Until about two years ago I viewed elective surgical reshaping of the neck differently than I do now. Then, I thought of the neck lift operation as something that should or should not accompany a face lift operation. Now, I view the neck quite differently. In many ways, I often find myself assessing whether a face lift should accompany the neck lift operation.

When examining the postoperative patient, my eyes begin and finish with the contour of the neck. The neck ultimately serves as the elegant pedestal for the face above. Without such elegance, even the perfect jawline and facial features seem incongruous. In fact, while suboptimal, the opposite also holds truth. That is, sometimes the beautifully contoured neck makes more youthful an unaddressed jawline or mild jowls, as in the photo below.

I have learned there can be no cookbook approach to neck lift surgery. As many specialized facial surgeons would attest, this seems true for most aspects of facial plastic surgery. As do the nose, midface, and lower eyelids, the neck affords a set of challenges unique to each patient. These challenges require a deciphering eye, a preoperative plan, likely intraoperative evaluation and adaptation, and action with careful attention to detail.

For example, any neck can have a variable amount of subplatysmal fat (fat deep to the muscle of the neck), submental fat (fat beneath the skin of the neck), cervical skin laxity (looseness versus elasticity of skin), position of cartilaginous structures (which often afford the scaffolding for soft tissue redraping), associated projection of mandible and chin, thickness and integrity of platysma muscle (thin sheet of muscle of the neck), size and prominence of submandibular glands, lateral triangle fat (fat adjacent the angle of the mandible), associated jowls, length, and associated hairline. Each of these elements (and more) is addressed specifically, and in relation to one another with a customized neck lift. Therefore, neck lift surgery is really an art form that requires what I like to call “surgical sensibility.”

Many patients who consult with me, enter consultation believing they want a miniature face lift operation. These patients are often correct, when it comes to the face. However, when we speak about the neck, and the modest improvement any “miniature” operation can yield there, we often find ourselves focusing the next 20 minutes on many of the details involving their true reason for consultation. Most patients want significant improvement along the contours of the neck. Subsequent surgical planning is often affected more by focused conversation regarding the neck, than the face.

Just as each patient finds themselves captivated by their own neck, I find myself similarly engaged. Manipulations of the neck can exist across a broad spectrum, from subtle to significant. Over recent years I have refined my operative technique from being less extensive with dissection, to being much more extensive. I have learned to appreciate the true aesthetic importance of a beautiful neck, and all that is involved with creating one.  

As the accomplished neck surgeon Dr. Joel Feldman once wrote:

“Where, you ask, does Beauty dwell?

I’ll share what I’ve discovered –

That though the face may draw a crowd,

It’s the neck that lures a lover.”

I recently completed the book Rework by Jason Fried and David Heinemeier Hansson. It was a very refreshing read, and far off the typical tone and agenda of a business book. 

I came across Rework at a time in my life when many of the essays within the book have especially strong impact. Over the prior year, I’ve relearned the lesson to keep life as simple as possible. I used to feel just the opposite – that the greater the relative complexity and diversification, and the greater the number of “pots” my hands “were in,” the more interesting life becomes. I believe now, such a principal was true before my strong, time-tested interests and passions became galvanized.  Furthermore, I noticed the greater the complexity of my life, the harder it is to adapt, or change directions, or embrace an opportunity. So in fact, life is prospectively less interesting in that way.

The authors have a chapter entitled “Less Mass,” which centers exactly on this point. “Embrace the idea of having less mass.” Just as in the physical world, “the more massive an object, the more energy required to change its direction.” Mass is increased by contracts, meetings, organizations, long-term obligations, political tie-ups, hefty expenditures, and the like. By reducing mass, you can focus more energy on what drives and inspires you, and what is truly important in your life. In many ways, this is how I ended up choosing my surgical specialty. My brain more easily attaches to the notion of focusing on a relative few things “full-time.” In so doing, you can develop the expertise of a specialist. I’m a big believer in core competency and depth of specialty.

With “less mass,” the decisions made today don’t need to endure forever. As circumstances evolve or change, so can your perspective and associated decision-making. This is the advantage of being exactly the right size for yourself – not too big, and not too small. As the winds change, so easily can the course of the small sea vessel.

This directly ties in with the authors’ final chapter in Rework. They focus on the idea that “inspiration is perishable.” While ideas can last forever, inspiration quickly expires, “like fresh fruit or milk.” “Inspiration is a magical thing, a productivity multiplier, a motivator. But it won’t wait for you. Inspiration is a now thing. If it grabs you, grab it right back and put it to work.”

In sum, much can be said for keeping things simple, adapting and changing with ease, and capitalizing off inspiration with now-ness.

Part of what makes rhinoplasty such a tremendously interesting surgical procedure, is that there exists an interrelated geometry and physics among the various structures of the nose. That is, no isolated anatomic structure can be assessed, or certainly manipulated, without consideration of other anatomic structures. Each anatomic element of the nose exists in relation to the others, and maintaining a balance among the elements is the beautiful symphony that is rhinoplasty.

This thoughtfulness needs to be observed with regard to both considerations of form, as well as function. An overly narrowed middle vault of the nose may afford a small relative aesthetic gain for a certain nose, but the associated compromise in breathing may render the small aesthetic improvement unworthy. Decisions like these are made all of the time before and during the rhinoplasty procedure.

Regarding modifications of the nasal tip, true success comes in balance of appropriate aesthetic refinement with integrity of structure. That is, the tip should appear defined and well-shaped, but should be strong and afford adequate intranasal patency.

Nasal tip refinement is perhaps of the most engaging endeavors for the facial plastic surgeon. A focused preoperative assessment with subsequent preoperative planning, bring to fruition the execution of the surgical plan which factors in fractions of millimeters. The level of attention to detail is at its highest among facial surgical procedures. Intricate, delicate, exact maneuvers are made to implement a plan designed to balance the rotation, projection, refinement, and general shape of the nasal tip. The vision of the surgeon combines scientific anatomic understanding, with artistic sensibility.

Interestingly, at the end and after healing, as I tell many of my patients, the nasal tip most perfectly addressed, is one which is never noticed. The beautiful nose shrugs the viewer past it, to instead focus upon the eyes.

The use of Botox® Cosmetic as a neuromodulator to treat hyperfunctional lines helped spark a cosmetic revolution with regard to minimally invasive approaches to creating a youthful appearance. However, in the early years, while creating a more “youthful” look, practitioners were not always yielding a very “natural” look. Often patients were treated to the endpoint of having a totally immobile upper face while the medicine was working. Adding to this, patients were requesting this look and complaining if even a hint of muscle movement was evident at the site of injection. It was not difficult to identify the “Botox look” by the seemingly “frozen” look of the upper face.

After this, much attention was paid to avoiding injection at the lateral forehead and keeping all injection points along a relatively central corridor. This allowed for some animation at the lateral forehead, but often at the expense of an unnatural peaking of the eyebrows, again yielding a certain “Botox look.”

Now, the science and delivery of Botox® Cosmetic has become quite an art appreciated by cosmetic surgeons and patients alike. Patients understand the stigma of looking unnatural, or injected, or “done.” This phenomenon has become true even across surgeries, as many patients now prefer less invasive facelifting and volumizing techniques over more invasive approaches. Patients often know exactly what they want their Botox to do, and expect a precise pattern of results with an uncompromised natural look. I view this “customization” as part of the art of delivery and it has made for successful outcomes.

Art in medicine is a prominent part of our practice. An exactness, and precise attention to detail, combined with a steeped understanding of medicinal science, collectively allow for artful and predictable outcomes. Come visit us for a free Botox consultation.

Beauty of the face remains a complex and arguable concept. The paradigm of our understanding and appreciation of the beautiful face has changed. As facial plastic surgeons, we have abandoned such techniques that “pull tightly” and “make tiny” and “keep thin.” In so doing, the pendulum has swung far the opposite way, and we have more recently embraced concepts of volume enhancement, tissue preservation, and minimally invasive techniques.

Within the art of hair transplantation, we have moved from grafting “plugs” of hair to individual follicles placed diffusedly throughout the scalp. With facelifting, we have reservations about excising cheek and jowl fat, and instead try to replace that tissue where it once was, and where it belongs. With fat transfer techniques, we bring body fat from the abdominal region and replenish the lost volume of the upper cheeks – the ever-youthful “apple of the cheek,” if you will.

There seems no doubt, however, that as with many phenomena as this, perhaps the pendulum has swung too far. Disproportion exists to both extremes, and it seems as easy to recognize an aged face with volume loss as a voluminous face with fallen, displaced contours. The challenge of defining and creating Beauty, rests in one’s capacity to identify the strengths and needs of any given face. In so doing, the facial plastic surgeon must have a sense of Balance in mind. To balance a need for tightening or lifting with a concomitant need for filling or resurfacing leads to success. Autologous fat grafting or filler enhancement are often excellent tools for more youthful facial rejuvenation, but for some, so are deep plane face or neck lifting with liposuction.   Similarly, with hair transplantation, finer grafts throughout the scalp may ultimately compromise the appearance of density at the mid-scalp. There are times when higher density grafts (along with finer grafts feathered naturally in front) ultimately lead to the optimal result.

In essence, we can still appreciate the face according to our more recently learned volumetric standpoints, but we must remember to be comprehensive with these standpoints. As with everything in life, Balance seems the key to success.

Among the many evident signs of aging are the changes that take place to our skin. These changes usually involve the accumulation of brown and red colored spots called dyschromias, loosening of the skin, loss of skin volume, fine and deep wrinkling, widening of the skin pores, and loss of elasticity of the skin. While there are many topical skin treatments and creams available, definitive improvements to the skin are usually achieved only from treatments designed to target both the deep and superficial layers of the skin.

Over the prior decades, carbon dioxide (CO2) laser skin resurfacing has been the most successful form of laser skin resurfacing, and remains the “gold standard” means of laser skin rejuvenation. While CO2 laser skin resurfacing has been associated with impressive results, the “downtime” following treatment has remained an obstacle patients often find difficult to accept. Newer technology has made available fractional CO2 laser skin resurfacing. This technology allows for comparable results with minimal downtime. As a result, there has been a revolution, of sorts, for laser skin resurfacing.   

The Sparano Face and Nasal Institute utilizes the Lumenis Encore UltraPulse technology. This technology allows us to deliver a fractionated CO2 laser beam across treatments known as ActiveFX™, DeepFX™, and TotalFX™. Each of these treatments involves treating the skin in a customized fashion with controlled depth. The treatment leaves surrounding healthy skin to aid in the regeneration process. The UltraPulse technology and TotalFX™ treatment is much more powerful than the other fractional CO2 lasers on the market. Thus not all fractional treatments deliver the same caliber of results. The unique aspect of this treatment is how a single TotalFX™ treatment can deliver impressive long-term results, with only 4-7 days of downtime.

As we age, we accumulate colored spots on the skin (dyschromias), and more importantly we lose both volume and organization of collagen fibers in the deeper layers of our skin. Collagen is a vital structural element that helps give the skin its strength and youthful qualities. One reason the TotalFX™ treatment is so effective, is because it treats in a way that stimulates the body to regenerate new collagen in a natural and cosmetically pleasing way. In fact , the new collagen is deposited over the subsequent 6 months following treatment. In addition, it ablates away the superficial dead and aging surface of the skin, allowing for a more fresh and vitalized appearance. This effects how the skin appears just after treatment, as well as years down the road as the treated skin appears to age more “gracefully.”

The TotalFX™ treatment is truly the ultimate in laser skin resurfacing. It is FDA approved and designed to treat colored spots, wrinkles, scars, acne scars, and dermal lesions. It tightens the skin while at the same time stimulating long-term collagen remodeling for a rejuvenated and refreshed appearance. It requires a single treatment with minimal healing time. The skin will appear tightened, more refreshed, and more homogeneous in color with a smaller pore size. The skin continues to improve over the first 6 months following treatment as new collagen is deposited along the deep layers of the skin. The TotalFX™ treatment is the only laser skin resurfacing technique that has been featured on television programs such as 20/20, Today Show, and The Doctors.

The Sparano Face and Nasal Institute is one of the few sites offering the TotalFX™ treatment in the region. Dr. Anthony Sparano has been selected as a regional instructor by the Lumenis company to teach other physicians around the country how to properly administer the technique. Please call to schedule a free consultation to further discuss whether the TotalFX™ treatment is right for you.

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