Our Procedures

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Non-Surgical Procedures

• Derma Fillers
• BOTOX®
• IPL
• Light Chemical Peels
• Obagi Skin Care Products

Surgical Procedures

• Abdominoplasty (Cosmetic Surgery of the Abdomen)
• Facial Ryhtidectomy (Facelift)
• Liposuction Surgery (Newest & Best techniques)
• Breast Surgery (Breast Uplift, Reduction & Enlargement)
• Blepharoplasty (Eyelids)
• Forehead (Browlift)
• Rhinoplasty (Nasal Surgery)
• Chin Correction (Chin Implants)
• Facial Chemical Peels
• Dermabrassion

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Derma Fillers

Dermal fillers are substances that are injected just below the surface of the skin temporarily adding volume, by filling lines, wrinkles and folds from the inside out. They can temporarily restore a smoother appearance. Today there are so many optional dermal fillers available. How does one choose what's best? There is no identifiable correct answer. We can however, state the standards by which this office determines what is safe. In anutshell, we will only endorse products that have been assessed and approved by the FDA. Current fillers include:

• Collagen (Human & Bovine)
• Restylane®
• Hylaform
• Hylaform Plus
• Captique

BOTOX®

BOTOX® is injected into the muscles to alter the function of the muscle. People often frown or furrow when they are in heavy concentration. This can give the false impression that they may be angry or unhappy. Over a period of time, this activity promotes deep lining even in a relaxed state. BOTOX® injections can alter this inclination temporarily by relaxing the generated tension created by the muscle contraction. (Some patients have actually reported a dramatic reduction or elimination from headaches altogether after treatment.)

For:

• Brow forehead lines
• Crows feet
• Down turned corners of the mouth
• Neck bands

• Frown furrow
• Nasolabial folds
• Lip lines
• Facial assymetry

IPL

Offering intense pulse light (IPL) Foto Facial treatment for rosacea, hyperpigmentation, fine lines, face/leg veins, sun damaged skin of face, neck, chest and extremities.

Light Chemical Peels

Glycolic, Refinity or TCA Peels (20%) can be performed by our nurse. These types of peels have little to no recovery time. They are designed to give subtle improvement to skin quality, but will not remove lining. Higher percentage application is applied by the physician and would involve recovery time. See surgical procedures for more information.

Obagi Skin Care Products

The Obagi New-Derm daily regimen is designed to prepare. correct, stimulate and protect the skin. Healthy skin is smooth, firm, evenly pigmented, hydrated, free of damage and tolerant. The Obagi Products differ from over the counter skin care products in that they address correction in the epidermis (top layer of skin) as well as the dermis (where new cells and elastic fibers are formed). Obagi Skin Care is essentially a restoration program.

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Abdominoplasty or Tummy Tuck

The abdomen changes as humans change. Early on the ab muscles (6 pack of Schwarzenegger) are parallel. As we age, gain weight, or have children the muscles bow forward and separate. They usually stay this way even after weight loss, exercise, and pregnancy. Only surgical correction of this midline muscle separation (hernia) corrects the problem and realigns the muscles again parallel.

In this section on the abdomen, I will address skin changes, fat changes, muscle changes, correction techniques, liposuction, exercise, longevity, maintenance, incisions, recovery, and pain issues.

The abdominoplasty (tummy tuck) consists of removing excess skin, excess fat, and repairing muscle separation. In addition, the umbilicus (belly button) is placed in a new site.

Incision
The incision (cut) is kept as low and as short as possible to allow bikini wear. The incision can be a problem but rarely is a problem. Every effort and trick is employed to minimize the scar. Although every attempt is made to minimize the incision, nevertheless it must be of sufficient length to remove the excess, stretch-marked, and droopy tissue. Mimi tummy tucks are rarely indicated. A mini procedure often is accompanied by mini improvement. In a rare case a mini procedure can be used to tighten the muscles but not to remove skin. Think about it. How much skin can be removed from a 3 or 4 inch incision? Not much.

Fat Removal
Excess fat is removed. Liposuction is usually used as a technique to perfect the contour results. Fat removal can be just a few pounds or up to 20 pounds, sometimes more.

Reconstruction
The tissues are then lifted to the rib cage. Several layers of sutures are used to reconstruct the rectus (ab) muscles. Once they are again parallel sit ups will actually help and not hurt. Your original belly button is saved and relocated in a new home in your tummy skin. It is designed to appear as it did prior to kids, age, and weight gain. The incision is then meticulously closed.

Hips and elsewhere
Liposuction of lateral (side) hip flank areas is done at the same time as well as liposuction of other sites.

Pain reduction and draining
A device to minimize pain is inserted. This is a 2 mm (tiny) garden soaker hose type device that constantly instills pain medicine (Marcaine). It is a wondrous device that has greatly limited discomfort by as much as 80%. The device is removed after several days and pain is reduced even after removal. A small drain is usually used to drain away any blood and tissue fluid, diminish bruising, and facilitate healing.

Return to activity
After repair patients can go to near full activity at 2 weeks and full activity at 3 weeks. Return to work requires 7-10 days. All sutures are usually out by 2 weeks. A small abdominal binder that you wear for the first 3 or 4 weeks is not mandatory but usually enhances comfort.

Candidates
A concave abdomen is the goal. People who are somewhat overweight are okay candidates. In a perfect world all would be ideal weight prior to surgery but those less than 50 lbs. overweight do well.

If a person is 50-100 lbs. overweight, the abdominoplasty may help to remove a large panniculus and make life easier. A panniculus is a large hanging fold of skin and fat that is a real problem for some people. A panniculectomy facilities exercise, hygiene, and a brighter outlook. Often people with back problems find some relief from a panniculectomy or abdominoplasty.

At consultation you will be examined and advised of your options and of realistic expectations.

Liposuction without abdominoplasty
In some patients with a rotund convex belly, liposuction alone may accomplish much. The skin may not fully adjust but contracts quite well. Skin adapts amazingly well after liposuction, but never perfectly. For liposuction to be of benefit, the external abdominal fat pad must be considerable. If the convexity is mainly due to muscle separation and laxity, liposuction alone rarely offers acceptable correction. Pictures of patients having had liposuction alone and liposuction and abdominoplasty will be shown and discussed at consultation.

Before and After Photographs
Generally, I do not do computer imagery. I have in the past but I feel showing actual post operative photos of my patients better demonstrates what can be accomplished. Computers can give any of us Abe Lincoln's beard, Richard Nixon's nose, George Washington's hairdo, Taft's belly, and Jay Leno's chin. You get the point. Computers can do things surgery cannot.

Longevity of the results
Abdominoplasty (tummy tuck and muscle repair) is a first rate operation. Patients appreciate it and enjoy the results. Appearance and function are enhanced. It is a once in a life time procedure usually. Extreme weight gain or pregnancy can somewhat negate ideal results but even then some good results are maintained. Skin that is removed is gone forever as is fat. Muscles can however separate under severe stress, such as pregnancy. I have only done one redo abdominoplasty in my career and this was a lady who at 53 had a large (and 6th) child to her surprise (but also delight). It happens. If the pregnancy is fine, then a second repair is easy.

Summary
Abdominoplasty is one of the best procedures in plastic surgery.

Facial Ryhtidectomy

The modern facelift is an excellent surgical procedure to enhance a youthful, healthy, natural, non-surgical appearance with longevity of results. My procedure has been developed and evolved over the past 25 years. Over the years the term facelift has been used to describe many facial procedures from minor to extensive. Generally the facelift refers to the correction of the neck, jowl, cheek, nasolabial, and cheek eyelid junction area. The procedure is designed to reverse the effects of aging caused by gravity, fat loss, and sun damage. All tissue including skin, fat, and muscle is addressed in the facelift.

The modern standard facelift is bidirectional. The skin is moved back and underlying connective tissues are shifted upward. Skin is lifted from some of its attachments and excess stretched skin is removed. The skin is moved in a horizontal direction towards the ears. The connective tissues of the facial muscles are lifted and advanced vertically. Tension is placed vertically on the deep tissue (the SMAS or superficial musculoaponeurotic system). The muscles themselves are thus better positioned to their original youthful position. Incisions are well hidden in the hair around the back of the ears and in the hair on the temples. The skin is not pulled or tethered but is gently sutured in a fashion to produce lines that defy detection. Hair is minimally disturbed in the well done facelift.

The jaw line is firmly and naturally supported by the mandibular island pedide designed by Dr. Commons. This establishes excellent longevity and a natural non-surgical appearance. In the neck area excess fat is removed (if necessary), the platysmal muscle is plicated and suspended, and if necessary the sub mandibular gland is reduced in size. This results in a beautiful, sculptured, youthful neck and chin. If the drooping chin deformity (witches chin) is present, this is corrected at the same time. While fat in the neck is often removed, check fat is generally protected and repositioned to maintain a youthful vibrant face. At the same time as a facelift the eyelids, forehead, and lips can also be connected if necessary.

There has been an increasing awareness of the role of fat loss in the facial aging process. Cheeks, eyes, temples, and the mouth-lip area become hollow. The lips and surrounding area become lined and sunken as fat is lost. It is possible to replace some of this fat by harvesting fat from the other body areas and very meticulously injecting it into the appropriate areas 1/10 of a cubic centimeter of fat at a time. Fat can be placed about the eyes, cheeks, mouth, lips, jaw line and neck.

The forehead, of course, is the upper 1/3 of the face. Forehead lines, frown lines, and brow droop can be corrected. The current procedure of choice is the endoscopic forehead frown-furrow operation. Forehead suspension holds the brow in ideal suspension until healing is complete. Alternately, frown correction can be done via BOTOX® but this must be repeated approximately every four months.Facial surgery brings satisfaction to 99% of patients. With time and effort this advances to nearly 100%. The facelift is a lovely enhancement enjoyed by many people.

How much younger or better the patient looks varies with many entities---hair style, willingness to color the hair, style of dress, attitude, skin care, and general health---many patients can look 10-15 years younger, possibly more. Some patients desire to look healthy and rested. All goals and solutions are discussed during your consultation. The actual conduct of the facelift is done in a formal surgical suite either at the office or hospital. I do most of my surgery at the Plastic Surgery Center at 1515 El Camino Real. I am the Medical Director and we have a very safe California state licensed facility. Our facility is used by the Stanford faculty for some of their cosmetic procedures. I also do my facelift operations at Stanford Hospital if that is desired. The facelift patient can be awake or asleep during the procedure which can take 3 ½ to 6 hours depending on the needs of the patient. After a facelift, some patients choose to go home while others may stay overnight in the hospital or other care facility.

Pain after a facelift is generally quite contained (ears and neck hurt) and is easily controlled with pain medication. Sutures come out in 5 to 12 days and healing is quite rapid. Return to work is anticipated 1 to 2 weeks. Appearance continues to improve up to 12 months or so but often at 6 to 12 months the desirable endpoint is attained. Longevity varies from 5 to 15 years but many gains are near permanent in the improvement of structure and appearance. The skin and fat that is removed does not return and the muscles hold up well. Nevertheless, aging continues and the time for a second facelift depends on the patient's desire as does the first facelift.

There are some myths about the facelift that are worth mentioning. These include the myth that once you do one facelift you will have to keep having facelifts. Untrue! It's up to you. Some of the results are permanent. Myth two is that you should wait until there is a strong need for a facelift. Untrue! In reality, the perfect age for a facelift is the age you and you alone choose. People looking a lot older than they actually are often are early candidates. Ages range from early 30's (fairly rare) up to the late 80's (also fairly rare). The largest facelift group for both men and women is the 40 to 70 age group. The perfect age is the age you choose. We all know when we start to look older. Looking our age or looking even a little older is for many a motivation.

Complications of a facelift procedure are generally quite minor and easy to remedy. Minor infection, bleeding, and scar tissue can occur and are correctable. Problematic complications are exceedingly rare.

During your consultation, the above details will be further discussed and explained. You will have ample time for questions. All of your questions will be answered in detail. Pictures are taken and I study them with you and we discuss your thoughts and desires. After your surgery, I will follow you for about one year. I welcome and encourage you to visit my office. My office door is always open for you. Thank you.

Liposuction Surgery

Liposuction is best done by the application of Vaser® Sound Surgical Ultrasonic technique. Period.

Over the years, there have been other liposuction techniques. Liposuction comes under many names including ultrasonic Vaser® liposuction, tumescent liposuction, dry liposuction, wet liposuction, laser liposuction, large volume liposuction, liposculpture, liposelection, and on and on. It suffices to say all are basically liposuction. Some are trade names, some are fancy contrived self-serving names, but all are simply liposuction.

Liposuction corrects unwanted fat of the body. "Lipo" which rhymes with "hypo" comes from the Greek word lipos and means fat. Liposuction is the removal of fat by suction. Liposuction corrects lipodystrophy, also called lipodisproportion-both mean too much fat in some places, not enough in others.

We all carry a little extra fat in favorite places often traced to our parents. (Pick your parents well. It helps!) Even marathon runners can have lipodisproportionate areas. I have performed liposuction on many very fat patients including 9 active marathon runners.

Let's sort out some liposuction methods. Liposuction originally, in 1982, was done by inserting a metal canula (flexible tube or wand) with a distal (far end) opening in a fatty area and moving it about. Mechanical motion broke off the fat cells, like knocking nuts off a tree, and suction removed the fat into a bottle. Later saline (wetting solution) was injected into the tissues and this facilitated the procedure. Bleeding was a problem and only limited liposuction could be done to protect against excessive blood loss.

In the later 1980s epinephrine and liodcaine were added to the injected fluid. The epinephrine constricted the blood vessels and thereafter blood loss was rarely a problem when liposuction was properly done.

I have taken as much as 28 lbs. of fat with less than a one unit blood loss. Although the lidocaine partially numbs the area and allows a small procedure to be done awake, most patients prefer to be asleep. Does it hurt when your dentist injects one or two cc of fluid lidocaine? Yes. For liposuction think of an injection of 1000 cc or 5000 cc or more. It hurts. Daily I see patients who have been done under local anesthesia injection elsewhere and hated it. I have the very finest M.D. anesthesiologists at every procedure. Comfort and safety easily justifies the cost. Local anesthesia procedures also take longer.

There are doctors who have technicians or nurses do some injections. I do all my own injections. I want no abdominal perforations by needles or canulas.

Today essentially all liposuction is via the tumescent technique, which uses infusions of epinephrine, and lidocaine in saline solution. The old dry technique procedure produced more excessive bruising and bleeding.

Laser liposuction has come in many waves, all fundamentally proven to be of no value and even harmful. The idea was the laser would blast down the tube and melt the fat and stop the bleeding. It simply did not work. It should not be used in its conventional form today.

The most recent wave of laser liposuction is called "Smart Lipo." A small fiber optic cord (several millimeters) is surgically placed under the skin and the idea is it melts the fat and then the fat is suctioned surgically. It is a surgical procedure. It is for tiny areas. I guess it works but I don't really know. The company that sells the machine visited me and wanted me to buy a "Smart Lipo" machine. I said fine, place one on trial in our surgicenter, The Plastic Surgery Center and if we like it we will buy it. I was shocked when they refused a trial period and mandated buying it for $95,000 plus tax. At the PSC there would have been exposure to over 12 surgeons including the Stanford faculty surgeons and residents. I wonder why they would not place it on trial. Vaser® Sound Surgical placed their equipment on trial and we bought it. I wonder why "Smart Lipo" would not. As medical director of the Plastic Surgery Center I pursued this placement further but was refused. Would you buy a suit without trying it on?

Anyway in 1996 I was appointed to this Ultrasonic Liposuction Review Committee to be one of the original preclinical release evaluators. I was given a new ultrasonic machine as were selected others with vast experience and for one year we evaluated the ultrasonic system.

The old ultrasonic systems worked but were a little hot so surgeons had to be very careful. Ultrasonic liposuction has made great stride since then and the world-wide state of the art is now the Vaser® system. Not laser-but Vaser®!

What is ultrasonic liposuction? Well, it works like this: The wetting solution is instilled in the tissues. Epinephrine nearly stops all significant bleeding. A titanium wand is placed under the skin and passed through the fat causing the fat to emulsify. The control and precision is excellent. The titanium canulas (wands) are excellent. The canulas in the Vaser® system and the system itself are so safe it is possible to treat the skin with ultrasonic energy and shrink the skin to an extent. This Vaser® system was the brain child of William Cimino, Ph. D., the most noted ultrasonic technology expert in the world. What a wonderful system.

Can liposuction still be done without a Vaser® ultrasonic system? Sure. But it is more laborious for the patient and doctor, more painful, less accurate, less complete, more likely to cause bruising. Vaser® is the way to go. Plain old liposuction works (as does the Model T Ford) but Vaser® is where it is at in state-of-the-art terms. I like my surgeon to be state-of-the-art, don't you?

Other ideas about microwave liposuction, radio frequency liposuction never became airborne. Again Vaser® is where it is at until of course another system is proven better.

So what areas are amenable to lipo treatment? A better question would be what areas are not amenable? Just about anywhere you can imagine may benefit from liposuction in the properly chosen patient. Lets make a list: face, cheek, neck, nasolabial folds (between the nose and the corners of the lips), back of neck, upper back hump, mid back, male chest, female breasts, axilla (armpit), axilla to stop sweating, arms, forearms, abdomen, rib cage, flanks and hips, iliac crest (top of the hips), buttocks, inner buttocks, thighs (front, back, and sides), knees, pubis, calves, ankles and on and on.

Liposuction is only for skinny people-you've heard this. Wrong! Overweight patients carefully selected can greatly benefit and often use liposuction as a launch pad to lose weight. Of course liposuction is not a weight loss technique. Almost no patients more than 100 lbs. overweight are candidates. There are a few patients in the 75-100 lb. weight excess zone that greatly benefit from having one especially problematic area liposuctioned (for example, a super large tummy). In the 50-75 lb. overweight group many can benefit from specific directed liposuction of troubling areas. This can inspire the patient to exercise and lose weight and lead to great success. In the 25-50 lbs. overweight group there are of course many good candidates.

Age, health, weight, etc. are all considered in your consultation. I ask all patients to reflect (match) the weight that is removed, ideally losing at least as much as I take. For example if a patient comes in with a weight of 200 lbs. who should be 140, I may do liposuction. Conceivably, I may take 10 to as much as 15 or 20 lbs. of fat in one session. If I take 20 lbs. the patient's new weight is 180. I want them to match what I took in one month, ideally.

Early on weight goes up a little because of fluid retention. If they reflect (match the weight reduction) they will have a nice benefit from the surgery. I encourage them to do their part to match what I removed, in this example 20 lbs. This would put the originally 200 lbs. patient at 160 and the results are uniformly spectacular.

I have written papers, presented lectures, and given courses for other plastic surgeons on the topic of large volume liposuction. If done properly large volume liposuction can be done very safely. As Dr. Bruce Halperin warns in general: always remember large volume liposuction can be done very safely but also remember it is possible that the smallest volume can be dangerous if improperly done.

So what about age? My patients have ranged from age 13 to age 79. It is important to evaluate the individual patient, not the age. There are good and not good candidates of all ages.

What about special restraining garments to be worn after surgery? We still use garments but only require them for the first 10-15 days. Patients may choose to wear them longer for comfort reasons and this often occurs for 1-2 months.

In conclusion, I frequently hear the silly statement of "Why have liposuction, you only gain it back anyway?" Certainly if you plan to gain weight, liposuction may be a waste of your time and money. For liposuction to be successful you must: Take care of yourself. Match the weight removed. Exercise. Don't gain weight. If you do gain then lose it. Lastly, stay active. You will live longer and feel better.

If you allow your fat % to increase significantly, you can look fat but still be at your high school weight. The high school quarterback or prom queen has to exercise also. If the quarterback graduates at 180 lbs. and promptly resigns himself to a life of growing roots on the sofa watching TV his fat % will go from 7 or 8% to 30 or 40%. Even at 180 he will look fat at the 40th class reunion. So will the prom queen.

A dose of liposuction goes hand in hand with a dose of good living and good diet. Weight management is not easy. It takes brutal painful discipline. There is no one on earth who would not lose weight in a concentration camp. I'm not advocating a concentration camp program but lets be realistic: you could lose weight. Again and again I hear patients say they can't lose weight. They say they eat like a bird (all the time). They deny the accuracy of my office scale. They blame me and get mad about weight gain. Believe me I've seen it all.

But in the end at least 90% plus of liposuction patients are successful. Although my efforts contribute to this success, the truly successful patients match my efforts with determination that affords a happy, healthy, joyful life. "Upward and onward," as my friend, partner, and mentor Dr. Donald Laub always said.

Breast Surgery

Types of Implants

Over the years, the companies producing breast implants have brought forth hundreds of different sizes, shapes, saline fill, silicone gel, tear drop, textured surface, smooth surgery, and low-mid-or-high profile. Many arguments and controversies ensued. The greatest controversy regarded the safety of the silicone gel itself. Much is now clear.

As of 2007, exhaustive studies worldwide have established the safety of silicone gel. It is safe, period.

Silicone shell-saline fill vs. silicone gel implants
All breast implants contain silicone. The main two types now available are the silicone shell-saline fill and the silicone gel implants. Although the saline fill are quite good, the silicone gel implants have a more nature feel and appearance.

Now that the silicone gels are freely available in the U.S. it is predicted 85-90% of all implants will be silicone gel, because the salines all eventually deflate and need replacement. The gel implants can break but rarely do. When they do break, the body's own capsule contains the gel just fine.

Shape
The most common shape is the mid-raised profile. Candidacy for low, mid or high profile is discussed and determined at the time of implantation.

Smooth surface vs. textured
Smooth surface implants are simply better, more natural, and safer than textured implants. The rough surface of a textured surface may act like sandpaper in the body of some patients. Natural round, smooth, gel implants "teardrop" when one stands up and do what breast tissue does in reclined positions. Unique custom shaped implants are costly and offer no benefit.

Distensible not recommended
Flimsy implants of the saline distensible variety are the type placed through the umbilicus (belly button). They break easily and like the belly button approach are mentioned only to be condemned.

Summary of Implant Types
So in summary likely 90% of implants in the U.S. and worldwide will be silicone gel, smooth surface, dry surface, mid profile, of the appropriate size.

I use gel 90%, saline 10%, round and mid profile 90%, smooth surface always. These give a pleasing nonsurgical appearance and feel.

Size
Size of the breast implant is a major point of discussion and interest. The right size is based on what is right for a given patient. I listen very carefully to what patients tell me in all consultations. It is a plastic surgeon's job to listen very carefully, then assess and examine, and then advise. There is simply not one right perfect size for each patient.

Breast implants come in cubic centimeter (cc) sizes. Thirty cubic centimeters equal one ounce. Breast implant sizes usually are in the 8 ounce to 13 ounce range. This means 240cc to 390 cc.

If breast is a different size from the other then larger implants are placed in the smaller breast to affect the best symmetry.

A woman who is 6 feet tall and 160 lbs. can accommodate easily a larger breast implant. The right size range does depend on a degree to the patient's size but desire is also critical. All plastic surgeons know that 95% of breast augmentation patients wish that they had gone larger at the one year post operative interview. But if excessively large implants are used there is a greater tendency for the implants to bottom out. This means that the lower pole of the breast expands and the implant drops. Gravity is often not our friend.

I discuss sizes with patients. I feel for every patient there are multiple "correct sizes." My categories are right size, right size a little smaller, and right size a little larger.

Confused? Many are. So here is what I recommend: get a measuring cup that shows ounces. Purchase a bag of dry rice. Obtain multiple sets of nylon stockings. Make sets of implants-a pair at 10 ounces (300 cc), a pair at 11 ounces (330 cc), and so forth. Place them in a comfortable stretchy jogging bra and try the sizes. Wear each for a day or so and in several outfits. If you are asymmetrical put different sizes on each side. Note and record your thoughts so that we can discuss them at your consultation. This system seems elementary but it works and patients generally select a size that pleases them. 99% of the time the size works out just fine.

After size, shape, and type are selected
At this point surgery can be scheduled. Breast augmentation is done with the patient asleep. After surgery you may go to your home and have a friend or relative care for you. You will have my office number, my cell number, and my home phone number. I am available and I want you to call if you have questions or concerns.

Breast Uplift
The breast uplift procedure is now a wonderful operation as a result of the vertical mammoplasty techniques developed over the past few years. The old operations were less favorable and had a longer scar pattern. The inverted T or "anchor incision" has been replaced forever by a better, quicker operation that gives an attractive natural, youthful shape to the breast and is more affordable because of shorter operating times. There have been many names applied to this truly remarkable operation including short incision mammoplasty, short scar mammoplasty, and vertical mammoplasty. The incisions are limited to around the areola (dark area around the nipple) and a short vertical incision. Basically, the incision is lollypop shaped. The old horizontal incision is gone forever.

The Benelli operation has had some popularity. The donut-shaped scars around the areola with this procedure are too obvious and the shape is suboptimal. It is mentioned to be condemned.

If desired an uplift can be done at the same time as a breast augmentation. This is discussed at consultation.

Ultrasonic Breast Uplift
Breast uplift via application of ultrasonic liposuction techniques to tighten the skin and create a better shape is useful in selected cases and will be discussed in your consultation. The only ultrasonic system that is safe and productive is the Vaser® Sound Surgical System of lower thermal ultrasonic energy. The titanium probes can be safely used near the skin and do effect contraction (shrinkage of skin).

Breast Reduction
Breast reduction techniques have made great advances in recent years. The application of the vertical short incision reduction is quicker, safer, less painful, and give a superior breast shape. Simultaneous use of the Vaser® Sound Surgical Ultrasound System in breast reduction further simplifies the operation and results in a natural, youthful breast. In most patients the anchor incision can be avoided. In a very few extremely large-breasted patients a horizontal incision component may be necessary but this also can be minimized via the Vaser® system application.

This is a fine operation for the appropriate patient. At the consultation all aspects are discussed including expectations, desires, picture review, potential complications, recovery and questions.

Blepharoplasty

There are many different procedures designed to improve the appearance of eyelids and the orbit area around the eyes. These include procedures to open up the upper eyelids, procedures designed to correct the puffiness and bags of the lower eyelids, procedures to correct the eyelid cheek junction definition that comes with age, procedures to lift the eyebrows, to correct the frown, to correct saggy lower lid rims, to correct cheek bags, to raise the lateral eyelid attachment, and even procedures that alter somewhat the native ethnicity of the eye. All of these, of course, must be accomplished without altering or harming vision. Most of these procedures can be done awake or asleep depending on the patient's desire. Although serious complications are exceedingly rare bleeding or infection can rarely occur. Both are easily corrected. Blepharoplasty surgery can be accomplished in office or hospital operating rooms. Recovery is rapid with back to work in a week or so.

Upper Eyelid
Eyelid surgery may involve just the upper eyelids, just the lower, or both. The upper eyelids are delicate structures with very fine movement. Function is obviously critical as well as appearance. Upper eyelids, with time, become saggy with excess skin, muscle, and fat. The upper lid may droop (ptosis) partially covering the pupil and affecting vision. The correction is a delicately planned skin excision and sometimes muscle and fat removal. The crease of the upper lid can be enhanced (anchor blepharoplasty) or in the Asian eyelid the crease can be established. When indicated the frown muscle (corrugator) can be adjusted to minimize the frown via the eyelid incision. The upper blepharoplasty procedure can be done alone, with other procedures, awake or asleep in about one hour. Sutures come out in 4 to 6 days and recovery is easy usually. The upper eyelid crease incision is designed to defy detection. At times, the upper eyelid procedure may be done with a forehead lift to raise the brow and further open the eye. All this is discussed at the consultation. Again to emphasize, surgery of the upper eyelids is done to remove excess skin, sometimes redundant muscle, and occasionally excess fat. Hooding or heaviness of the upper lid occurs on a congenital basis or acquired with age basis. Heaviness of the upper lids may result in a tired or sleepy appearance. The incision is in the eyelid crease and hides well. It must defy detection. The upper eyelid surgery is called an upper blepharoplasty and opens the eye in 100% of patients. Some may prefer an even more open look if brow droops or encroachment is a problem. This can be done via a brow lift procedure. There are many procedures to lift the brow and correct the frown. These will be covered in the forehead section. When doing the upper eyelid it is easy and efficient to reduce the frown muscle medially and thus reduce the frown via the same incision. Through the lateral eyelid incision a limited brow lift is possible. At times upper lid hooding causes visual obstruction. If substantial via photographs and visual field computer tests, insurance may occasionally partly cover upper eyelid surgery. The blepharoplasty is a popular procedure that patients appreciate. In conclusion, the incision for both upper and lower blepharoplasty (eyelid surgery) defies detection when properly placed. Pain is minimal. Recovery is rapid. After suture removal in 4 or 5 days patient may retire to work and play. After 2 weeks full activity is allowed. Eyelid surgery (blepharoplasty) can include upper or lower eyelids or both, with mid face correction or not, with mid face correction or not. The blepharoplasty procedure is gratifying for both surgeon and patient. Often the blepharoplasty is performed at the same time as the facelift. Your needs, desires, and questions will be discussed at the consultation.

Lower Eyelid
The lower eyelid deformity of lax skin, puffy fat, and eyelid-cheek demarcation with droop of the eyelid-cheek junction all can be corrected via the lower lid blepharoplasty with a cheek lift component. At times this is referred to as mid face correction. The fat of the lower lid should be retained and repositioned in 98% of patients. Most of us are fat negative (deficient) about the eyes and face. Age brings a hollow skeletal appearance. We must save the fat and reposition it in deficient areas. This works beautifully. I emphasize again; lower eyelid fat should almost never be removed. Fat loss is what causes aging (partially). Lower eyelid fat is abundant in youth and we must always save it in blepharoplasty surgery. At the same time as the blepharoplasty the cheek is gently elevated and sutured to the covering of the orbital rim bone (periosteum). This restores a youthful appearance. The eyelid- cheek demarcation deformity of age is corrected. In our 20's its almost impossible to tell where the cheek stops and the eyelid starts but as time advances there is a substantial demarcation. Fat herniates from around the eye and we see puffs. Combining a cheek lift (mid face) with eyelid lift corrects this deformity. The cheek is suspended to the orbital rim. The results are pleasing and youth enhancing. Longevity of the results is excellent. In elaboration, lower eyelid puffiness or bags are usually acquired with age but occasionally can be congenital. The puffiness is usually fat that herniates through the eyelid-orbit septum. It is not excess fat and should almost never be removed. Congenital based lower lid fat may be in excess and a little removal may be okay. In general, however, lower eyelid fat must be saved. Almost no one over the age of 35 has excess eyelid fat. Think about human aging. Generally we can "guess" a persons age + or - or at least the decade. As we age we begin to look a little hollow about the eyes. We start to look a little skeletal as we age. This is caused by fat loss, a normal process in aging. In lower eyelid blepharoplasty surgery it is extremely important that all fat be saved and placed where it is needed medially or laterally. Fat removal makes a person look older about the eye area. Hollow equals older. Even the very small amounts of fat that may be okay to remove from the upper lids are saved and placed in the lower eyelids. Discussion of the lower lids must include a discussion of the cheek eyelid junction and its definition or lack thereof. Think of the 20 year old appearance and compare it to an older person. In the younger person it is often hard to see when the cheek ends and the eyelid starts. There is a distinct lack of cheek eyelid junction definition. There is no line of demarcation. No line where you can say this is definitely eyelid and this is definitely cheek. This is the appearance of youth! As the aging increases, the distinct demarcation is obvious. Sure, in some teenagers you see a demarcation and in some older people you can't, but in 97% of humans the cheek eyelid demarcation becomes increasingly obvious with aging. This demarcation can be improved and often nearly eliminated by elevating the cheek and securing it to the orbital bony rim at the same time as a lower lid blepharoplasty and via the same incision. Historically, much fanfare was made about this procedure and it was called a mid face lift or a cheek lift or a malar component lift, or a composite lift. The main accomplishment is correction of the fatty puffs (they are transferred to concave areas, elimination of the cheek-eyelid junction, muscle suspension, with some skin removal and all resulting in a substantially more youthful appearance. There are many devices that have been designed at substantial extra expense to help hold the cheek up. These are usually biodegradable and essentially almost always unnecessary. Fixing the underside of the cheek tissue to the tough covering of the bony orbital rim is all one needs. It is definitely true that if a facelift is being done simultaneously with lower eyelids, the facelift can be of the high SMAS (high support) type that may adequately lift the cheek in most cases and eradicates the eyelid cheek junction demarcation. Even in this case the mid face, cheek elevation via the lower lids is so straight forward and productive I like to do it for even a better result. This facelift, eyelid, mid face combination gives maximum enhancement of a youthful appearance with excellent enhancement of longevity. Even the nasolabial fold is improved but not eliminated by this nice extended blepharoplasty procedure. The lower eyelid incision is just under the lashes and is designed to defy detection. Patients sometimes ask about the inside the eye incision for lower lid-mid face surgery. I use this at times if fat removal is definitely indicated. Although some mid face work is possible through this incision it is awkward and often the side result (complication) is a sore eye for some time. In addition, the inside of the eye incision allows no skin removal and this is essential for a nice result in many patients. Some feel the laser can be used to "tighten" the lower eyelid skin. I have found laser improvement of the lower lids very short lived and unimpressive at best. Pushing the laser to effect greater skin contraction may result in a pulled down hound dog look in the lower eyelids. The laser sounds good, high tech, and all, but I have found it not nearly as effective as a chemical peel of the skin. Also, laser is a lot more costly.

Eyelid Wrinkle Rx
To subdue eyelid wrinkles or smooth eyelid skin the surgeon must remove the upper layer of skin of an area and let it heal smoother and yes even a little tighter. Upper layer skin can be removed by burning it off (laser, peel, or electrocautery). The chemical peel is the best, the safest, and the least costly for the eyelid area. We have lasers available but rarely use them. They just aren't very productive and they sure do add to costs. Exotic procedures produce exotic results and are rarely requested or desirable. Raising the lateral canthus can change the entire appearance and shape of the eye. In general, the eyelid shape and eye shape stay the same after traditional blepharoplasty. Patients in fact usually specify that their eyelid and eye shape not be changed. Nevertheless raising the lateral canthus is occasionally requested. This is a significant undertaking and recovery is long. Few desire this.

Asian Eyelid
The ethnicity of the upper eyelid can be somewhat changed by establishing the upper eyelid crease when there is none. This is at times requested by Asian patients who may lack the supratarsal crease. Sometimes it is referred to as the westernization procedure. When this is done, it is important not to disturb the beauty of the Asian eye. Maintaining the medial canthal area in its natural state and keeping the new crease no higher than 6 mm gives a pleasing result. At times removal of a little fat is also indicated according to the patient's desire. The recovery is quite rapid and return to work and play may occur in 5-7 days. Eyelid procedures are gratifying to both patient and surgeon. Your needs, desires and questions will be discussed at length during your consultation.

Forehead

In conjunction with a facelift, I often perform forehead surgery (forehead / frown procedure ) to elevate drooping brows, to give an open, alert upper eyelid, and to soften frown lines. Advances in forehead surgery include the use of mini incision endoscopic surgery, employment of "detection defying" hairline technique, and improved versions of the coronal technique. Because each approach has merit, the important issue is to match each patient with the technique that is best for him / her. A hairline incision approach works well if the patient has a high forehead with receding hair. When I use the hairline approach, I elevate the brows and bring the scalp hair forward. If the patient has a narrow forehead, I use the endoscopic procedure. Clearly, the "cookbook" technique has no place in the individuality of plastic surgery. My job is to select the correct technique for each individual patient to ensure the desired results.

Rhinoplasty or Nose Reshaping

As with many plastic surgery procedures, the rhinoplasty (nose surgery) procedure is as different as there are numbers of people on earth. We are all different. Our noses are different. Individual assessment is very important. The consultation is critical. Nose surgery (rhinoplasty) is done to straighten a crooked nose, to make a very large nose smaller, or to increase certain dimensions of a nose perceived as too small or just not adequate in certain places. Some people prefer a dorsal hump or bump be removed. Some people prefer a tip to be narrower and better shaped. Some patients prefer the nostrils be made smaller. At times, patients request a stronger bridge or a better tip of increased nasal tip projection. Sometimes, narrowing wide nasal bones are indicated. The surgeon must listen very carefully and plan the rhinoplasty operation in accord with the patient's desires. A careful discussion with photography is informative and necessary.

Careful planning in rhinoplasty further assures a result that pleases the patient, is very natural and nonsurgical in appearance, and functions well. Function or airway must always be considered. Natural breathing is critical of course to all. Often airway problems are corrected simultaneously with rhinoplasty. A beautiful nose that doesn't breathe very well is not a successful endpoint. A successful rhinoplasty is all about aesthetics and function.

At the consultation, expectations are discussed and realistic expectations are explained. Probably 99% of the time the patient's desires and what is possible and appropriate in rhinoplasty are in good accord. Rarely a patient may have unrealistic expectations, so careful discussion is important. Facial pictures are taken and printed. I discuss what the patient wants and what I can do. I am again and again amazed at how intelligent patients are and how well-read they are on most plastic surgery procedures. This certainly is true of surgery of the nose. I rarely use computer imaging to suggest a result. This only shows what a computer can do and may be way off a realistic possible rhinoplasty endpoint. After the patient and I review all of the patient's pictures we look together at pictures of patients I have done (well over 1100 rhinoplasties) and specifically look at pictures of patients with similar noses to the consult patient. All questions are answered carefully and thoughtfully. All questions a patient may have are good questions.

A rhinoplasty can be done with patients awake or asleep. Although local anesthesia is a possibility it is always nice to be asleep for both comfort and total safety. An M.D. anesthesiologist enhances safety and comfort. Yes, there is a cost for an anesthesiologist but one worth every penny. An alternative to total anesthesia, the twilight sleep procedure is accomplished with sedation. The patient is relaxed but not asleep. You still may feel a little pain but not much. Of course, surgeons tend to be kind hearted people and always make every effort to assure comfort and gentleness.

What is actually done in a rhinoplasty? The rhinoplasty may include many techniques and procedures. Technical aspects in rhinoplasty include adjustment of the nasal bones, removal of bone and cartilage from humps, cartilage adjustment or removal from the tip, cartilage or bone grafts, placement of implants, correction of the airway, and nostril correction for symmetry and narrowing. Surgery is usually done on an out-patient basis and the patient returns home to recuperate. There is no nasal packing unless extensive airway work was done. A small splint is applied for 48 hours or so to protect the nose. Patients return to work, school, or play in 4-7 days. Full recovery takes 6-12 months or longer depending on the procedure. Most patients look fine in 10 days but resolution of swelling takes longer. Sutures are usually the dissolving type but occasionally some need to be removed.

The nose reshaping is a popular procedure which is gratifying to patient and surgeon. I have done rhinoplasty procedures on patients of ages 13 to 76. Candidacy depends on anatomical facts plus the patient's desires. Secondary nasal surgery after rhinoplasty is needed about 2% of the time for minor adjustment. The needs for major secondary rhinoplasties are rare. One of the wonders of practice in the bay area is the delightful diversity of our patients. I have done nasal surgery on patients with worldwide heritage (Asian, European, Middle Eastern, African, Indian, American Indian and Latin). All do well and all merit very individual attention to their specific nose shape and their desires. For the proper candidate, rhinoplasty surgery is a much appreciated endeavor and enjoyed by both patient and surgeon.

Chin Correction

Congenital chin recession or what is commonly known as a "weak" chin, may result in a profile that lacks the harmony, that you desire.

There are many different chin implant types and sizes available. Materials can include silicone. proplast, irradiated cartilage, or even cartilage or bone taken from your own body.

A chin implant can be inserted either intraorally or by an incision under your chin. Chin augmentation is accomplished under a local anesthetic.

Facial Chemical Peels

This is an outpatient procedure that is performed in either our office or in our general operating facility. The purpose of a facial peel is to cause the even, controlled shedding of several layers of damaged cells, so you are left with a new fresh layer of skin with more even texture and color. A facial chemical peel tightens skin and softens wrinkle lines as much as possible. Dr. Commons applies either TCA or Phenol Peels. These are not the superficial peels performed in day spas that only produce a nice little buff to the skin. Depending upon the depth of the peel, the patient would need about a week or two before returning to work.

Dermabrassion

Dermabrasion is a procedure used in plastic surgery to help smooth the upper layer of skin and epidermis. It can diminish the effects of scarring due to trauma or acne as well as address fine wrinkles about the mouth and face. The effect is very similar to chemical peels, but there are some distinct differences in how these procedures are used. Skin type and problems will dictate which procedure is preferable. Recovery is similar to chemical peels.