NO face-lift stops time, so as aging continues, even a satisfied patient may choose to have another one a decade later. But what if your face-lift never pleased you, not because of complications or monstrous scars, but because of aesthetics pure and simple? Perhaps your first surgeon’s technique resulted not only in a tighter jaw line, but also a flat wind-swept cheek and a stretched mouth. Or your nose no longer has an unsightly bump, but now, postsurgery, is asymmetrical.
These days, there’s such a critical mass of plastic surgery patients dissatisfied with their results that many doctors market secondary surgeries, or re-dos. It’s not hard to find surgeons’ Web sites that describe in detail how an asymmetrical nose job or an unsatisfactory face-lift can be righted. Last month, Dr. Sam T. Hamra, a plastic surgeon in Dallas, published “The Facelift Letdown: When Results Don’t Meet Expectations” to arm patients with information so they can better articulate their desires to their doctors and avoid postsurgery discontent.
No organization tracks how many procedures are done to correct cosmetic work. (Muddying the situation is the fact that some doctors tweak their own work if it falls short of the patient’s goals and that some complications call for immediate reoperation, like a hematoma, or a collection of pooled blood, beneath a closed incision.)
In this still-shaky economy, cosmetic surgery is down, and revisions for unhappy patients are included in that slump. But doctors who do a lot of revision face-lifts and nose jobs (two common redos) say demand for those operations is still strong.
Reasons vary, depending on the procedure. Rhinoplasty, for instance, is tricky because surgeons can’t control healing or how good the building materials are. Cartilage can be too thick or too flimsy; skin draped over a newly fashioned nose structure might not shrink to the shape the surgeon wants.
“It’s a difficult operation with a lot of variables,” said Dr. James C. Grotting, the editor of the textbook “Reoperative Aesthetic and Reconstructive Plastic Surgery.” “So even in the best of hands, people who only do rhinoplasty,” he said, there is still “a revision rate of up to 20 percent.” Some of the best fix-it nose doctors are sober about the limitations. Dr. Mark B. Constantian, a nose specialist in Nashua, N.H., whose practice is 75 percent revisions, said rhinoplasty is unique in that “you can lose ground every time.” With other kinds of plastic surgery, patients “are not worse off than when they started.”
Some doctors refuse to tackle secondary or tertiary rhinoplasties, and sometimes patients seeking these operations get unfairly labeled as “a fussy neurotic group,” Dr. Constantian said.
He pinpointed four reasons for dissatisfaction: breathing is worse, which can happen if a doctor doesn’t compensate for aesthetic changes; postoperative deformity that patients don’t like (perhaps removing a bump leaves the patient’s nose crooked); the patient never reached the original goal; and last, the patient got the requested change but now finds it unacceptable. “After, they feel they lost a familial or ethnic characteristic, and ask, ‘Can you do something to put my nose back to what it was?’ ” he said.
One of Dr. Constantian’s revision patients, a nurse in New Hampshire, got her first rhinoplasty in 2004 to fix her nose’s too-wide tip and a hanging columella, the tissue on the underside between the nostrils. As the post-operation swelling subsided, “Everyday I would look and wait for changes,” said the nurse, who asked to remain anonymous. But the nose tip “was still wide” and the columella didn’t look “touched at all.” She searched on Google for nose specialists and found Dr. Constantian. Today her profile is straight, her columella no longer hangs, and she breathes better. “My breathing was never a problem until after the first surgery,” the nurse said.
Sometimes earnest miscommunication between patient and doctor is at the heart of the matter. “What the patient is seeing in their mind is hard to describe to the doctor,” said Dr. Jack P. Gunter, who devotes 40 percent of his nasal-surgery practice in Dallas to redos. “Patients will say, ‘I just want a little taken off.’ How much is a little?” Other doctors sweet-talk patients into thinking the perfect nose or face-lift is within reach, leading to discontent. “People are marketing things they cannot achieve,” Dr. Gunter said.
These days advertising creates unrealistic expectations, said Dr. Grotting, whose practice is in Birmingham, Ala. The idea that a procedure can be quick, simple, painless, “all of these catchphrases are heavily marketed to plastic surgery patients,” he said.
When it comes to plastic surgery, Dr. Hamra said, the “customer is always right.” A gynecology patient isn’t the one to determine if she wishes to spend less money to remove fewer of her uterine fibroids. A plastic surgery patient, however, can choose a minimally invasive face-lift instead of a more complete one, said Dr. Hamra, who favors comprehensive face-lifts that address upper cheeks and foreheads. If one surgeon won’t give him what he wants, the patient finds one who will.
Celebrity cases of too many face-lifts overshadow a common problem these days: paying thousands for small improvements that don’t last.
“In face-lifts, you see undercorrections,” said Dr. James M. Stuzin, a plastic surgeon who specializes in face-lifts in Miami and does a “big volume of redos.” Mini face-lifts, he said, require “little recovery,” but have “little longevity.” He also cautions that some surgeons who do only occasional face-lifting “don’t reconstruct the internal anatomy, and that has more longevity.”
In other words, you get what you pay for. “I’m seeing more people who have gone to clinics where price is a major concern for them going there, and often they are dissatisfied with the result,” said Dr. Stuzin, a past president of the American Society for Aesthetic Plastic Surgery. “Instead of muscle work, they are oversuctioning the neck, so the neck looks skeletal.”
Furthermore, not every plastic surgeon tailors his work to each face, but instead “do it the same way every day, and that doesn’t work for faces,” said Dr. Mark E. Richards, a plastic surgeon in the Washington, D.C., area. Patients have sought out Dr. Richards for revision face-lifts ever since Linda Tripp announced on TV that he redid her botched face-lift in 2000.
Other experts caution to be wary of the doctor whose technique is stuck in the dark ages. “There are still a lot of surgeons who just redrape the skin — that’s it,” Dr. Grotting said.
For decades, doing face-lifts hasn’t been about simply pulling the skin toward the ear. At the very least, underlying layers of tissue and fat should be repositioned; some doctors also try to restore the curves and volume lost to aging.
Lately, Dr. Richards says that he has found that many of his unhappy patients are missing “cheek curves.” Pulling the connective and fatty tissue layers just below the skin “doesn’t make an attractive face,” he said. “It just makes a tight face.”
Surgeons’ philosophies vary widely, so it’s crucial to meet with a few to ascertain which one will best achieve your goals. Some love a high full cheek or use transplanted fat to fill out that area. Others think a face-lift that doesn’t address the eye area is incomplete. And some aim to deliver simply a tight neck and a defined jaw line. Dr. Hamra’s guide advocates the composite face-lift, a fairly aggressive surgery that also addresses hollow eyes and lifts cheeks vertically. (If readers can get past the book’s dollops of self-promotion, its descriptions of post face-lift issues prove useful.)
Dr. Constantian, for his part, wrote a new textbook “Rhinoplasty: Craft and Magic” because he feels the “basic ideas of how to fix a nose aren’t correct.” Two misconceptions get surgeons started on the wrong foot, he said. First, the mistaken notion that if a surgeon fashions a good-looking skeletal shape, skin draped over it will “take on the nose shape.”
Not so. The skin of the lower nose “won’t necessarily shrink to the shape the surgeon wants,” Dr. Constantian said.
“We were taught if you just change one area in the nose, nothing else changes,” he added. But “if you reduce the tip cartilage to make it prettier, you can also weaken the ability of the cartilage to support the nostrils,” he said. So he compensates for that weakness.
But some surgeons think impaired breathing is an acceptable trade-off for aesthetic improvement. “Breathing worse after a rhinoplasty is so common that I’ve heard surgeons say on panels at meetings that they expect it to happen, they tell their patients it will happen,” Dr. Constantian said. “I don’t think it should ever happen.”
Dr. Joseph M. Gryskiewicz, the vice president of the Rhinoplasty Society, a nonprofit educational organization for surgeons, wrote in an e-mail message, “Only a sadist would say breathing compromise is O.K.”
This article is from www.nytimes.com By CATHERINE SAINT LOUIS
Published: October 28, 2009
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