Center of Aesthetic & Reconstructive Surgery

The children with syndromic craniosynostosis usually have multiple cranial sutures fused. There are also several other differences, including bulging eyes, retruded midface, causing airway obstruction. In kids with Apert Syndrome, there is a classic fusion of their fingers and toes. Diagnosis includes Dr. Chaiyasate performing a complete physical examination. Many of these syndromes can be diagnosed based on the physical exam only. All of these children will require CT scan of the craniofacial region and genetics consultation. Often, a sleep study is indicated to assess the severity of the airway obstruction . Treatment of syndromic craniosynostosis varies from institution to institution. Dr. Chaiyasate initially focuses on expansion of the skull to accommodate the rapid growing brain. Dr. Chaiyasate performs posterior skull distraction, which is the most advanced and current treatment in the craniofacial field. See pictures for more information. The posterior cranial vault distraction should be performed in the first year of life. The next step would be expanding the anterior skull to not only increase the room in the front of the skull, but also to correct the bulging of the eyes. These frontal-orbital advancements are usually performed between age 12-18 months. The retruded midface is usually reconstructed during age 3-5 years old using the technique of distraction osteogenesis. It is not uncommon that these children will require a secondary midface distraction during their teen years. In some situations, the frontal bone and the retruded midface need to be advanced at the same time. This operation is called monobloc advancement. Eventually, all of the children will require orthodontic treatment and jaw surgery to achieve a normal bite. They will also require a definitive rhinoplasty during their late teens.

Hemifacial microsomia (HFM) is a condition in which the tissue on one side of the face is underdeveloped, affecting primarily the aural (ear), oral (mouth), and mandibular (jaw) areas. Sometimes, both sides of the face can be affected and may involve the skull, as well as the face. Hemifacial microsomia is also known as Goldenhar syndrome, brachial arch syndrome, facio-auriculo-vertebral syndrome (FAV), oculo-auriculo-vertebral spectrum (OAV), or lateral facial dysplasia. The deformity in hemifacial microsomia varies greatly in the degree of severity and in the area of the face involved. The disorder varies from mild to severe. In the more severe cases, the following structures are underdeveloped: the external and middle ear the side of the skull the thickness of the cheek tissue the upper and lower jaws the teeth some of the nerves that allow facial movement In the milder forms, only some of the structures are affected and to a lesser degree. One of the most obvious problems in hemifacial microsomia is the underdevelopment of the upper and lower jaws on the affected side. It may appear that your child’s mouth slants upward toward the involved side. Often the forehead and cheek are flattened on the affected side with one orbit (eye socket) smaller than normal. Other areas of your child’s face that may be affected by hemifacial microsomia include the following: Your child may have unequal cheek fullness (asymmetry) because of the underdeveloped fat and muscle. Some parts of the face may not move normally, which may cause a “crooked” smile. There is a wide range of ear abnormalities associated with HFM. Your child may have a mildly misshapen ear or almost complete absence of the external ear (atresia). Small tags of skin may also be present in front of the ear(s). Occasionally, the central nervous system is affected, causing parts of the face to not move symmetrically (equally). CAUSES Hemifacial microsomia usually occurs sporadically (occurs by chance), but is thought to be inherited in some families. This is because of the many familial (cases occurring more than once in a family) cases reported. The following patterns of inheritance have been observed: Autosomal Dominant Autosomal dominant means that one gene is necessary to express the condition, and the gene is passed from parent to child with a 50 percent risk for each pregnancy. Males and females are equally affected and there is great variability in expression of the gene. In other words, a parent may unknowingly have a very mild sign of hemifacial microsomia, such as preauricular tags (skin tags by the ear), but the child is more severely affected. The family may not come to the attention of a geneticist until the birth of the child with a more severe condition. Other relatives with mild expression of the gene are often discovered at that time, confirming autosomal dominant inheritance. Autosomal Recessive Autosomal recessive means that two copies of the gene are necessary to express the condition, one inherited from each parent, who are carriers. Carrier parents have a one in four, or 25 percent, chance with each pregnancy to have a child with hemifacial microsomia. Males and females are equally affected. Multifactorial Multifactorial inheritance means that “many factors” are involved in causing a birth defect. The factors are usually both genetic and environmental. Often one gender (either male or female) is affected more frequently than the other in multifactorial traits. There appears to be a different “threshold of expression,” which means that one gender is more likely to show the problem, over the other gender. In hemifacial microsomia, males are slightly more likely to be affected than females. Observations made from families who have one child with hemifacial microsomia show that the overall chance for another child to be born with hemifacial microsomia is about 2 to 3 percent. Parents and other family members should have a thorough evaluation to help give more definite recurrence information. In addition, hemifacial microsomia is sometimes found in children with various types of chromosome abnormalities. Chromosomes are the structures in our cells that carry our genes. Genes determine traits such as blood type and eye color. Chromosome abnormalities are usually sporadic (occur by chance). DIAGNOSIS HFM is typically diagnosed after a comprehensive medical history and physical examination by a geneticist. There is not a blood test to diagnose HFM. Because the spectrum of severity is so wide, the diagnosis should come from an experienced geneticist skilled in diagnosing craniofacial anomalies. CT scans and x-rays of the face may also be ordered for accurate diagnosis.

Cleft lip and cleft palate are the most common craniofacial differences. The instance is about 1 in 1000 births. The modern comprehensive cleft care multidisciplinary approach among different specialties includes a plastic surgeon, speech pathologist, orthodontist, dentist, oral surgery, speech, occupational therapy, social worker and dietician. The first priority in cleft care is making sure the baby can feed appropriately and gain weight. A special nipple, such as Haberman Feeder, is required for children with a cleft palate. Breast feeding is not an option for a child with a cleft palate, however, the breast milk can be given through the feeder. Children with cleft lip only may be able to breast feed, depending upon the size of their cleft. However, they may require the feeder as well. Many children who have wide clefts and bilateral cleft lip and palate may require a pre-surgical orthopedic, performed by a cleft orthodontist, to narrow the gap and make the subsequent surgeries easier. Dr. Chaiyasate typically repairs the lip at the age of 3-4 months old. The cleft palate is usually repaired at the age of 9-12 months. It is recommended in children with clefts to follow up annually with a craniofacial team. At around the age of 3, an initial speech evaluation will be performed by a speech pathologist. This may be evaluated by several methods including speech therapy, videofluoroscopy and nasendoscopy. About 20% of children with cleft palates will require a speech surgery to correct hypernasality. It is not uncommon for children with cleft lips to require cleft lip revisions before starting kindergarten. During mixed dentition age, the children with cleft lip and palate will require orthodontic treatment to align an asymmetrical gumline. Many of them will require taking a piece of bone from their hip and placing it into a gap in their gumline to restore the arch of the gum. About 20 % of children with cleft lip and palate will require definitive jaw surgery to achieve a normal bite. Many of these children will also require a definitive rhinoplasty (nose job) during their late teens. Dr. Chaiyasate is a leader of Beaumont’s Craniofacial Clinic and works closely with the other specialists. Treacher Collins Syndrome Treacher Collins syndrome is a condition that affects the development of bones and other tissues of the face. The signs and symptoms of this disorder vary greatly, ranging from almost unnoticeable to severe. Most affected individuals have underdeveloped facial bones, particularly the cheek bones, and a very small jaw and chin (micrognathia). Some people with this condition are also born with an opening in the roof of the mouth called a cleft palate. In severe cases, underdevelopment of the facial bones may restrict an affected infant’s airway, causing potentially life-threatening respiratory problems. People with Treacher Collins syndrome often have eyes that slant downward, sparse eyelashes, and a notch in the lower eyelids called an eyelid coloboma. Some affected individuals have additional eye abnormalities that can lead to vision loss. This condition is also characterized by absent, small, or unusually formed ears. Hearing loss occurs in about half of all affected individuals; hearing loss is caused by defects of the three small bones in the middle ear, which transmit sound, or by underdevelopment of the ear canal. People with Treacher Collins syndrome usually have normal intelligence. This condition affects an estimated 1 in 50,000 people. TREATMENT The treatment of individuals affected by TCS needs a multidisciplinary approach and may involve the intervention of different professionals. The primary concerns in individuals with TCS are breathing and feeding problems, which are a consequence of the hypoplasia of the mandible and the obstruction of the hypopharynx by the tongue. Sometimes even a tracheostomy is necessary to maintain an adequate airway. Also a gastrostomy could be necessary to assure an adequate caloric intake while protecting the airway. Surgery to restore a normal structure of the face is normally performed at defined ages, depending on the development state. An Overview Of The Present Guidelines: If there is a cleft palate, the repair normally takes place at the age of 9–12 months. Before surgery, it is necessary to perform a polysomnography with a palatal plate in place, this may predict the postoperative situation and gives insight on the chance of the presence of OSAS after the operation. The hearing loss is treated by bone conduction amplification, speech therapy and educational intervention to avoid language/speech problems. The bone-anchored hearing aid (Baha) is an alternative for individuals with ear anomalies. The zygomatic and orbital reconstruction is performed when the cranio-orbitozygomatic bone is completely developed. Usually at the age of 5–7 years. In children an autologous bone graf

Treacher Collins syndrome is a condition that affects the development of bones and other tissues of the face. The signs and symptoms of this disorder vary greatly, ranging from almost unnoticeable to severe. Most affected individuals have underdeveloped facial bones, particularly the cheek bones, and a very small jaw and chin (micrognathia). Some people with this condition are also born with an opening in the roof of the mouth called a cleft palate. In severe cases, underdevelopment of the facial bones may restrict an affected infant’s airway, causing potentially life-threatening respiratory problems. People with Treacher Collins syndrome often have eyes that slant downward, sparse eyelashes, and a notch in the lower eyelids called an eyelid coloboma. Some affected individuals have additional eye abnormalities that can lead to vision loss. This condition is also characterized by absent, small, or unusually formed ears. Hearing loss occurs in about half of all affected individuals; hearing loss is caused by defects of the three small bones in the middle ear, which transmit sound, or by underdevelopment of the ear canal. People with Treacher Collins syndrome usually have normal intelligence. This condition affects an estimated 1 in 50,000 people. TREATMENT The treatment of individuals affected by TCS needs a multidisciplinary approach and may involve the intervention of different professionals. The primary concerns in individuals with TCS are breathing and feeding problems, which are a consequence of the hypoplasia of the mandible and the obstruction of the hypopharynx by the tongue. Sometimes even a tracheostomy is necessary to maintain an adequate airway. Also a gastrostomy could be necessary to assure an adequate caloric intake while protecting the airway. Surgery to restore a normal structure of the face is normally performed at defined ages, depending on the development state. An Overview Of The Present Guidelines: If there is a cleft palate, the repair normally takes place at the age of 9–12 months. Before surgery, it is necessary to perform a polysomnography with a palatal plate in place, this may predict the postoperative situation and gives insight on the chance of the presence of OSAS after the operation. The hearing loss is treated by bone conduction amplification, speech therapy and educational intervention to avoid language/speech problems. The bone-anchored hearing aid (Baha) is an alternative for individuals with ear anomalies. The zygomatic and orbital reconstruction is performed when the cranio-orbitozygomatic bone is completely developed. Usually at the age of 5–7 years. In children an autologous bone graft is mostly used. In combination with this transplantation, lipofilling can be used in the periorbital area to get an optimal result of the reconstruction. The reconstruction of the lower eyelid Coloboma includes the use of a myocutaneous flap, which is elevated and in this manner closes the eyelid defect. The external ear reconstruction is usually done when the individual is at least 8 years old. Sometimes also the external auditory canal or middle ear can be treated. The optimal age for the maxillomandibular reconstruction is still a major point of discussion, at present, this classification is generally used: Type I (mild) and Type IIa (moderate) 13–16 year, Type IIb (moderate to severe malformation) at skeletal maturity, and Type III (severe) 6–10 years Orthognathic treatments usually take place after the age of 16 years; at this point all teeth are cut and the jaw and dentures are mature. Whenever OSAS is detected, the level of obstruction is determined through endoscopy of the upper airways. Mandibular advancement can be an effective way to improve both breathing and aesthetics, while a chinplasty only restores the profile. If a nose reconstruction is necessary it is usually performed after the orthognathic surgery and after the age of 18 years. The contour of the facial soft tissues generally requires correction at a later age, because of the facial skeletal maturity. The use of microsurgical methods, like the free flap transfer, has improved the correction of facial soft tissue contours. Another technique to improve the facial soft tissue contours is lipofilling. For instance, lipofilling is used to reconstruct the eyelids.

Parry–Romberg syndrome (also known as progressive hemifacial atrophy) is a rare neurocutaneous syndrome characterized by progressive shrinkage and degeneration of the tissues beneath the skin, usually on only one side of the face (hemifacial atrophy) but occasionally extending to other parts of the body. An autoimmune mechanism is suspected, and the syndrome may be a variant of localized scleroderma, but the precise etiology and pathogenesis of this acquired disorder remains unknown. It has been reported in the literature as a consequence of sympathectomy. The syndrome has a higher prevalence in females and typically appears between 5 – 15 years of age.In addition to the connective tissue disease, the condition is often accompanied by significant neurological, ocular and oral signs and symptoms. The range and severity of associated symptoms and findings are highly variable. Signs And Symptoms SKIN AND CONNECTIVE TISSUES Initial facial changes usually involve the area of the face covered by the temporal or buccinator muscles. The disease progressively spreads from the initial location, resulting in atrophy of the skin and its adnexa, as well as underlying subcutaneous structures such as connective tissue, (fat, fascia, cartilage, bones) and/or muscles of one side of the face. The mouth and nose are typically deviated towards the affected side of the face. The process may eventually extend to involve tissues between the nose and the upper corner of the lip, the upper jaw, the angle of the mouth, the area around the eye and brow, the ear, and/or the neck. The syndrome often begins with a circumscribed patch of scleroderma in the frontal region of the scalp which is associated with a loss of hair and the appearance of a depressed linear scar extending down through the midface on the affected side. This scar is referred to as a “coup de sabre” lesion because it resembles the scar of a wound made by a sabre, and is indistinguishable from the scar observed in frontal linear scleroderma. In 20% of cases, the hair and skin overlying affected areas may become hyperpigmented or hypopigmented with patches of unpigmented skin. In up to 20% of cases the disease may involve the ipsilateral (on the same side) or contralateral (on the opposite side) neck, trunk, arm, or leg. The cartilage of the nose, ear and larynx can be involved. The disease has been reported to affect both sides of the face in 5-10% of the cases. Symptoms and physical findings usually become apparent during the first or early during the second decade of life. The average age of onset is nine years of age, and the majority of individuals experience symptoms before 20 years of age. The disease may progress for several years before eventually going into remission (abruptly ceasing). NEUROLOGICAL Neurological abnormalities are common. Roughly 45% of people with Parry–Romberg syndrome are also afflicted with trigeminal neuralgia (severe pain in the tissues supplied by the ipsilateral trigeminal nerve, including the forehead, eye, cheek, nose, mouth and jaw) and/or migraine (severe headaches that may be accompanied by visual abnormalities, nausea and vomiting). 10% of affected individuals develop a seizure disorder as part of the disease. OCULAR Enophthalmos (recession of the eyeball within the orbit) is the most common eye abnormality observed in Parry–Romberg syndrome. It is caused by a loss of subcutaneous tissue around the orbit. Other common findings include drooping of the eyelid (ptosis), constriction of the pupil (miosis), redness of the conjunctiva, and decreased sweating (anhidrosis) of the affected side of the face. ORAL The tissues of the mouth, including the tongue, gingiva, teeth and soft palate are commonly involved in Parry–Romberg syndrome. 50% of affected individuals develop dental abnormalities such as delayed eruption, dental root exposure, or resorption of the dental roots on the affected side. 35% have difficulty or inability to normally open the mouth or other jaw symptoms, including temporomandibular joint disorder and spasm of the muscles of mastication on the affected side. 25% experience atrophy of one side of the upper lip and tongue. CAUSES The fact that some people affected with this disease have circulating antinuclear antibodies in their serum supports the theory that Parry–Romberg syndrome may be an autoimmune disease, specifically a variant of localized scleroderma. Several instances have been reported where more than one member of a family has been affected, prompting speculation of an autosomal dominant inheritance pattern. However, there has also been at least one report of monozygotic twins in which only one of the twins was affected, casting doubt on this theory. Various other theories about the etiology and pathogenesis have been suggested, including alterations in the peripheral sympathetic nervous system.

There are a variety of surgical techniques for breast reconstruction. Most mastectomy patients are medically appropriate for breast reconstruction, either immediately following breast removal or at a later time. The best candidates, however, are women whose cancer, as far as can be determined, seems to be eliminated by mastectomy. There are legitimate reasons to delay breast reconstruction. Some women may be advised by their surgeon or oncologist to wait until other forms of necessary cancer treatment are completed. Other patients may require more complex breast reconstruction procedures. Women who smoke or who have other health conditions such as obesity or high blood pressure may be advised to postpone surgery. In any case, being informed of your options concerning breast reconstruction can help you prepare for a mastectomy with a more positive outlook on the future. Breast reconstruction has no known effect on altering the natural history of breast cancer or interfering with other forms of breast cancer treatment such as chemotherapy or radiation. The DIEP flap is the most advanced form of breast reconstruction available today. It is the preferred technique performed by Dr. Chaiyasate. The DIEP flap technique of breast reconstruction involves the use of lower abdominal skin and fatty tissue with as little as possible amount of the abdominal muscle. This tissue is transferred to the chest wall region in order to reconstruct a breast mound. The blood vessels providing circulation to the tissue are re-connected to the blood vessels on the chest to re-establish flow of blood to the tissue in the new position. This vascular connection usually requires microsurgical techniques. Following the reconstruction of the breast mound, the lower abdominal incisions are closed. This is a modification of TRAM abdominal muscle flap breast reconstruction, but attempts to preserve the “six-pack” muscle function. In some cases, your plastic surgeon may recommend that a breast implant be inserted underneath the flap to give the breast mound additional projection. Tissue flap techniques of breast reconstruction are useful in the following situations: Inadequate chest wall tissue for breast reconstruction with implants or expanders Past history of radiation to chest wall after mastectomy Patients with concerns about silicone breast implant/expander Failure of earlier breast reconstruction Contraindications to DIEP flap breast reconstruction procedure exist: A patient who is medically or psychologically unsuitable for breast reconstruction A past history of abdominal surgery which has impaired DIEP flap blood supply Stacked DIEP Flap Or Bipedicle-Folded DIEP Flap For patients seeking reconstruction of one breast, but who do not have much tissue on their lower abdomen or need a larger reconstruction in order to achieve symmetry, using stacked DIEP flaps may be an option. The stacked DIEP flap procedure describes the use of two DIEP flaps to reconstruct a single breast. Similar to DIEP flaps used for double mastectomy reconstruction, the stacked flap procedure utilizes both the right and left halves of tissue on the lower abdomen. The main difference with the stacked flap being that both pieces of tissue are used to reconstruct a single breast.

The SIEA flap is very similar to the DIEP flap procedure. Both techniques use the lower abdominal skin and fatty tissue to reconstruct a natural, soft breast following mastectomy. The main difference between the SIEA flap and the DIEP flap is the artery used to supply blood flow to the new breast. The SIEA blood vessels are found in the fatty tissue just below skin whereas the DIEP blood vessels run below and within the abdominal muscle (making the surgery more technically challenging). While the surgical preparation is slightly different, both procedures spare the abdominal muscle and only use the patient’s skin and fat to reconstruct the breast. Though the SIEA is similar to the DIEP, it is used less frequently since the arteries required are generally too small to sustain the flap in most patients. Less than 20% of patients have the anatomy required to allow this procedure. Unfortunately, there are no reliable pre-operative tests to show which patients have the appropriate anatomy. The decision as to which type of reconstruction to perform is therefore made intra-operatively by Dr. Chaiyasate based on the patient’s anatomy.

Women who do not have an adequate amount of abdominal tissue for reconstruction may be eligible for GAP (gluteal artery perforator) flap breast reconstruction. This procedure uses excess skin and fat from the gluteal (buttock) region and leaves all the gluteal muscle behind. Like the DIEP flap all the patient’s muscle is left in place to preserve function and make recovery easier. Dr. Chaiyasate may take skin and fat from either your upper (“superior”) or lower (“inferior”) buttock region. These are referred to as the “SGAP flap” or “IGAP flap” respectively. Both incisions are easily hidden with underwear.

The TUG flap procedure uses tissue from the inner portion of the upper thigh (just under the groin crease) to reconstruct a “natural”, warm, soft breast. The resulting thigh scar is generally very well hidden near the groin crease. Patients also receive an “inner thigh lift” as an added benefit of the surgery. The TUG flap is a very good option for women who: have small to medium sized breasts want to avoid an abdominal scar do not have enough abdominal tissue for DIEP or SIEA flap breast reconstruction have had previous abdominoplasty (“tummy tuck surgery”) have had multiple previous abdominal surgeries The procedure uses skin, fat and the gracilis muscle to reconstruct the new breast. Unlike loss of other muscles (like the rectus abdominus), loss of the gracilis muscle does not result in any noticeable functional impairment. The tissue is dissected from the inner thigh and transplanted to the chest where it is reattached micro surgically. PREPARATION FOR SURGERY The surgery usually takes 4- 6 hour for one side and 8-10 hours for both sides. It will take about 1-2 hour longer if you will also have mastectomy at the same time. You will stay in the surgical ICU for flap monitoring for 48 hours. Most patients will be discharged home by postoperative day 4 or 5. RESTRICTION AND RECOVERY It is important that you restrict your physical activities for 4-6 weeks. All patients will get back to their baseline activities by the end of 6 weeks. Revision Surgery For one breast reconstruction, many patients requests the opposite breast lift or reduction which usually performs after the reconstructed breast settling down (usually 3 months). Your health insurance is obligated to cover you care. Sometimes, the fat grafting technique is required to further increase the size of reconstructed breast. The fat is harvested using liposuction technique. This “free” liposuction will further shaping your body. The nipple reconstruction usually performed after you satisfy with the size and shape of both breasts.

Free tissue transfer (microvascular surgery) offers solutions to enhance form and function for congenital anomalies of the head and neck such as bony and contour restoration for hemifacial microsomia, re animation techniques with functioning muscle transplants for facial paralysis (smile reconstruction), and for congenital deficiencies of the hand such as toe-to-hand transfers for symbrachydactyly (fused and short fingers). With childhood cancer, the role of pediatric plastic surgeon/ pediatric microsurgery is an integral part of team approach. After cancer resection, the defect of surgery could be large. The defect could be bone or soft tissue, which requires reconstruction for optimal function and quality of life. Dr. Chaiyasate can facilitate the cancer removal surgeon by providing an acceptable functional and cosmetic reconstruction.

Scar revision is typically performed on patients with scars from injury or from a previous surgery and aims to improve the appearance and function of the affected area through one of several different techniques. Many minor scars can be treated by injecting a steroid medication into the scar, while others may require laser treatments, skin grafts, collagen injections or other types of reconstructive treatment.

A vascular anomaly is a kind of birthmark caused by a disorder of the vascular development, although it is not always present at birth. A vascular anomaly is a localized defect in blood vessels that can affect each part of the vasculature (capillaries, arteries, veins, lymphatics or a combination of these). These defects are characterized by an increased number of vessels and vessels that are both enlarged and sinuous. Some vascular anomalies are congenital and therefore present at birth, others appear within weeks to years after birth and others are acquired by trauma or during pregnancy. Inherited vascular anomalies are also described and often present with a number of lesions that increase with patients’ age. Vascular anomalies can also be a part of a syndrome and, occasionally, they can be acquired by trauma. The estimated prevalence of vascular anomalies is 4.5%. Vascular anomalies can occur throughout the whole body (skin, bone, liver, intestines, i.e.), but in 60% of patients vascular anomalies are localized in the head and neck region. Vascular anomalies can present in various ways. Vascular anomalies that are situated deep below the skin, appear blue and are often called cavernous. Superficial vascular anomalies appear as red-coloured stains and are associated with vascular anomalies affecting the dermis. Historically, vascular anomalies have been labeled with descriptive terms, according to the food they resembled (port wine, strawberry, cherry, salmon patch). This imprecise terminology has caused diagnostic confusion, blocked communication and even caused incorrect treatment, as it does not differentiate between various vascular anomalies. VASCULAR TUMORS Vascular tumors, often referred to as hemangiomas, are the most common tumors in infants, occurring in 1-2%. Prevalence is even higher (10%) in premature infants of very low birth weight. Vascular tumors are characterized by overgrowth of normal vessels, which show increased endothelial proliferation. It can be present at birth, but often appears within a couple of weeks after birth or during infancy. There are different kinds of vascular tumors, but the 4 most common types are: infantile hemangioma, congenital hemangioma, kaposiform hemangioendothelioma and pyogenic granuloma. INFANTILE HEMANGIOMA Infantile hemangioma is the most common vascular tumor. It is a benign tumor, which occurs in 4-5% of Caucasian infants, but rarely in dark skinned infants. It occurs in 20% of low weight premature infants and 2.2 to 4.5 times more frequently in females. IH most commonly presents in the head and neck region (60%), but also involves the trunk and extremities. One third of these lesions is present at birth as a telangiectatic stain or ecchymotic area. During the first four weeks of life, 70% to 90% appear. Lesions that are situated beneath the skin may not appear until 3 to 4 months of age, when the tumor is large enough. During the first 9 months, IH undergoes rapidly growth, which is faster than the growth of the child. This is called the proliferating phase. After 9 months, the growth of the tumor will decrease and equal the growth of the child for about 3 months. After 12 months, the tumor will start to involute and might even disappear. Involution occurs in one-third of patient by the age of 3 years, in 50% by the age of 5 years and in 72% by the age of 7 years. Involution may result in residual telangiectasis, pallor, atrophy, textural changes and sometimes fibrofatty residuum. Since 90% of IH is small, localized and asymptomatic, treatment mainly consists of observation and awaiting until involution is complete. IH can be treated with corticosteroids, which accelerate involution: in 95% of patients, growth is stabilized and 75% of tumors decrease in size. Intralesional corticosteroids are most effective, but may require additional injections, as the effect is only temporarily. Systemic corticosteroids may cause lost of side-effects and are only used in problematic IH, which is too large to treat with intralesional injections. During the proliferating phase, the tumor is highly vascular. Patients who undergo operative treatment during this period, are at risk for blood loss. Moreover, surgery during this phase, often leads to an inferior aesthetic outcome. However, patients may require intervention during childhood, because 50% of IH leave residual fibrofatty tissue, redundant skin, or damaged structures after involution. Waiting until involution is completed, ensures that the least amount of fibro fatty residuum and excess skin is resected, giving the smallest possible scar. Another option for treatment in the pulsed-dye laser. After involution residual telangiectasias can be treated with laser therapy. CONGENITAL HEMAGIOMA Congenital hemangioma can be distinguished from infantile hemangioma because it is fully developed at birth. It forms during prenatal life and has reached its maximal size at birth.

KAPOSIFORM HEMANGIOENDOTHELIOMA Kaposiform hemangioendothelioma (KHE) is a rare vascular neoplasm that is locally aggressive but without metastatic potential. It occurs particularly in the skin, deep soft tissue, retroperitoneum, mediastinum, and rarely in bone. Although lesions occur solitary, they often involve large areas of the body, such as the head/neck region (40%), trunk (30%), or extremity (30%). Usually, it is present at birth as a flat, reddish-purple, tense and edematous lesion. Although half of lesions are congenital, 58% of KHE develop during infancy, 32% between age 1 and 10 years (32%) and 10% after 11 years of age. Moreover, adult onset has been described too with mainly males being affected. Both sexes are affected equally in children. Lesions are often greater than 5 cm in diameter and can cause visible deformity and pain. During early childhood, KHE may enlarge and after 2 years of age, it may partially regress. Though, it usually persists longterm. In addition, 50% of patients suffer from coagulopathy due to thrombocytopenia (<25,000/mm3), presenting with petechiae and bleeding. This is called the Kasabach-Merritt Phenomenon, which is caused by trapping of platelets and other clotting factors within the tumor. Kasabach-Merritt Phenomenon is less likely in patients with lesions less than 8 cm. As two-thirds of adult-onset KHE tumors are less than 2 cm, KHE in adults is rarely associated with Kasabach-Merritt Phenomenon. Patients with KHE and Kasabach-Merritt Phenomenon present with petechiae and ecchymosis. Most KHE tumors are diffuse involving multiple tissue planes and important structures. Resection of KHE is thus often difficult. Treatment of kaposiform hemangioendothelioma is therefore medical. The primary drug is interferon alfa, which is successful in 50% of children. Another option is vincristine, which has lots of side-effects, but has a response rate of 90%. Drug therapy is often used in shrinking the tumor and treating the coagulopathy. However, many of these kaposiform hemangioendotheliomas do not completely regress and remain as a much smaller asymptomatic tumor. However, KHE still has a high mortality rate of 30%. Although complete surgical removal with a large margin has the best reported outcome, it is usually not done because of the risk of bleeding, extensiveness, and the anatomic site of the lesion. Operative management may be possible for small or localized lesions. Removal of larger areas also may be indicated for symptomatic patients or for patients who have failed pharmacotherapy. Resection is not required for lesions that are not causing functional problems, because KHE is benign and because resection could cause deformity. PYOGENIC GRANULOMA Pyogenic granuloma, also known as lobular capillary hemangioma, is a small benign vascular tumor that primarily involves the skin (88.2%) and mucous membranes. Pyogenic granuloma appears as a red macule that grows rapidly, turns into a papule and eventually becomes pedunculated, being attached to a narrow stalk. The average diameter of these lesions is 6.5 mm. Although these lesions are small, they are often complicated by bleeding, crusting and ulceration. Microscopically, pyogenic granulomas are characterized by vascular proliferation amidst granulation tissue and chronic inflammatory infiltrate. Pyogenic granulomas are rarely congenital. It commonly develops in infants: 42.1% develops within the first 5 years of life. This vascular tumor is twice as common in males as in females and 25% of lesions seem to be associated with trauma, an underlying cutaneous condition, pregnancy, hormonal alterations and medications. Pyogenic granulomas can also arise within a capillary malformation. Of all pyogenic granulomas, 62% is distributed on the head or neck, occurring mainly on the cheek and in the oral cavity. Lesions on the face may cause visible deformity. Numerous treatment methods have been described for pyogenic granuloma. Lesions involving the reticular dermis, may be out of the reach of pulsed-dye laser, cautery or shave excision and therefore have a recurrence rate of 43.5%. Definitive management requires full-thickness skin excision. Other options are curettage or laser therapy. Furthermore, thorough curettage and cauterization are often used for small lesions and full-thickness excision for larger lesion.

VASCULAR MALFORMATIONS Vascular malformation is a collective term for different disorders of the vasculature (errors in vascular development). It can be a disorder of the capillaries, arteries, veins and lymphs or a disorder of a combination of these (lesions were named based on the primary vessel that was malformed). A vascular malformation consists of a clew of deformed vessels, due to an error in the vascular development (dysmorphogenesis). However, endothelial turnover is stable in these defects. Congenital vascular malformations are always present at birth, although they are not always visible. In contrast to vascular tumors, vascular malformations do not have a growth phase, nor an involution phase. Vascular malformations tend to grow proportionately with the child. Vascular malformations never regress, but persist throughout life. Vacular malformations can be divided in slow-flow vascular malformations, fast-flow vascular malformations and complex-combined vascular malformations. Slow-Flow Vascular Malformations Capillary malformation (also known as port-wine stain): Capillary malformations are flat, reddish lesions that typically affect the skin, mostly around the head and the neck, who darken with age, contrary to birthmarks such as salmon patch, Nevus simplex or vascular stain, who lighten or disappear within the first few years of life. Capillary malformations are 11% of the vascular malformations. Syndromes associated with capillary malformations are: Sturge-Weber syndrome and Klippel-Trenaunay syndrome. Capillary malformations can be treated with IPL-(Intensed-pulsed-light)-therapy or surgical reduction. Venous malformation is a bluish lesion compressible on palpation, the masses enlarge with physical activity or a dependent position. The bluish lesion is caused by dilated venous channels. Venous malformations can be painful in the morning due to stasis and microthrombi within the veins. Venous malformations’ localization is usually in the head and neck. Venous malformations are the most common vascular anomaly, they are 40% of all vascular malformations. Venous malformation can be treated with sclerotherapy and surgical reduction. Lymphatic malformation is a benign growth of the lymphatic system. They result from a blockage or defect of the lymphatic vessels as they are forming. 28% of all vascular malformations consists of lymphatic malformations. Lymphatic malformations can be treated with sclerotherapy and surgical reduction. Fast Flow Vascular Malformations All fast flow malformations are malformations with an arterial type in it. Contain about 14% of the vascular malformations. Arterial malformation Arteriovenous fistula (AVF) : a lesion with a direct transition in fistulas between an artery and a vein. Arteriovenous malformation : a lesion with a direct connection between an artery and a vein, without an intervening capillary bed, but with an interposed nidus of dysplastic vascular channels in between. Congenital Nevus Congenital melanocytic nevus is a type of melanocytic nevus (or mole) found in infants at birth. This type of birthmark occurs in an estimated 1% of infants worldwide; it is located in the area of the head and neck 15% of the time. Congenital melanocytic nevi may be divided into the following types: Small-sized congenital nevocytic nevus is defined as having a diameter less than 2 cm. Medium-sized congenital nevocytic nevus is defined as having a diameter more than 2 cm but less than 20 cm. Giant congenital melanocytic nevus (also known as “Bathing trunk nevus,” “Garment nevus,” “Giant hairy nevus”, and “Nevus pigmentosus et pilosus”) is defined by one or more large, darkly pigmented and sometimes hairy patches. SIGNS AND SYMPTOMS The congenital melanocytic nevus appears as a circumscribed, light brown to black patch or plaque, potentially very heterogeneous in consistency, covering any size surface area and any part of the body. As compared with a melanocytic nevus, congenital melanocytic nevi are usually larger in diameter and may have excess terminal hair, a condition called hypertrichosis. If over 40 cm projected adult diameter with hypertrichosis, it is sometimes called giant hairy nevus; more usually these largest forms are known as large or giant congenital melanocytic nevus. The estimated prevalence for the largest forms is 0.002% of births. Melanocytic Nevi often grow proportionally to the body size as the child matures. As they mature, they often develop thickness, and become elevated, although these features can also be present from birth. Prominent terminal hairs often form, especially after puberty. With maturity, the nevus can have variation in color, and the surface might be textured with proliferative growths. DIAGNOSIS Benign congenital nevi can have histological characteristics resembling melanomas, often breaking most if not all of the ABCD rules.

Whether we notice it or not, full cheeks are often a part of how we judge a person’s face. Cheek implants can have a major impact on the appearance and self-confidence of a person whose cheeks have thinned or sunken due to age, illness or other causes. Likewise, the chin helps provide harmony to the facial features. Patients often seek a smaller nose when, in fact, a chin augmentation provides a balance to the facial features. Implant sizes and shapes to augment the cheek and chin areas are tailored to each patient’s desired appearance. The implants are placed during an outpatient procedure under local or general anesthesia, which usually takes less than an hour to perform. Your doctor will make the necessary incisions in inconspicuous locations to allow for minimal scarring.

Ear surgery, or otoplasty, is a cosmetic procedure to improve the appearance of a person’s ears. Although otoplasty does not affect hearing, it can provide great psychological benefits to anyone who has been teased about the size or shape of their ears, has had a serious ear injury, or simply wants to improve their appearance. Otoplasty typically serves two functions: setting prominent ears back closer to the head, and reducing the size of large ears. Ear surgery may also be helpful for the following conditions: Large or protruding ears Lop ear (top of the ear folds downward or inward) Cupped ear (a small ear) Shell ear (no outer curve in the cartilage) Large, stretched, or torn earlobes Earlobes with large creases and wrinkles Surgeons are also able to construct new ears for patients who are missing them from injury or other causes. CANDIDATES FOR OTOPLASTY Candidates for otoplasty may be anyone who feels self-conscious about their ears and wants to improve their appearance. Although the operation is most often performed on children aged four to fourteen, this procedure can be very beneficial to people of all ages. Ears are almost fully grown by age four, and early surgery can prevent a child from being teased in school. It is also important that you are in good general health and have realistic expectations about the outcome of the procedure. Discuss your goals of otoplasty with your surgeon so that you can achieve the results you desire. THE OTOPLASTY PROCEDURE Otoplasty, also known as ear pinning, generally lasts two to three hours and is performed on an outpatient basis. The type of anesthesia used typically depends on the age of the patient. General anesthesia is recommended for very young patients, while local anesthesia and a sedative may be used for older children and adults. The otoplasty procedure begins with a small incision made behind the ear, in the natural crease where the ear meets the head. The cartilage is then sculpted and bent into its new position to achieve the desired appearance. In some types of otoplasty, skin is removed but the cartilage is left in one piece and merely bent back on itself for a smaller-looking ear. After sculpting the cartilage to the preferred shape, sutures are used to hold the ear in the new position until healing is complete. A bandage is then wrapped around the head to ensure the new positioning. To achieve better balance, both ears may be operated on even if only one has a problem. OTOPLASTY RECOVERY Patients of all ages usually feel back to normal after a few hours, although the ears may ache or throb for a few days. Prescription medication will be made available to help alleviate any discomfort. A few days after the otoplasty procedure, the bandages around your head will be replaced with a surgical dressing that should be worn for about one week. The stitches will be removed within one week. Otoplasty patients should avoid sleeping on their side for the first two weeks after surgery. After about one week following otoplasty, children may return to school and adults are often able to return to work and resume normal daily activities. After the ears have healed completely, there will usually be a faint scar on the back of the ears. However, because of the strategic placement of the incisions in ear surgery, the scars should be virtually unnoticeable and will typically fade with time. RISKS AND COMPLICATIONS OF OTOPLASTY As with all surgery, there are risks associated with otoplasty. A small percentage of patients may develop a blood clot on the ear. This generally dissolves naturally or can be treated with a needle. Another potential risk is an infection in the cartilage, which can cause scar tissue to form. This can usually be treated with antibiotics, but may occasionally require surgery. Also, you should not expect your new ears to match exactly; even normal, natural ears are not identical. Complications are rare and usually minor, and can typically be minimized by choosing a qualified and experienced surgeon and by carefully following your surgeon’s aftercare instructions.

The deformity of face and jaw could significant impact in patient well being and quality of life. In addition, the deformity causes unacceptable appearance to the society, which lead to social isolation in many patients. The deformity could be after cancer surgery, trauma, infection, radiation injury, and congenital diseases. The Chaiyasate passionate in restore and rebuild the face back using innovated modern surgical techniques. It is common to bring a tissue and its blood supply from another part of the body to face area. The blood supply of interested tissue will be re connected to the neck vessel. This type of surgery called microvascular surgery. Dr. Chaiyasate has performed several hundreds of this type of surgery with very high success rate. The operation usually takes 6-8 hours from start to end. Generally, Dr. Chaiyasate will replace the missing tissue with “like” tissue. If the skin only is missing, the new replacing tissue will be skin. However, if the missing tissues are skin, muscle and bone. The reconstruction will be more complicated. The leg bone (fibula) with skin, the hip bone with skin, the forearm bone with skin could be brought up to the face to restore the missing bone and skin. This type of reconstruction requires a skilled plastic surgeon with artistic mind who understand facial proportion, facial anatomy, and science of beauty. Facial Paralysis Reconstruction Facial paralysis is a multifaceted disorder involving functional, cosmetic, and psychosocial issues. When the muscles of the face do not work, functional problems revolving around the eye sphincter and the oral sphincter can occur. The eye sphincter is crucial in protecting the cornea and providing appropriate lubrication to prevent irritation and potential desiccation and ulceration. The oral sphincter, comprising the orbicularis oris muscle, provides for oral competence. From a functional standpoint, this affect one’s ability to maintain liquids within the mouth and to produce effective bilabial sounds. Paralysis to the facial musculature can also have major aesthetic effects. These may range from an asymmetrical blink, which may be troublesome to some patients. On the severe end of the cosmetic scale, one may observe gross asymmetry at the rest with drooping of the involved side because of lack of muscle support and tone. These facial differences produced by the asymmetry can have devastating emotional consequences. The lack of active normal facial musculature can impact on the psychosocial wellbeing of patients. This is mainly reflected in asymmetrical or absent of facial expression. The quality and progression of the interaction are compromised and a variety of misinterpretations may occur. Thus the facial muscle is paramount in an individual’s ability to effectively communicate, interact normally on a psychosocial basis, appear within the scope of normality on a cosmetic basis, and to provide functional protection against corneal exposure and oral incompetence. For Moebius syndrome, Dr. Chaiyasate prefers to wait until children are at least 5 years of age. For the adult patients, the reconstruction can be performed at any age. The surgical approach to the management of facial paralysis will be divided into the upper face and lower face. The upper face will be addressed as it relates to the brow, to the upper eyelid, and to the lower eyelid. The lower face will be addressed as it relates to the noise and cheek, the commissure, and upper lip and lastly the lower lip. Dr. Chaiyasate’s approach includes: Drooping eyebrow : corrected by Brow Lift. Unable to close upper eyelid : corrected by upper lid gold weight loading or dynamic upper lid support with a temporalis transfer. Toneless Lower lid : corrected by lower eyelid tendon sling. Asymmetry Lower lip : corrected either by static suspension with tendon graft or dynamic reconstruction with gracilis muscle transplantation.

The external ear is composed of a complex cartilaginous framework giving rise to the many involutions and folds that make ear reconstruction a challenging task. Missing a part of the ear or all parts of the ear could lead to a significant psychosocial embarrassment, which lead to social isolation and low self esteem. The defect of the ear could be congenital or acquired. The congenital missing ear is commonly referred to “microtia”. The most common causes of acquired missing ear are cancer and trauma. Microtia is estimated to occur in 1 in 7,000-8,000 births. Eighty percent of cases of microtia or anotia are unilateral, with just over half occurring on the right side, and there may be a male preponderance. Many microtia patients have associated congenital craniofacial difference such as hemifacial microsomia, Goldenhar syndrome and Treacher Collin syndrome. ‘Isolated’ microtia occurs in about 65% of cases. The ear reconstruction could be divided to “partial reconstruction” and “total ear reconstruction”. The treatment options for partial ear reconstruction include local tissue flaps, and skin grafts. The framework reconstruction from rib cartilage graft or opposite ear may be indicated depending on the size of the defect. Dr. Chaiyasate will evaluate the defect and come up with surgical plans specifically for your deformity. The total ear reconstruction including “microtia” reconstruction is much more complex. The ear framework is needed to be reconstructed. There are two options for framework reconstruction including patient own rib cartilage (autologous)or premade ear framework implant (alloplastic). In Autologous reconstruction, the pieces of rib cartilage are carved to match the opposite ear and placed underneath the affected side. In alloplastic reconstruction, the ear framework implant was inserted underneath the skin just like the autologous reconstruction. No matter what framework is chosen, it is important to make sure that the skin and soft tissue on the affected side is healthy to allow to framework to heal without extrusion. The total ear reconstruction is multi stage reconstruction. It is usually takes 2-4 stage to complete a reconstruction. Dr. Chaiyasate will use his craniofacial skills combined with microvascular skills to come up with the best surgical plans specifically for individual patient.

The dominant cosmetic impact of the nose on the central face renders any deformity of its significant, and markedly affects the patient’s overall appearance and sense of self. Dr. Chaiyasate’s principle of nasal reconstruction includes: The use of own tissues can be considered to represent the old standard for successful nasal reconstruction. Optimal results are achieved through a staged approach, allowing suitable time for healing and recovery of the tissues before the next intervention. All of the affected or missing parts must be restored to achieve both a cosmetic and a functional reconstruction.

Rhinoplasty, or nose surgery, is one of the most common plastic surgery procedures performed today. It can reshape, reduce or augment a person’s nose to achieve facial harmony and boost self-confidence. It may be performed as a reconstructive procedure to correct a birth defect or an injury such as a broken nose. Rhinoplasty may be performed for functional rather than cosmetic reasons as well. Combining nose reshaping with septoplasty or endoscopic sinus surgery can effectively treat certain breathing problems, such as those caused by a deviated septum. GOALS OF RHINOPLASTY Rhinoplasty is an excellent procedure for achieving the following: Balance the size of the nose with the other facial features Modify the width of the nose at the bridge Improve the nasal profile, including removing humps or depressions Contour a nasal tip that is too large, “boxy,” drooping or upturned Change the angle between the nose and the mouth Narrow and reshape the nostrils Correct asymmetry or deviation THE RHINOPLASTY PROCEDURE Rhinoplasty is usually an outpatient procedure performed under IV sedation or general anesthesia. Surgeons use one of two techniques when performing nose surgery. In a closed rhinoplasty, incisions are made within the nostrils. In an open rhinoplasty, the incision is made across the columella, the tissue between the nostrils. With both methods, the surgeon gently lifts the soft tissues covering the nose. He or she sculpts the bone and cartilage to the desired shape. Any additional cartilage needed to augment the nose can often be taken from the septum. If the patient has a deviated septum, the surgeon will adjust the septum and the inner structures of the nose to improve breathing. Then the tissues are re-draped and stitched closed. If the patient desires nostril reshaping, this is done as the final stage of rhinoplasty. The entire procedure generally lasts one to two hours. RECOVERY AND RESULTS AFTER RHINOPLASTY For a short time after surgery, patients may experience puffiness, nose ache or a dull headache, some swelling and bruising, bleeding or stuffiness. Most patients feel like themselves within two days and return to work in about a week. The results of rhinoplasty become gradually apparent as the days pass after surgery and swelling recedes. Swelling may reappear from time to time in the first year after the procedure. It is typically more noticeable in the morning and fades during the day. Contact lenses can be worn immediately, but glasses may need to be taped to your forehead or propped on your cheeks for up to seven weeks. Patients with realistic goals for rhinoplasty are generally very happy with the new shape of their nose. The exact results depend on the patient’s nasal bone and cartilage structure, facial shape, skin thickness and age. Revision Rhinoplasty Many people who have undergone a rhinoplasty may be unhappy with the aesthetic and/or functional results of their procedure, and may seek additional surgery to correct their problem in order to achieve the results they desire. Unsatisfactory results may occur as a result of a complicated condition, an inexperienced surgeon, or simply due to the patient’s healing techniques. Revision rhinoplasty, also known as secondary rhinoplasty, is a complicated procedure that is most successfully performed by a rhinoplasty specialist to reshape or resize the nose after an initial procedure. Some of the problems patients complain of after their initial rhinoplasty procedure include: Pinched tip Pulled up nostrils Creases around the nostrils Scooped out profile Breathing difficulties These problems can range from minor imperfections to severe deformities. Dr. Chaiyasate strives to help patients achieve the highest level of satisfaction from their rhinoplasty and will do his/her best to produce the results that the patient desires. CANDIDATES FOR REVISION RHINOPLASTY Anyone who is unhappy with the results of their initial rhinoplasty procedure may be a candidate for revision rhinoplasty. Patients should discuss their initial procedure with either their original surgeon or a different one in order to determine the new goals for revision. It is also important for patients to be both emotionally and financially prepared for additional surgery. Your doctor will determine whether or not revision surgery is a possibility for you after discussing your goals for surgery and performing a physical examination. REVISION RHINOPLASTY PROCEDURE The revision rhinoplasty procedure is usually performed on an outpatient basis under deep sedation or general anesthesia to help reduce any potential discomfort. Revision rhinoplasty is usually performed using an open technique, allowing for greater visualization of the nasal cavity because the already-reshaped bone and cartilage may be more difficult to sculpt.

A facelift is one of the most common plastic surgery procedures available, designed to treat wrinkles, sagging and skin laxity within the face for a younger, more refreshed appearance. As we age, the effects of time, gravity, sun exposure and stress inevitably take their toll on our faces, producing wrinkles, folds, fat deposits and loose skin. Patients unhappy with the changing appearance of their face may seek relief through a facelift. This time-tested procedure targets the mid- to lower face, including the cheeks, mouth, chin and neck. Ideal candidates are usually those in their 40s, 50s or 60s looking to reverse the early signs of aging in the face, are generally healthy and have realistic expectations for surgery. PROCEDURE During the facelift procedure, an incision is made around the ear, sometimes extending into the scalp. There are several different techniques that may be used depending on each patient’s facial structure and desired goals, but most include sculpting, lifting and repositioning the underlying fat, muscle and deep tissues, while also trimming and redraping the skin for dramatic yet natural-looking results. In most cases, a facelift is performed under general anesthesia, but may be performed under a local anesthetic and sedation for some patients. The entire procedure usually takes two to four hours to perform on an outpatient basis. RECOVERY After a facelift, patients may experience mild discomfort, bruising, swelling and drainage for a few days. You can wash your hair after two days and can likely return to work within a week. It is recommended that patients avoid strenuous activity for four to six weeks after surgery until swelling has completely subsided. The results of the facelift will be immediately noticeable and will continue to improve for up to three months, as swelling and other side effects begin to fade. While results are not permanent and do not make patients immune to the effects of aging, you will continue to look younger than if you had never undergone any treatment.

Browlifts (forehead lifts) can revitalize drooping or lined foreheads, helping you look less angry, sad or tired. Using either traditional or minimally invasive (endoscopic) methods, browlifts involve the removal or alteration of the muscles above the eyes to smooth lines and raise the eyebrows for a more youthful appearance. The procedure is often combined with other operations such as blepharoplasty (eyelid surgery) and facelifts to improve the look of the eyes and other areas of the face. TRADITIONAL BROWLIFT First, the patient’s hair is tied with rubber bands near the incision site. Then the surgeon makes a coronal (headphone-shaped) incision behind the hairline, stretching between the ears and across the top of the forehead. The incision may be placed further back or made along the skull bone joints to minimize its appearance in patients with thinning hair or who are bald. Then the forehead skin is lifted, tissue is removed, muscles are adjusted and the eyebrows may be lifted. Excess skin is trimmed and the incision is closed with stitches or clips. The site is washed and the rubber bands are removed. Some surgeons will protect the stitches with gauze or bandages. ENDOSCOPIC BROWLIFT After the hair is tied as with the traditional procedure, the surgeon makes three to five short incisions (less than an inch long) behind the hairline. The endoscope is placed in one so the surgeon can see beneath the skin without having to make a large incision, while he or she lifts the skin and adjusts muscles through the other incisions. If the eyebrows are lifted they will be stitched or screwed (temporarily) into place. The site is washed and the rubber bands are removed. Some surgeons will protect the stitches with gauze or bandages. With both procedures, you will be on your feet and able to wash your hair in a day or two, and many patients return to work or school in 7-10 days or less. Swelling and bruising should fade by the third week.

By removing excess fat, skin and muscle from the upper and lower eyelids, blepharoplasty can rejuvenate puffy, sagging or tired-looking eyes. It is typically a cosmetic procedure but can also improve vision by lifting droopy eyelids out of the patient’s field of vision. Blepharoplasty cannot be used to raise the eyebrows or reduce the appearance of wrinkles, crow’s feet or dark circles under the eyes, but the procedure can be combined with others such as a facelift and Botox ® treatments to achieve these results. The procedure is usually performed in an office with local anesthesia and lasts 45 minutes to a few hours depending on how much work is done. Incisions are made along the eyelids in inconspicuous places (in the creases of the upper lids, and just below the lashes on the lower lids). The surgeon removes excess tissue through these incisions and then stitches them closed with fine sutures. In the case that no skin needs to be removed, the surgeon will likely perform a transconjunctival blepharoplasty, where the incision is made inside the lower eyelid and there are no visible scars.

Cosmetic eyelid surgery is the most common elective procedure among people of Asian ethnicity in the United States and in Asia. The procedure can thin a full eyelid, alter the shape or height of the upper or lower eyelid, decrease a pronounced epicanthal fold (the flap of tissue on the nasal side of the eyelid), or create a natural-looking crease in a double eyelid, which occurs in about 50-70% of the Asian population. A common misconception is that blepharoplasty is performed to “Westernize” the eyes in an attempt to look “less Asian.” While each person’s reasons for having surgery are unique, this kind of cultural dissatisfaction is almost never a factor. Rather, the overall goal is to help the patient look and feel his or her best by changing the eyelid shape to achieve a more attractive or younger look, balance the facial features and boost self-confidence. The procedure itself varies depending on the techniques used as well as the patient’s goals and eyelid anatomy. Generally, the surgery is performed under local anesthesia. An incisional approach is usually taken for double eyelid surgery, in which the skin and sometimes muscle are trimmed and some fat may be removed. In some cases, particularly for lower eyelid surgery, a transconjunctival (minimally invasive) approach is possible. Occasionally, the physician may be able to employ a non-incisional method using permanent sutures. Incisions and sutures are carefully placed to minimize visible scarring.

Lip augmentation increases the size of the lips through a variety of surgical and nonsurgical techniques that provide temporary or permanent results, depending on the type of material used. This procedure may be performed on one or both lips, and offers patients noticeable yet natural-looking results through a single treatment session. This procedure is often combined with others, such as a facelift, rhinoplasty or chin augmentation to achieve a fully rejuvenated, balanced facial appearance. PROCEDURE There are several different options to enhance the lips, each offering patients different benefits. Injectable fillers such as Restylane®, Hylaform® and Artecoll® are performed on an outpatient basis and are injected directly into the lips for safe, noticeable results that can last for several months. Additional injections can help maintain the results of this procedure. For more permanent results, implants can be placed in the lips during a surgical procedure performed under local anesthesia. During this procedure, an incision is made inside the mouth to place an implant material taken from the patient’s own body, a donor or made from synthetic materials. Many patients satisfied with the appearance of their enhanced lips through injectable fillers seek lip augmentation with implants for long-lasting results. Your surgeon will discuss these options with you and determine which method is best for you during your pre-surgical consultation.

Breast augmentation is one of the most frequently performed cosmetic surgery procedures in the U.S. and one of our most popular services. Breast augmentation can give women with small or unevenly sized breasts a fuller, firmer, better-proportioned look through the placement of saline or silicone implants in the breast. Our patients elect to undergo breast augmentation for many different medical and aesthetic reasons, including balancing breast size, compensating for reduced breast mass after pregnancy or surgery, and correcting a congenital breast defect. Under our doctors’ expert care, patients enjoy great-looking, natural-feeling breasts that are one or more cup sizes larger after the operation. FULLY CUSTOMIZED BREAST ENHANCEMENT We know that every woman is unique in both her desires and her body shape. With that in mind, we take the time during the pre-operative consultations to learn what each patient hopes to gain from breast augmentation surgery and to decide which implant type and implant placement is best. In this way, every one of our patients enjoys completely customized treatment designed with her specific goals in mind. COMPLEMENTARY PROCEDURES Breast augmentation can achieve dramatic and beautiful results on its own as well as in conjunction with other cosmetic surgery or non-invasive procedures. We sometimes recommend combining breast augmentation with other procedures such as a breast lift for more satisfying results. SALINE AND SILICONE GEL BREAST IMPLANTS Breast implants are silicone shells filled with either saline (salt water) or silicone gel. Both implant types are very safe, and each offers its own advantages. We will help you decide which kind is right for you. During surgery, we will place the implants behind each breast, underneath either breast tissue or the chest wall muscle. After many years, the U.S. Food and Drug Administration (FDA) has approved silicone breast implants for breast augmentation surgery. We are proud to offer patients the option of silicone gel-filled breast implants, since they are much softer and feel more natural than saline-filled breast implants. BREAST AUGMENTATION SURGERY – INCISION TECHNIQUES The breast augmentation procedure lasts one to two hours and is typically performed with general anesthesia. Incisions are made in inconspicuous places on the breast to minimize scar visibility. These may be located: In the armpit (Transaxillary), In the crease on the underside of the breast (Inframammary), or Around the areola, the dark skin around the nipple (Periareolar). The breast is then lifted, creating a pocket into which the implant is inserted. Saline implants may also be placed endoscopically through an incision in the navel. This minimally invasive breast enhancement technique is known as a Transumbilical Breast Augmentation or TUBA approach. BREAST AUGMENTATION SURGERY – PLACEMENT OPTIONS Implant placement beneath the muscle of the chest offers a few advantages over placement beneath the breast tissue only. These include reduced risk of capsular contracture (post-operative tightening around the implant) and less interference with mammogram examinations. Possible disadvantages include need for drainage tubes and elevated pain in the first few days following surgery. We will discuss which option may be best for you. After the implants have been inserted and positioned beneath the nipples, the incisions are stitched closed, then taped and bandaged. In a few days, these bandages may be replaced with a surgical bra. RECOVERY Most patients feel tired and sore after breast augmentation surgery, but this usually passes in a day or two. Many patients return to work within the week. Stitches are removed in a week to 10 days after breast augmentation. Any post-operative pain, swelling and sensitivity will diminish over the first few weeks. Scars from breast augmentation incisions will begin to fade in a few months and will continue to fade for months or years.

A breast lift, or mastopexy, is performed to return youthful shape and lift to breasts that have sagged as a result of weight loss, pregnancy, loss of the skin’s natural elasticity or simply the effects of gravity.The procedure can also reduce areolar size (the dark skin surrounding the nipple), and it can be combined with augmentation mammaplasty (breast augmentation) for added breast volume and firmness. Breasts of any size can be lifted, but results last longest when they are originally small and sagging. Women planning to have children are advised to postpone surgery, since pregnancy and nursing can counteract its effects by stretching the skin. However, breast lift should not affect your ability to breast-feed. Breast lift may be performed in a hospital, an outpatient surgery center or a surgeon’s office-based facility. It is usually done on an outpatient basis under general anesthesia, and lasts from 1-½ to 3-½ hours. A number of pre-operative steps are typically taken such as a mammogram, measurement of the bustline, and discussion with the surgeon about the desired size and shape of the breast and placement of the nipple. During the procedure an anchor-shaped incision is made from the location of the new nipple down to and around the crease beneath the breast. The surgeon removes excess skin, relocates the nipple and areola, and reshapes the breast using skin from around the areola before closing the incisions with stitches. Patients with small breasts and minimal sagging may be recommended for smaller-incision mastopexy. One such modified procedure is concentric (“doughnut”) mastopexy, in which two concentric circular incisions are made around the areola and a doughnut-shaped swathe of skin is removed. After breast lift surgery the breasts are wrapped with gauze dressings, over which an elastic bandage or a surgical bra is placed. After a few days this is replaced with a soft support bra which is worn 24 hours a day for about a month. Breasts will probably be bruised, swollen, and uncomfortable for a few days but this will pass. Numbness in the breasts and nipples should lessen as swelling subsides, although occasionally it lasts for months or even permanently. Stitches are removed after one to two weeks, and many patients return to work then.

Large breasts can negatively impact a woman both physically and emotionally, causing symptoms such as chronic back pain, rashes, poor posture, low self-esteem and restricted activity. Many women seek treatment to reduce the painful effects of their large breasts, while also improving their self-confidence and overall quality of life. Also known as reduction mammaplasty, breast reduction surgery reduces the size of large, disproportionate breasts by removing excess fat, tissue and skin for a more desirable appearance and relief of physical and emotional symptoms. During the breast reduction procedure, the surgeon makes either two circular incisions around the nipple or an anchor incision that circles the nipple and extends down the breast and along the breast crease. Fat and glandular tissue is then removed, while excess skin is tightened to produce a smaller, natural-looking breast. In some cases, the nipple and areola may need to be removed and then repositioned higher on the breast. The results of a breast reduction are visible right away and will continue to improve as swelling and bruising subside. Scars will continue to fade over time, becoming less and less noticeable.

We are proud to offer patients our extensive experience and expertise in liposuction, the single most popular cosmetic surgery procedure in the U.S. today. Liposuction sculpts the body by removing undesirable fat that has not responded to diet and exercise from the abdomen, waist, hips, buttocks, thighs, knees, upper arms, chin, cheeks and neck. Liposuction not only offers the opportunity to slim and contour chubby areas of the body; by removing the fat cells, it also ensures that these areas will not accumulate fatty deposits in the future. PERSONALIZED CARE Our doctors know that all patients are different, both in their body shapes and in what they wish to achieve with liposuction. We take as much time as necessary during every pre-operative consultation to learn what each patient wants liposuction to do for them, and to decide which technique is best. In this way, every one of our patients enjoys completely customized treatment designed with his or her specific goals in mind. LIPOSUCTION TECHNIQUES The liposuction procedure begins with the injection of a solution composed of saline (salt water), a local anesthetic called lidocaine, and a small amount of adrenaline to decrease bruising and bleeding. This is known as either the tumescent or super-wet technique, depending on the ratio of the fluid to the fatty tissue being removed. Once this solution has been introduced into the area planned for liposuction treatment, the doctor proceeds with one of two different methods of liposuction currently approved by plastic surgeons: suction-assisted lipectomy (SAL) or ultrasonic-assisted lipectomy (UAL). In both methods, a tiny incision is made in as inconspicuous a place as possible. In SAL, a cannula (small tube) is inserted and moved back and forth beneath the skin, breaking up the fat layer and suctioning it out. In UAL, ultrasonic energy is used to liquefy the fat before it is suctioned out with a cannula. The liposuction procedure may last from one to five hours, depending on the amount of fat being removed. The doctor will use either local anesthesia or general anesthesia, again depending on the size of the area(s) being treated as well as several other factors. We will discuss which method is best for you during your preoperative consultation. RECOVERY After liposuction surgery, drainage tubes, compression garments and antibiotics may be needed to facilitate the healing process. Patients are encouraged to walk as soon as they are able, and many return to work within a few days. Strenuous activity should be avoided for about a month. RESULTS OF LIPOSUCTION Results are visible immediately, and improvement often continues as swelling subsides during the first three months.

If you want to enlarge or reshape your buttocks and have discovered that the area does not respond to diet or exercise, buttock augmentation may be the solution you’ve been looking for. A buttock lift (butt lift) contours the buttocks and compensates for low amounts of fat in the area. Women and men who enlarge their bottoms can enjoy a more voluptuous and perky profile. This type of augmentation can be safely achieved through injections of the patient’s own body fat. Buttock augmentation with fat transfer, also known as the Brazilian butt lift in honor of the country in which it was developed, is performed with the patient under general anesthesia. The surgery involves two steps. First, the patient’s own fat is collected through a process similar to liposuction. The most popular areas for harvesting fat before buttock augmentation are the lower back, waist, flanks (love handles), thighs and stomach. This not only provides the raw material for buttock enhancement, it also contours the areas around the butt for a more dramatic result. The fat that has been removed is then purified using a special device so that the fat cells are ready to be reintroduced to the body with minimal reabsorption. In the second step, the harvested fat is added to the buttocks with hundreds of tiny injections at a variety of depths to ensure an even, attractive augmentation. This method of fat injection lends a shapely contour to the buttocks that lasts a long time. Special attention is given to the upper buttocks so the entire rear looks youthfully and naturally lifted. The entire procedure will typically take between two and four hours. FAT TRANSFER VS. IMPLANTS The preferred method for performing buttock augmentation is a Brazilian butt lift because it uses the patient’s own body fat to reshape the butt. Fat injection achieves a more natural result, has a lower risk of infection and no risk of allergic reaction or rejection. In addition, this procedure contours the areas around the buttocks to enhance the overall effect. Implants are generally only recommended for patients who have very little body fat to harvest, such as body-builders and those patients who are exceptionally thin. RECOVERY After a Brazilian butt lift, patients should avoid sitting directly on the buttocks or lying on their backs for two to three weeks to maximize results. During this time, compression garments may be worn to reduce swelling. Patients may experience some pain or discomfort, bruising and swelling after the procedure. Most patients return to work two weeks after their buttock augmentation and are able to resume all normal activities within four weeks. Swelling typically dissipates by the sixth week and the final outcome is visible.

Giving birth can be one of the most rewarding experiences of a woman’s life. Unfortunately, pregnancy and breastfeeding often result in unwanted changes in a woman’s body, such as drooping breasts, enlarged areolas, a straighter waist, pockets of fat in the abdomen, stretch marks, and a sagging tummy that no amount of exercise and dieting seems to fix. The loose muscles and stretched skin improve somewhat over time, but the body never completely returns to the way it was before pregnancy. It used to be that women were resigned to living with these natural changes in their bodies. Now, however, more and more women are seeking out plastic surgeons to rejuvenate their breasts and tummies to the youthful firmness they enjoyed before having children. These procedures are collectively called “mommy makeovers” or post-maternity breast and body reshaping. MOMMY MAKEOVERS: BREAST LIFT The aftermath of pregnancy can leave you with sagging breasts, uneven breasts, lost breast volume, drooping nipples and stretched areolas (the dark skin surrounding the nipple). A breast lift, or mastopexy, is performed to reverse these changes and return a youthful shape and lift to your breasts. This is accomplished by trimming excess skin and tightening supporting tissues to achieve an uplifted, youthful contour. After a mastopexy, the breasts are higher on the chest and firmer to the touch. Breast lifts after pregnancy can also reduce areolar size and reposition downward-pointing nipples. Your post-maternity breast lift will be tailored to you, depending on your individual case and goals. Breast size does not change after a breast lift, nor does the fullness or roundness in the upper part of the breasts. Women who desire larger, smaller or more rounded breasts may want to consider a breast augmentation or breast reduction together with a breast lift. MOMMY MAKEOVERS: BREAST REDUCTION Most women find that their breasts swell to a fuller size and shape while they are pregnant. Afterwards, a natural reduction in breast size leaves some women with the empty-looking, drooping breasts discussed above in the breast lift section. For many other women, however, the breasts remain larger than desired after childbirth. Breast reduction surgery may be the solution in these cases. One reason women may seek breast reduction after giving birth is to return the breasts to the smaller size they had before becoming pregnant. In addition, breast reduction can relieve the common symptoms of large breasts, such as pain, improper posture, rashes, breathing problems, skeletal deformities and low self-esteem. Breast reduction achieves these goals by removing fat and glandular tissue and tightening skin to produce smaller, lighter breasts that are in a healthier proportion to the rest of the body. Note: Breast reduction surgery is not recommended for women who intend to breastfeed in the future, since many of the milk ducts leading to the nipples are removed. MOMMY MAKEOVERS: TUMMY TUCK Perhaps nowhere else on the body is pregnancy more unforgiving than in the abdomen. By stretching and weakening the skin and muscles of the tummy and waist, pregnancy can leave you with loose skin, stretch marks and a straighter waistline that no amount of exercise will correct. A tummy tuck, also known as abdominoplasty, can help. Tummy tucks help to flatten and shape the abdomen and waist by removing excess skin and tightening muscles. The result is a firmer tummy and more defined waistline. Our doctors have been performing abdominoplasties with excellent cosmetic results for many years. Women who also suffer from areas of fat in the abdomen or flanks after pregnancy may benefit from liposuction. Note: Results from the tummy tuck procedure will likely diminish if women continue to bear children, so we advise patients who plan to become pregnant to delay abdominoplasty. MOMMY MAKEOVERS: LIPOSUCTION New mothers may find that they have pockets of fat in the lower abdomen that don’t respond to diet or exercise. They may also find that they have lost definition in their waistline. Women who had C-sections may also suffer from areas of fat hanging over their surgical scar. Each of these post-maternity body changes can be improved through liposuction. Liposuction sculpts the body after pregnancy by removing undesirable, resistant fat from the abdomen, waist, hips, buttocks and/or thighs. It offers the opportunity to slim and contour areas of the body that did not “spring back” to their pre-baby tone. With liposuction, you can minimize areas of fat caused by pregnancy and enhance the curve of the waistline. There are several different methods surgeons use when performing liposuction, including ultrasound-assisted lipectomy (UAL) and suction-assisted lipectomy (SAL). In both types, fluid is injected into the area to be treated.

Major weight loss achieved through either natural means or bariatric surgery is a great accomplishment that allows patients to significantly improve their appearance and overall quality of life, while also reducing the risk of weight-related health conditions. After large amounts of weight loss, many patients are left with loose, hanging skin that has been stretched out by the excess weight and does not conform to the body’s new contours. There may also be one or more problem areas that has not responded well to weight loss methods and still contains localized areas of stubborn fat. Many patients seek body contouring procedures to complete the weight loss process and achieve a smooth, toned appearance that they will be proud to show off. Body contouring procedures often target problem areas such as the: Abdomen Buttocks Thighs Breasts Arms Face Multiple procedures may be needed in order to achieve desired results and to reduce the trauma of treating several different body areas at once. Your surgeon will develop a personalized treatment plan for you based on your individual needs and goals for surgery.

Abdominoplasty, often called a tummy tuck, is a very popular surgery in America. Tummy tucks help flatten and shape the abdomen and waist by removing excess fat and skin and tightening muscles. Our doctors have been performing abdominoplasties with excellent cosmetic results for many years. Patients love the look of their new flat stomachs after surgery under our doctors’ exceptional care. The best candidates for abdominoplasty are in good physical condition with pockets of fat or loose skin that haven’t responded well to diet and exercise. We can also help older, slightly obese people whose skin has lost some of its elasticity. Abdominoplasty can also be useful for women with stretched skin and muscles from pregnancy. Results from the tummy tuck procedure will likely diminish if women continue to bear children, so we advise patients who plan to become pregnant to delay abdominoplasty. PROCEDURE Abdominoplasty takes approximately two to five hours under general anesthesia. The surgeon will make two incisions: one from hipbone to hipbone close to the pubic area, and another around the navel. He or she will separate the skin from the abdominal muscles, which are then pulled together and stitched into place for a firmer abdomen and narrower waist. He or she will stretch the skin flap down and over the newly tightened muscles, remove excess skin, and reattach the navel in a natural position. Finally, he or she will close the incisions and apply sterile surgical dressings over the sutured areas.

As we get older, our buttocks and thighs may begin to droop and sag like other areas of the body, such as the breasts and stomach. Stubborn pockets of localized fat may develop as well, which do not go away despite traditional weight loss attempts such as diet and exercise. Fortunately, like these other areas, there are surgical options available for reversing these changes and restoring a tighter, firmer and more youthful appearance to the buttock and outer thigh area. These cosmetic procedures can be performed alone, or in combination with other cosmetic procedures, such as part of a body lift or with a gluteal augmentation. When combined with other procedures, patients can achieve maximum aesthetic results and enjoy a younger and more refreshed appearance overall. PROCEDURE The buttock and outer thigh lift procedure is performed on an outpatient basis under general anesthesia. The entire procedure usually takes two to three hours to perform. Your doctor will place the incision across the top of the buttocks, low enough to be concealed by underwear or a bikini. This incision spreads along the back from one hip bone to the other. After the incision is made, excess skin and fat are removed from the buttocks and thighs. This may be done using liposuction if there is a large amount of fat to be removed. The skin is then stretched to position the buttocks and thighs into their new position, and the area is sutured closed. Compression garments are usually applied to help reduce swelling and expedite the healing process. Some patients may need to stay overnight after this procedure, while others can leave shortly after the effects of anesthesia have worn off.

Also called belt lipectomy, torsoplasty and panniculectomy, the circumferential body lift is performed to remove excess skin from the torso and upper legs. Candidates for body lifts typically suffer from loose (inelastic) skin on many or most areas of the body as a result of age, childbearing or significant weight loss due to diet, exercise or bariatric surgery. Because of this, the procedure is often combined with others such as breast lifts, arm lifts and liposuction to retain a proper body proportion. Body lifts tighten and tone the abdomen, back, buttocks, hips and thighs. During the procedure, skin is lifted from underlying tissue, muscles are tightened and stitched, fat is removed where necessary, and the skin is sutured closed. The navel is often removed and replaced in its new position. Surgical tubes may be needed for a few days to drain any fluid, and patients may need to wear compression garments for a few weeks to facilitate faster healing. After surgery, patients are encouraged to walk as soon as they are able to, although strenuous activities must be limited for about a month. Results are visible immediately.