performed in an office. (Most dermatologists do not have surgical privileges in hospitals or in certified outpatient surgical centers) MOHS surgery for cancer lesions can be as highly accurate as Plastic surgery in experienced hands and with Board Certified Pathologists. Concerns With MOHS in Dermatology Offices Unfortunately ,however, most Dermatologists do not employ experienced Pathologists to work in their offices as was originally promoted by DR. MOHS.This situation means that patients can incur more office visits, biopsies and surgeries for tumor removal than absolutely necessary. My principle goals are: to inform the patient of the correct diagnosis and nature of their problem, its prognosis, the best solution surgically for them, and deliver care efficiently and safely. Patients would be wise to ask questions regarding how many procedures are necessary, where they should be performed (office or hospital), where and by whom the pathology will be examined , and what complexity of wound will there be before making a final decision about their procedure and who is most capable of performing all of their care. Patients should understand that if a surgery requires complex methods of closure or reconstruction, a Board Certified Plastic Surgeon is most capable of providing this expertise.

SURGERY OF NEUROFIBROMATOSIS HISTORY Neurofibromatosis, or, what we commonly call NF1, is an autosomal dominant genetic condition of chromosome #17 which leads to formation of tumors of skin and all other parts of the body. Approximately 1 in 3000 persons are affected. One half of all cases are spontaneous mutations, the rest of patients having inherited the gene from a relative. The original descriptions of the disease were by Von Recklinghausen in the 1860’s. The lesions he described were mainly of the skin, which represent the majority of patients with NF1. Other NF1 tumors which can emerge in both skin and deeper areas of the body are called plexiform tumors. These tumors, once they have appeared, have a strong tendency to grow unpredictably, similar to other solid tumors. Plexiform tumors also have the ability (5-10%) to transform into a malignant form of NF1 called Malignant Peripheral Nerve Sheath Tumor (MPNST). These tumors present the greatest risks of pain and damage to a patient’s normal tissue and functions. SURGERY The history of surgery for resection of cutaneous tumors is mostly successful since they are easily accessible and small, although recurrence of tumor has been a problem for many patients. Surgery of plexiform tumors has a history of significant blood loss, high recurrence of tumors and unintended but permanent injury to normal nerves and tissues. This history has nurtured a wariness by pediatricians and surgeons to postpone surgical attempts at removal until after puberty or until serious morbidity from the tumors is present. This default strategy results in significant morbidity and suffering for patients since unchecked tumor growth is the usual result of no surgery. Dr. McKinnon’s Experience Over a 40 year experience of treating patients with NF1, I have observed that “radical” resection of plexiform NF tumors has resulted in permanent “non-recurrence” of nearly all tumors. This includes even tumors over 50 pounds and some MPNST tumors. In children, who have enormous growth spurts until the end of puberty, there is no certainty of permanent surgical results. However the successful logic gleaned from radical surgery in adults has been successfully applied to a large pediatric population, and without facial mutilation, even if surgery may need to be repeated during growth. This success also depends on preservation of normal motor nerves and other normal tissue during the resection of NF tumors. ANATOMY CRANIOFACIAL Most facial and frontotemporal scalp tumors derive from sensory branches of cranial nerve V. The ophthalmic division of the trigeminal nerve includes some sensory nerves that are within the musculofascial cone (annulus of Zinn) of the orbit. This area presents special risks of injury to the optic nerve and the extraocular muscles and should be avoided in surgery. Orbital NF is often (even from birth) accompanied by a defect of the sphenoid greater wing. This defect may permit herniation of the temporal lobe of the brain into the orbit and subsequent orbital dystopia, pulsation exophthalmos or enophthalmos, and pressure on the globe and optic nerve. Destruction of bone, ligaments, fascia, muscle and skin may also be present. Tumor confined to the optic nerve (optic glioma) deserves neurosurgical management. It is important (and an original observation by Dr. McKinnon) to understand that motor nerves are not intrinsically involved with NF tumor. NF tumors of the mandible, parotid gland, ear and temporal scalp develop largely from the mandibular division of the trigeminal nerve, including the auriculotemporal nerve. Tumors of the neck and posterior scalp derive from upper cervical sensory nerves (C1-C4), including theoccipital nerves. Lower cervical nerves (C4-C8, sensory and motor) constitute most of the brachial plexus. TRUNK AND EXTREMITY Plexiform NF can exist anywhere from the spinal cord to the sensory nerve terminus in the skin, bone or viscera. Plexiform tumors most commonly appear between the deep fascia and the skin but may involve and destroy skin, muscles, bones, joints, and visceral organs. Careful dissection proximal to the tumor mass (towards their CNS origin) often reveals the specific sensory nerve tumor origin. Large truncal lesions over time can develop paraspinal hypervascularity. This can resemble an arteriovenous malformation. Scoliosis of the spine is common with posterior trunk lesions, and limb hyperplasia is common with extremity lesions. PATHOGENESIS NF is an autosomal dominant condition which can be attributed to a defect on chromosome 17, but mosaicism can also occur. The consequential lack of neurofibromin (a tumor inhibitor) permits growth of myelinated axonal tumors in any bodily location. Tumor types are cutaneous or plexiform. So-called plexiform tumors are solid tumors.