Rod J. Rohrich's Blog

Question: Are there different techniques for achieving an excellent result in rhinoplasty?

Dr. Rohrich: Yes, there are different techniques. However, it is not so much about the technique used as long as that particular technique delivers the desired result. The nose is the most looked at facial feature so it must not shout out rhinoplasty.

The main different techniques are open vs. closed rhinoplasty. I prefer the open technique in most cases. This means you make a very small 6 mm incision in the middle of the columella (the structure in the middle of the bottom of the nose). This procedure allows the surgeon to look directly at the nasal deformity, while with the closed approach he has to do everything in a blind way, so to speak, which means he doesn’t have the same level of control.

And rhinoplasty is all about controlling every aspect of the procedure…

In the open approach, the surgeon can see the deformity and correct it with the patient’s own tissue – and reshape the cartilages using sutures and/or invisible grafts. With the open approach, the nose looks more natural longer and ages well with the patient, without the need for revision in most cases.

In the closed approach the surgeon has to use more grafts as it is impossible to see the deformity – so, instead of correcting it, the surgeon has to camouflage it. Not the best thing to do long term as visible grafts can become distorted with time.

Rhinoplasty is a surgical procedure of millimeters. It is the most precise technique in cosmetic plastic surgery, therefore if you are off by a millimeter one way or the other you can have either a great or phenomenal result or a poor outcome.

Rhinoplasty, in fact, epitomizes plastic surgery as a whole because it is a surgery of such great finesse and three dimensional thinking and execution, as well as precise pre-op planning – all of which require constant learning and take years to master if you truly want to be a real expert. Experts are not born but are made through tireless learning, critical self-analysis and always seeking a higher level of excellence. It takes an average of about 10 years or 10,000 hours to become a true expert in anything in life!

Question: What is the difference between liposculpture and traditional liposuction?

Dr. Rohrich: Terms like lipostructure and liposculpture are used to distinguish liposuction from 3 dimensional body contouring. It’s not just about fat removal, it’s about reshaping the body by removing (and sometimes adding) the right amounts of fat in the right places.

With liposuction the surgeon is doing just that – suctioning fat only without true 3 dimensional contouring of the entire body silhouette. Considering the overall 3D shape and outcome is truly body sculpting which means you need to perform artistic lipoaspiration while refining the body contours without masculinizing the female silhouette.

This defeminizing of the female shape can be seen frequently and is done by those who do liposuction of a “spot area” like the love handles only. It does not look natural and is a source of great disappointment to patients worldwide. I see many secondary liposuction patients with these problems.

The bottom line is that liposculpting is difficult to do well and requires a very artistic eye and great surgical technique to obtain consistent great results in body contouring for both female and male patients.

Question: Is it ok to mix the different dermal fillers?

Dr. Rohrich: Yes it is ok, in general.

Fillers should only be injected by people that are superbly trained, competent, and have the experience to do so. Having trained thousands of plastic surgeons to use both Botox and fillers, I always stress how vital it is to understand the anatomy, the mode of action, and the duration of each filler.

In general, the longer lasting fillers are placed in a deeper fashion and the hyaluronic fillers should have a more superficial range.  You can add both of these which are done commonly in the nasolabial fold areas and the commissures where stacking is performed for increased longevity – such as the use of Radiesse in the deep nasolabial fold followed by an application of hyaluronic acid superficially in the commissures.

Question: Is it ok to mix hyaluronic fillers and local anesthesia?

Dr. Rohrich: It is very important and essential.

I have been using fillers with local anesthesia and epinephrine for over two years now to decrease patient discomfort, as well as post operative bruising and swelling significantly.  It is a very useful technique and many of the fillers are incorporating this locally into their fillers.

The key is including epinephrine as it decreases the sensation of the bruising and swelling.  Another way to diminish bruising and swelling is the use of cold application massage therapy and the application of ice pre and post operatively as well as topical agents 20 minutes beforehand.

Question: What are the best treatments to manage and minimize scarring after surgery?

Dr. Rohrich: 90% of how you heal depends upon your genetic makeup as well as the location of the incision. In general, incision scars in the head and neck area usually heal quite well, especially those in the eyelid and nose areas. It is very rare to have any type of keloid hypertrophic scarring in these areas, even in patients of color.

There is a higher incidence of keloid and hypertrophic scarring below the clavicle (neck area) and especially in areas like the presternal (sternum area), the deltoid (shoulder area), and the back, so one needs to be cautious in these areas.

The most important thing, beyond the genetics, is to prevent infection, to do accurate wound closure, early post operative taping, sun avoidance, and massage therapy. The application of vitamin E or antioxidants has not been shown to significantly enhance wound healing or to mature the scar.

Question: What should I expect from a Botox treatment in the forehead?

Dr. Rohrich: The key thing in Botox is to not paralyze the face. This paralyzed appearance being normal has been a myth with Botox and gives an unnatural result.

The true goal is to have a soft look with reshaping of the brow and forehead so that it looks natural and not fake.  The natural look is the hallmark of an excellent Botox injector, and that requires skill, analysis, experience and an understanding of anatomy.  You must seek out someone who is an experienced injector in Botox.  A true expert is someone who teaching it, has written about it and does it daily.  Those are the triad that one must seek out if you want to get excellent results.

I also see all of my patients in two-weeks, especially if this is a first time Botox injection, to see how they are doing and how they are shaping of the brow.

Question: Can you correct the downward sagging of the mouth from Botox?

Dr. Rohrich: Yes, it is a very nice, simple and good way to correct the downward turn of the lips at the corners of the mouth, by weakening the depressor anguli oris muscle. This must be done very accurately, so as to prevent lip asymmetries when smiling.  It is a very useful technique.

I use Botox in the upper lateral portion of the lip a significant amount of the time when I’m doing lip enhancement to provide for increased fullness in this area.  A cautionary note for patients – I usually only inject the upper lip and not the lower lip.  If the injection is not done correctly the patient may have some difficulty puckering or actually drinking from a straw.  However, that is usually not a problem.

Question: Does rhinoplasty hurt?

Dr. Rohrich: Rhinoplasty in general does not hurt significantly, if at all.  Even when doing the fractures of nasal bones, this is really not an issue.  The procedure is usually done as an out-patient under general anesthetic so that it is a very comfortable almost pain free experience.

Question: How long should you wait after rhinoplasty to get a secondary rhinoplasty?

Dr. Rohrich: In general, it is important to wait at least 1-year in most patients and in secondary patients I wait 1 to 1 and a half years. This is especially important if the patient is male, a patient with thick skin, or a patient who has had multiple previous rhinoplasty procedures. Rhinoplasty is the most difficult operation in cosmetic surgery and a secondary rhinoplasty is a order of magnitude more difficult.  It is very important to not do these operations too early, as all you will get is more scar tissue and swelling and therefore another unsatisfactory result.

For secondary rhinoplasty, it’s extremely important to seek out someone who has experience and expertise in rhinoplasty.  The gold standard is to find someone who performs this procedure as a significant part of their practice, has written about it and teaches it, and has advanced the art in this area. That is the golden triad for a true expert in rhinoplasty.

Secondary rhinoplasty is a very, very difficult operation and it is especially crucial that you to go the distance to find someone who can do this operation for you, as you can only have so many operations on your nose.

Question: Is nasal packing after a rhinoplasty necessary?

Dr. Rohrich: Absolutely not. There is no rationale for nasal packing in a routine rhinoplasty.  Most of the time if you are not doing a functional septal work, no packing and splinting is necessary.  If splinting is required a small splint is placed temporary, which is then removed in 5-7 days.

Question: Is Retin-A still the gold standard for skin care?

Dr. Rohrich: Absolutely. The only skin care agents that truly have a scientific basis are the retinoids, specifically Retin-A. There is a considerable amount of clear, real science which shows that long term use of Retin-A decreases the effects of photo aging, brown spots and increases the dermis.

Normally, our skin turns over every 6 weeks, but use of Retin-A significantly increases this rate to as little as 6 days and in the interim allows you to increase the dermal thickness. Retin-A also enhances the production of collagen in addition to blocking agents that help break down collagen. This reverses some of the aging effects of sun damage.

Perhaps one of the biggest problems we have with retinoids is patient compliance and the early irritation. This is where the guidance of a skin care expert is important, helping you to apply retinoids with a more gradual manner or providing for a mild, more tolerable formulation.

Retin-A is usually prescribed to be used once a day before bed, but some patients may need to start with 2 to 3 applications a week and ease in to daily use.

Question: How effective is liposuction for a small area, like my ankles?

Dr. Rohrich: Targeted liposuction can be very effective for certain isolated areas where skin tone is good. Most common areas are under the lower arms, neck area, calves and ankles, back and flanks.

For target areas such as these, the surgeon will use a small, fine cannula to reshape and contour the area carefully. Finesse in the use of these smaller instruments is essential, as is experience in the most sophisticated liposuction like ultrasound assisted liposuction.

They key to avoiding an unnatural look is to make sure not to over suction the area and to operate carefully to prevent depressions or deformities. The goal is to gracefully contour the area to make it more shapely and the surgeon’s aesthetic sense plays a major role here.

This surgery is usually performed as an outpatient procedure and patients will wear compression garments for about two weeks after their surgery. These garments will help improve post operative healing and reduce swelling in a uniform manner.

After your surgery, weight gain or loss will usually not effect your results as much as a more traditional circumfential liposuction which can be more dramatic with weight change. However, keeping a stable weight, with change being less than 10 to 15 lbs in either direction, will help to best maintain results and of course innate genetics always plays a major role as well.

Question: Is rhinoplasty performed differently on a person with a non European ethnicity?

Dr. Rohrich: Ethnic rhinoplasty is considered a type of specialty rhinoplasty, like secondary or revision rhinoplasty. When we talk about ethnic rhinoplasty, we are talking about both the differences in the surgical approach to an ethnic nose as well as the way you approach and analyze this type of nose to retain its ethnic origin. It is very important to understand that true ethnic rhinoplasty focuses on preserving ethnic qualities of the nose while reshaping it. A person’s nose is a defining ethnic facial characteristic and it should not be the intention of the surgeon to significantly alter those basic ethnic features. Surgeons must take great care to maintain the patient’s ethnic harmony.

There are several challenges with ethnic rhinoplasty which are not present in a more traditional rhinoplasty and make it a more difficult type of surgery. The skin is usually thicker, which can obscure the underlying structures of the nose and make it more difficult to predict the results. The nasal framework tends to be more delicate, requiring more care and often necessitates the use of cartilage grafts to achieve good results. Darker skin requires more care of the incisions during closure to help minimize scarring. Overall, ethnic rhinoplasty often requires a more complex and elaborate surgery in order to be successful.

If you are seeking a plastic surgeon which has expertise in ethnic rhinoplasty make sure you do your research very well. A true expert in this area has written about it, lectures on this topic, and teaches others how to perform this type of surgery. Look though the doctor’s CV and note any publications and courses he has given on Ethnic Rhinoplasty, which might also be listed as Non-Caucasian Rhinoplasty.

As plastic surgeons, we are focused on getting good results and many will not attempt to perform ethnic rhinoplasty, preferring instead to refer them to a surgeon that regularly performs these difficult procedures. This is why there are not many rhinoplasty surgeons which are highly experienced in ethnic rhinoplasty in the USA.

1. Why do you put breast implants below the muscle?

Dr. Rohrich: There is very good scientific evidence in the literature to show that breast implants look more natural and feel better if placed below the muscle.  It also does not obscure mammography (both silicone and saline implants) and there is good evidence based data to support that the implants (both silicone and saline) stay softer longer by a significant margin if placed below the muscle.

2. How do you prevent rippling in breast implants?

Dr. Rohrich: The ideal to prevent rippling is to decide pre-operatively what type of implant you need and whether it should be placed above or below the muscle.  The optimal ways to prevent rippling or at least minimize rippling is to place the implant below the muscle, make sure there is adequate breast tissue, and not oversize or under inflate an implant if you are using saline or silicone implants.  Sometimes the use of silicone implant may be better, especially in patient with no breast tissue as well as placement below the pectoralis major muscle.  If you are using saline implants make sure you maximally fill it and not over fill or under fill, as that can cause more scalping or rippling.  If you under fill, it can cause more deflation in saline implants.  Remember, one can almost always feel any implant in the lower outside quadrant of your breast.

3. Why should you under or overfull saline implants?

Dr. Rohrich: One should never underfill a saline implant because that is a higher chance of having a deflation or rupture because of full flow problems.  You should always maximally fill the implant so that it will get less scalping and no rippling in this area, and it will deflate much less.

4. Do you have to replace a ruptured silicone gel implant and why?

Dr. Rohrich: Yes, if there is radiographic evidence or an MRI it should be replaced for several reasons.  Primarily, because long-term the silicone can cause small granulomas or small masses in the breast which can mimic breast tumors that may be similar to breast cancer and can disseminate throughout the breast.  It is optimal to remove the implant with the capsule and attempt to replace with a new implant below the muscle.  All implants need to be considered for removal at 10-15 years, whether the implant is saline or silicone.

5. How long should I wait before I have a ruptured silicone implant replaced or removed?

Dr. Rohrich: Replacement of implants that have ruptured is not an emergent operation, but it is one that should be undertaken within several months from the diagnosis.  Over time silicone implants that have ruptured tend to leak and can cause more scar tissue formed by interaction around the implant.  The procedure requires removing the implants and also the scar tissue around the implant.  Therefore, in most cases, you do need a drain when replacing the implant.  The recovery is brief – about 3-5 days.

6. Should one use high profile or moderate profile implants plus for sagging breasts rather than perform a breast lift?

Dr. Rohrich: In most cases I don’t think that it is prudent to use high profile implant or moderate profile implants (saline or silicone) to correct sagging breasts as this is not the solution.  If you truly have breast ptosis or sagging breasts you should do a breast lift with or without implants.  Obviously, if patients want a lift and more upper fullness they should do a lift with implants (with moderate profile implants) in most cases.

The problem with high profile implants is that they have not been adequately studied and may have much higher incidence of breast tissue and glandular thinning and subsequent long-term rippling effects, whether they are silicone or saline, although this has not be studied extensively.

7. Does the number of cc’s in a breast implant correlate with the breast size?

Dr. Rohrich: It usually does not, because it depends upon the size of breast that you are beginning with.  The resulting cup size does not directly correlate with the implant size.  Just as different size, whether it is a B, C, or D cup varies from patient to patient and from retailer to retailer, there is no way to guarantee that one will have a B, C, or D cup breast after implants.  The goal is to make them proportionate to the patient’s chest wall diameter, amount of breast tissue the patient has and their size and shape.  It is very important not to over augment patients, as they will then have further movement of their breast tissue out to the outside (or lateralization) which will cause distortion and the breast will look too large for the patient’s body and chest wall.

8. How can one breast be hard and the other breast be soft?

Dr. Rohrich: Yes, this can occur since we did not know the real cause of capsular contracture (breast implant hardness).  It is uncommon for capsular contracture to occur, especially with saline implant below the muscle, but is saline implants do get hard they will begin getting hard earlier than later (the first several 3 months) vs. silicone gels, if they get hard, will get hard progressively over time.  One can attempt to do early aggressive breast massage for perhaps 6-8 weeks.  However, if capsule contracture develops then a simply inferior capsulotomy or release of the scar tissue may be all that is needed, especially with saline implants, to restore shape and symmetry.  This is done easily as an outpatient under IV sedation.

9. What is the potential for loss of nipple sensation; numbness on one side and not the other.

Dr. Rohrich: It is not uncommon to have some sensory changes after breast augmentation, especially if there is a larger implant.  Most of the time sensation does return, especially if placed below the muscle, therefore one should wait 3-6 months for the sensation to return.  However, it is acceptable to have some nipple sensation loss with breast augmentation.  The ratio of sensory loss from breast augmentation is 5-10% with the inframammary fold incision being the least (lowest) ratio of nipple sensation loss.

10. How do you make cleavage with breast implants?

Dr. Rohrich: It is somewhat a myth that breast implants will create significant cleavage.  It depends more on the shape of your breasts and the diameter of your breasts pre-operatively as well as the degree of breast augmentation and the amount of breast tissue that you have.  Often, if you have an average chest wall size, there is a better chance for having improved cleavage.  However, it is not a guarantee and just increasing the size does not necessarily increase breast cleavage.  It is actually counter intuitive as with the implant the breast is actually pushed to the side and actually diminishes the cleavage amount one would anticipate.