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Chapter 3

Other Facial Procedures

Procedures

Other facial procedures include blepharoplasty (surgical improvement of the eyelids), rhinoplasty (nose surgery), liposuction (fat removal from the neck and cheeks), forehead or brow lift, chin augmentation, chemical peel, dermabrasion, and collagen injection. Forehead lift, chin augmentation, chemical peel, and non-surgical injections will be discussed in this chapter. Rhinoplasty, blepharoplasty, and liposuction will be discussed in later chapters.

Forehead Lift
Forehead Lift is done to alter a sagging of the forehead and eyebrows, and is especially associated with wrinkle lines. The sagging and lines cause a person to look sad, unhappy, angry, or tired in addition to looking older. The facial aging process affects the upper third of the face in a manner similar to the rest of the face. Improvement in the lower face from face lifting can actually accentuate the signs of aging in the upper face. For this reason, many patients choose to combine a forehead lift and/or blepharoplasty with a face-lift. Additionally, for the younger patient, often the forehead falls before the face does (this is the main reason for the development of crow’s feet). A simple fact that also is not widely known or recognized is that a forehead lift often lasts a lifetime, it is a very long-lived lift due to the anatomy of the area. A face-lift often needs to be repeated or mini-lifts performed as needed at intervals as further aging occurs. This is often not the case with the forehead lift. For this reason, it is a surgical procedure often performed on younger individuals as compared to the facelift.

        The forehead lift is usually performed with an incision within the hair. Occasionally, a lift at the hairline, within the forehead or above the eyebrows can be done. This is rarely the case. Once the forehead tissues are separated from the underlying layer, the muscles causing the wrinkles or frown lines can be modified or removed. The amount of forehead and eyebrow elevation is determined and the excess skin is trimmed. This is usually determined prior to the procedure.
           By means of this technique, differences in eyebrow position can be adjusted to help even up the eyebrows. In addition, hanging upper eyelid skin can be improved without the need, in many cases, for blepharoplasty or eyelid surgery.

Procedures & Frontal Corrugators Orbicular is Depressor Super
          There is a way of performing this procedure with an endoscope and using limited incisions. Many of us have found little use for this approach and loss of the lift over a relatively short period of time. In those who have a high forehead and early balding, the hair-bearing scalp can actually be advanced with a slightly modified technique to help both problems at the same time. The only down side to this is a relatively fine scar at the frontal hairline.

(Forehead Furrows) (Frown, Scowl Lines) (Crows Feet) (Frown, Scowl Lines)

Risks
          Complications are very infrequent and are similar to those discussed in the face-lift chapter: bleeding, skin healing, skin numbness, scars, and, very rarely, hair loss. In addition, asymmetry or unevenness of the eyebrows is sometimes present, early after the operation. This may be due to swelling or differences in muscle tone and generally improve with time. The area of numbness above the incision line, which occurs in this operation, decreases progressively with time. In a few individuals some permanent sensory loss is found just in front of the incision line. It is also normal to have some bruising and swelling after the operation. This will subside in five to ten days.

Chin Augmentation
          Some men and women have a small, flat ("weak") chin that can detract from the overall pleasing characteristics of the face. Procedures are available which can enlarge or augment the chin to bring it into harmony with the rest of the face. This can be done alone, but may also be done with a face lift or nose procedure to enhance facial proportions.
           The two most common methods of chin augmentation are either placement of an implant over the chin bone or cutting part of the chin bone to slide it forward and secure it in a more prominent position.The first is usually best if a minimal augmentation is required. Many surgeons now use larger and thinner implants which give a very pleasing contour to the chin. The newer implant materials also allow for bony in growth so that the implant actually becomes a part of you and does not move or cause erosion of the bone. The incision for these operations is placed either externally through the skin beneath the chin or internally on the inner surface of the lower lip near the gum tissue. The latter is the most common site since the scar is completely hidden.

Risks
         Complications from chin augmentation are uncommon. Things such as infection, bleeding, or shifting of the implant can occur. Occasionally, with some types of implants, slight erosion of bone can occur beneath the implant.

Summary
          The benefits of chin augmentation can be very satisfying for those who need this procedure to improve facial balance.

Chemical Peel
          Chemical Peel in various forms has been utilized for many years as an effective addition to the treatment of aging facial skin. It is used to decrease the fine, moderate, and even deeper wrinkles that typically occur around the lips, forehead, cheeks, and eyes. These wrinkles are the result of aging, heredity, sun damage, and the constant action of facial muscles. These fine lines occur gradually as the skin loses its normal elasticity and becomes dry and thinned out. It is impossible for a face-lift or eyelid operation alone to remove these undesirable changes as these procedures only tighten and remove the folds of excess tissue.
          Part or all of the face can be peeled. How much depends upon the judgment of the surgeon and the desires of the patient. A chemical solution of phenol, trichloroacetic acid, or a "fruit acid," also called glycolic acid, is applied to the skin to produce a controlled peel that results in the improvement of the wrinkles. Phenol peeling has largely been replaced with laser resurfacing as a safer and more effective means of removing wrinkles without causing permanent skin lightening or scarring. The peels produce deposition of new collagen and realignment of the elastic fibers present in the dermal tissue. The duration of improvement from a chemical peel depends on the type and concentration of the solution used as well as the number of peels obtained. In this procedure the superficial skin layer actually sheds. The texture of the skin is improved, rejuvenated, and smoothed, giving it a more youthful appearance. It must be kept in mind, however, that chemical peeling is not a substitute for a face-lift. The two procedures are used to treat different problems but are often done in conjunction with one another. Deep chemical or laser peeling and a full facelift are not compatible with safety of the skin since it being injured on both its front and deep sides. When a deep peel and a facelift needs to be done, procedures may be modified or the procedures may be staged with a few weeks or longer between them so that each may be optimized.
          Some types of skin are more suitable than others for this type of procedure. Patients with fair complexions usually have better results with heavier peels than those with dark pigmentation. In fact, people with darker, olive skin may not be good candidates for heavier peels but do well with repetitive lighter peels or laser resurfacing. Postoperatively there may be a decrease in pigmentation in the treated skin. This is particularly true for deep chemical and, to a lesser extent, deep laser peels. Inherent skin color is an important consideration in every patient. In those with fair complexions, a slight decrease in pigmentation is usually not noticed and rarely creates problems for the patient.
          The newest peels are the alphahydroxy, beta hydroxyl, glycolic, or fruit acid peels. These are more superficial and can be done on virtually any type of skin. It usually takes a series of three or more of these peels to achieve the desired effect. However, since the peels are more superficial, the downtime for the patient is much less, ("lunchtime peel") which appears to be a good trade-off. It must be noted that a few superficial peels do not equal one deeper peel. There is no way to have superficial peels perform a deep resurfacing no matter how often they are repeated. The patient can also benefit from a good, simple, reliable home care skin program. The peeling of the skin following the procedure is usually minimal but is still a downside to the procedure since makeup will not adhere well to peeling skin.
The newest resurfacing procedure in this country is particle resurfacing that also goes by many other names: Power Peel, Derma Peel, Parisian Peel, etc. This process involves micro dermabrasion of the skin with tiny particles drawn across the skin by a vacuum. The particles resurface the top layer of skin and then the vacuum cleans the pores and whisks away the debris. The older models of the machine use Aluminum crystals but due to health concerns over breathing these crystals and having them on the skin, many of us have switched to sodium bicarbonate crystals which dissolve readily and are completely safe. Salt is mentioned as a crystal agent only to be condemned. The dehydrating and stinging effects on the skin are counterproductive to the process. The process is rapid and allows for variable peeling depending upon depth of peel desired. Again, a series of three or more is required to reach the desired effect and many people then go on a maintenance schedule of one to two per month. Make certain that it done by qualified health professional since there are stories afloat of crystals being reused and handles not being properly cleansed between uses. The beauty of the procedure is that it can be done on active skin conditions such as acne and that there is minimal or no subsequent peeling. The person is usually slightly pink for a few hours and then appears normal but with smoother and softer skin. This is truly lunchtime resurfacing.
          The heavier phenol chemical peel is performed by careful application of the solution to the skin. Sedation is used to control the initial burning feeling that occurs. This sensation may last for a few hours following the procedure, and pain medication is usually given. Some surgeons tape the peeled area and then remove the tape in forty-eight hours. Often the superficial layer of skin is peeled away with the tape. The skin will continue to weep a straw-colored fluid for three to four days following the procedure. The weeping will then subside and smoother, lovely skin will be evident within seven to ten days. Again, deep phenol peels have largely been supplanted by laser resurfacing. More superficial TCA peels rarely require sedation and there is no period of wetness. The skin, rather, is red for a few days followed by peeling for about 7 to 10 days. During this period of time makeup cannot be used and will not stay on. Glycolic peels and micro dermabrasion require no anesthetic or sedation and there is little aftermath other than smoother skin.

Phenol Chemical Peel: Post Procedure
           During the "weeping period," the patient is instructed to either keep the skin covered with a special powder to allow scab formation or keep the area covered with a special antibacterial cream or ointment. Once the scab forms, ointments are used for seven to ten days until the scab separates from the skin. Redness of the skin is often seen after a good phenol peel and can take from two to three months to dissipate. Sun exposure is restricted for three to six months following the procedure and sunscreens are mandatory. If the patient does not carefully adhere to these postoperative instructions, undesirable pigment changes may occur, which may take several months to disappear. Bleaching creams can alleviate many pigmentation problems.

Risks of Laser Peel
          Scarring is possible but rare. The patient must be extremely careful about sun exposure after surgery. If not, there may be irregular, blotchy pigmentation of the treated skin. Some decrease in pigmentation may occur following the procedure. This is often dependent upon the patient’s natural pigmentation. The deep phenol peel, again, is rarely performed today due the safety and fewer side effects afforded by laser resurfacing.

Laser Skin Resurfacing
          The laser beam, when focused on the skin, delivers short bursts of gentle, invisible light to the outer surface of the skin. With each short burst of light the outer layers of the skin and wrinkles can be diminished. The laser also causes a tightening of the collagen within the skin and this can be significant in many individuals. The new skin then grows and "locks in" the new skin length.
           Skin is an ever-regenerating part of the body. We all know that surface skin tissue sheds constantly. Under a microscope you can see the skin flake onto your clothing and your pillow and sheets at night. All of us leave a dusting of skin flakes wherever we go. We don’t see it easily, but it is there. Since the body is constantly shedding this large covering of surface skin, new skin is constantly regenerated to replace the old. It is perfectly normal.
           The laser, in select cases and when used appropriately, may help accelerate this process in a way similar to the chemical peels. The laser, however, is a powerful instrument and must be used judiciously. Otherwise, prolonged redness or even severe scarring may result. Training is all-important to this end. An excellent plastic surgeon or dermatologist may not be an excellent laser surgeon.
The proper laser in the proper hands is the best approach to many problems. For example, there are lasers for vein removal, rosacea improvement, tattoo removal, age spot removal, treatment of facial growth, hair removal and, we are now testing some laser devices which tighten the skin without removing the top layer. This will allow us to treat many conditions of skin looseness when removing the top layer is not necessary or desirable.
           A laser peel performed by an experienced surgeon can be a safe and precise peel. It is possible to remove fine and moderate wrinkles around the mouth, eyelids, and other sensitive areas without the scarring. One of the potential serious side effects of deep chemical peeling on the entire face is an affect on the heart caused by the phenol. The laser peel has no internal side effects. Deep chemical peels can leave darker skin unnaturally lighter. The laser peel leaves the skin smooth, soft, and more normal in color.
          Light and medium chemical peels are not effective in removing the medium-to-deep wrinkles that can be removed with a laser peel. Laser resurfacing is more effective in these areas. The laser is also the most effective modality available for the treatment of acne scarring. The deep resurfacing afforded by the laser is also an effective treatment for many early pre-cancerous skin lesions.
           Face, forehead, and neck lifts only help with folds and sagging of the skin. Lifts do nothing for wrinkles on the upper lip, bridge of the nose, eyelids, and most areas of the chin and lower lip. A face-lift does take out the extra sagging skin that hangs and produces jowls. Some people may need both a face-lift and a laser peel to obtain maximum improvement if they have a lot of loose, sagging, wrinkled skin. Neck lifts are helpful for loose skin on the neck but alone do not restore the youthful appearance of the skin. Think of aging as occurring with several visible effects. The first is that large structures fall. This is true of the neck skin, eyebrows, etc. To correct this problem, a surgical lift needs to be performed. Aging also results in textural changes of the skin. To correct these, some type of resurfacing must be performed. Mere tightening of the old skin will not help this problem. The CO2 laser also tightens to some degree and newer lasers will tighten without resurfacing but for now, for major skin excess, surgery is the only corrective measure. The third visible sign of aging is the loss of skin and subcutaneous tissue thickness. This is best addressed by soft tissue fillers such as collagen or by implants in the appropriate areas (such as the cheeks). Deep plane facelifts can also reposition the fatty tissue that remains. This helps to correct this problem as well.

Laser Skin Resurfacing or Dermabrasion?
           Dermabrasion is performed using a high-speed, diamond sanding wheel or a wire brush. The surface of the skin is sanded, including wrinkles and scars. Dermabrasion is only effective on the flat areas of the face, upper lip, forehead, and chin. It is dangerous and difficult to use dermabrasion around the eyes. Laser resurfacing as a better and safer means of controlled skin ablation, has largely supplanted the technique of dermabrasion, as a whole. Most surgeons who are well versed in laser resurfacing no longer perform dermabrasion in their practices.

How Long Does It Take to Perform Laser Skin Resurfacing?
          A laser peel of the upper lip takes a few minutes. To do the whole face generally takes thirty minutes to several hours, depending on the laser used, the anesthetic, and the severity of the wrinkles.

How Painful Is the Procedure?
           Laser peeling (resurfacing) without any anesthesia causes a sharp stinging sensation on the skin while it is being performed. Pain medications, sedatives, and/or local or general anesthetics are usually given to make the procedure more comfortable. Most surgeons prefer to perform a full facial laser resurfacing using general anesthetic, not only for patient comfort but because without sedation, often the patient will move in response to the laser. Even if this is not remembered afterward, it does not allow the precise control of the resurfacing which is necessary for an excellent procedure. Most patients can have the laser peel performed as an outpatient. After the laser peel has been completed, there is very little pain.

How Long Does It Take to Recover from a Laser Skin Resurfacing?
         It takes between fourteen to thirty days to recover from a laser peel. It depends on how deep the wrinkling is, as well as other factors that affect healing. Minor complications such as skin infection may extend the healing time. Both antibiotic and antiviral medications are given prophylactically for this procedure.

How Long Do I Need to Be Off Work?
           Usually, two weeks is sufficient. Some people can appear in public with makeup as soon as ten days after a laser peel. There is usually a pink coloration in the skin that persists for a few weeks to several months following a laser peel. This pink color can be covered with makeup until it disappears naturally. In non-Caucasian patients, there is often a ruddy complexion to the skin that can last for a few months. This is readily covered by makeup or is hardly noticed.

What Are the Risks of Having a Laser Skin Resurfacing?
Laser procedures done properly have a very favorable benefit-to-risk ratio. They are rare, but undesirable effects do occur. These include scarring, infection, blotchy discoloration of the skin, and a few other less-common complications.

How Can I Prepare for a Laser Skin Resurfacing?
          Your physician may recommend the use of glycolic-acid products. Skin-lightening products will help to condition the skin and suppress pigment blotches, which frequently appear from hormones and sun exposure. Retin-A™ or Renova™ (Ortho) can also be used alone or together with the glycolic-acid products to help prepare the skin for a laser procedure. Skin-lightening agent may be used so that the new skin emerges lighter than the surrounding skin. In time, sun exposure will darken the skin so starting lighter makes sense. Normally, two to three weeks of skin preparation helps the skin heal faster after a laser procedure. Sunscreen and sun protection before and after the procedure are also very helpful to encourage a good result. The sunscreen used is also very important and for all my resurfacing patients I suggest one that has a metal protecting agent in it. The best of these, in my opinion, is zinc oxide.

What Do I Look Like While My Skin Is Healing?
          During the recovery period following a laser peel, there will be some oozing and swelling of the skin for several days. A dressing or ointments are usually applied to the skin to prevent crusting and scabbing. The skin will gradually heal within fourteen to thirty days. Most patients avoid public appearances for at least two weeks after a laser peel. The skin heals very much like it does after a clean scrape. There is an initial few days of oozing followed by redness that gradually fades. We use special dressings to allow for rapid healing and decrease the risk of infection during the early days and then progress as the healing progresses to lighter and lighter protection. Laser skin resurfacing allows patients to enjoy beautiful skin.

How Should I Care for My Skin after Skin Resurfacing?
          Many patients worry whether their skin will be normal in appearance after the laser peel. The concern is real because about two weeks after the laser peel the skin will be quite pink. Fortunately, makeup may be applied at this time. Strict sun avoidance is necessary until the pink discoloration disappears. There are creams that can be applied to help heal and protect the skin. EXTREME CARE MUST BE GIVEN TO AVOID THE SUN WHILE THE SKIN IS HEALING. Going out in the sun before the skin has returned to a normal color increases the risk of pigmentation blotches. The sun may damage the new skin by sun burning, making the skin remain pink longer than is necessary. Be sure to follow all the instructions given to you by your surgeon following a laser procedure.

Additional Considerations
• Crusting and tightness will last from seven to ten days, and a bright redness for up to twelve weeks and occasionally longer. It is common for a faint discoloration of the skin to last for two to three months following a good phenol peel.

• Following treatment, exposure to direct sunlight within a six to eight week period and possibly longer, depending on skin type, may result in unfavorable pigmentation.

• The final results are usually excellent in fair-skinned individuals and with the proper preparation, in all individuals.

• Peels may also be used to remove pigmentation.

• Partial treatment (small areas) may produce patchy discoloration that can result in unfavorable appearance when compared to the rest of the face. For this reason, treatment is mostly done in anatomic segments (forehead, cheeks, circumoral area, eyes) or the entire face.

• In darkly pigmented or oily-skinned individuals, chemical peeling may result in unfavorable discoloration. Fortunately, these individuals seldom show fine wrinkle lines as a predominant aging sign.

Collagen Injection
         Collagen is used by some doctors to treat depressions in the skin caused by acne scarring, scars secondary to trauma or surgery, and fine wrinkles that occur with the aging process. It is a highly purified protein substance from the hides of cattle (bovine). It is injected into the superficial layers of the skin to temporarily fill in defects and improve appearance. The newer types of collagen can be used in injectable form or placed subcutaneously in sheets. This is one of the best methods of improving the contour of a cheek or adding volume to a lip that has lost some volume through the aging process. These newer collagens are derived from human collagen and there is no known allergic response to them reported. Since there is little inflammation with their use, there is less transient swelling, though larger amounts are needed than with the bovine counterpart. The human collagen lasts longer within the skin. There are many newer soft tissue filling agents being tested but none have proven as safe as collagen.
           Although the bovine material is known to have few, if any, harmful side effects, possibly two to three percent of patients have been found to be allergic to collagen. Therefore, it is mandatory that at least one skin test first be done on the forearm of the prospective patient. If no reaction is noted after four weeks, treatment with collagen can begin. Skin testing is not necessary with the human product.
          After collagen is injected as an implant into the superficial portions of the dermis, it tends to smooth and fill out wrinkles. As collagen has both liquid and solid components, most treatments will require overfilling of the area. The liquid material will then be reabsorbed within the first twenty-four to forty-eight hours, leaving the solid implant material behind. Several treatments are generally required in each area of the skin in order to obtain the best results and can be repeated at 2 to 3 week intervals.
          The number of treatments necessary depends upon the degree of collagen absorption, the patient’s expectations, and proper technique. Many areas may require "re-treatment" or a "touch-up" after several months. Some slight redness in the area of injection may be present for several hours after the treatment session. Patients can generally resume normal activities almost immediately. It is also permissible to cover the treated areas with makeup within a period of two to three hours.
           Collagen is a filling material, so it can be used to fill out depressions caused by traumatic scars or aging (such as the deep furrows in the forehead or the grooves between the cheek and upper lip). Collagen treatments may be done after a face-lift to provide maximum benefit to those areas not surgically corrected. It is also used to alleviate some of the early signs of aging before a patient is ready to undergo a surgical face-lift procedure.

Additional Filling Agents
            Injectable collagen is certainly not the only answer to filling in soft-tissue depressions. However, it is a safe, effective, and currently available treatment. New filling agents are constantly being developed and refined. Your surgeon can best evaluate where and how collagen filling materials should be used. It is hoped that more permanent and less costly fillers will soon be developed. Hyaluronic acid is being studied but to date has been found to last a shorter time than collagen. There is also a filler material being studied that contains micro granules of methyl methacrylate (a type of bone cement used by surgeons for many years). There have been problems with extrusion of this substance through the skin and there may also be a prolonged higher risk of infection. Many other soft tissue fillers have been used in the past, many with disastrous results. Some unscrupulous physicians commonly use liquid silicone and paraffin in many areas of the world. Patients have been permanently disfigured from the use of these filling agents. Do not, ever, let anyone inject your skin with anything that they say will lead to permanent correction of the contour problem.

Botox Injections
Botox is a toxin derived from the bacterium Clostridium botulinum. It is the causative agent in botulism where a large amount of the toxin is ingested from spoiled food and then kills the patient by paralyzing the diaphragm that essentially stops breathing. The purified toxin, used in minute quantities to paralyze specific muscles is perfectly safe when used in the right hands. The toxin binds to the area where a nerve tells a muscle to contract. The effects of the toxin lasts as long as it takes the body to make a new connection between the nerve and the muscle; usually about 4 to 6 months. The most common use of this injectable agent is to prevent twitching of the eye and face in certain medical conditions. Its use has been expanded to specifically stop the action of one or more muscle. The most common use for the Botox is in the area of the corrugator supercilious muscle (the frowning muscle between the eyebrows) and also in people who squint a lot and therefore develop crow’s feet when they actively animate. The paralysis of functional muscle groups is not desired with the use of this product. Some muscles can be weakened. For example, the large muscle of the forehead (frontals) can be partially paralyzed so that there are fewer forehead creases or the Orbicularis oris muscle (the one that runs circularly around the mouth) to reduce the number of wrinkles of the upper and lower lips.
With continued use of the product, there is some evidence that muscle can permanently weaken and get smaller (atrophy).Some patients, after multiple injections, no longer require injections since the muscle no longer works effectively.
The risks are mainly involved in inappropriate placement of the agent. If it is injected into the wrong muscles, paralysis will result. The most common area for this to occur is in the muscles of the upper eyelid that keep it open.It is best to have someone such as a surgeon who knows the anatomy of the area of injection intimately through operating on it every day, to perform the injection. There are also small risks of infection and bruising although this rarely occurs.

Mentoplasty (Plastic Surgery of the Chin)
            Mentoplasty is done to either increase or decrease the size of the chin. As in rhinoplasty surgery, the object is to achieve harmony with the surrounding facial characteristics. Ideally, the chin should project to a point immediately below the lower lip. Orthodontia to correct the position of the teeth or bony surgery to change the position of the jaw. At times this is necessary.
           The size of the chin and its projection from the face is always considered when the surgeon analyzes the aesthetic harmony of the face. Quite simply, the best profile for the patient is the main thought and goal.
           Usually, the chin is too small and an augmentation mentoplasty is required to increase its projection (bring it forward). This is achieved with a medical-grade chin implant that has the consistency of normal tissue. It is an inert substance that is safe. There are several implants to choose from. In a few instances the chin is too large, whereby a reduction mentoplasty is done to reduce its projection (set it backward). This is accomplished by removal of excess bone, or the jaw may be reduced in size by a surgical procedure on the lower jaw.
             Most often mentoplasty (chin) is incorporated at the time of rhinoplasty (nose), since the surgeon doesn’t consider the nose as an isolated feature but rather as part of the entire face. If the chin recedes too much, it will cause the facial features to taper to a point at the nose. This unsightly appearance is further accentuated when accompanied by a backward slanting forehead. Augmentation of the chin in such instances brings about a dramatic improvement in the profile and a more harmonious look to the face.
              A chin implant has also become a valuable adjunctive procedure to the face lift operation (rhytidectomy) since it lengthens the jaw and produces a more youthful appearance to the neck, which could not be accomplished by face lift or neck lift alone.

Surgery
             The chin implant operation is of short duration (fifteen minutes) and can be done under local anesthesia with minimum discomfort. An intraoral (within the mouth) or a sub mental approach (small incision under the chin) are the two methods employed. Swelling and bruising are very slight. An adhesive dressing is applied for seven days, and the sutures are removed about the fifth day. Internal sutures dissolve by themselves. The scar resulting from the sub mental incision is placed in a natural crease and becomes quite inconspicuous with time.

Complications
             There are minimal risks of infection, bleeding, or asymmetry. The implant could move if the patient suffers a severe blow to the chin at a later time. Many of us use implants made of materials that allow for bony in growth and, therefore, long-term stability of the implant. Late rejection of an implant of infection from an outside source occasionally occurs, however the scar tissue that has formed around the implant maintains some of the correction.

Malar (Cheek) Implants
            In Western civilization, the ideal cheeks are those with "high cheek bones" which are prominent and slightly rounded. High cheekbones improve facial contour and accentuate the eyes.
          Cheek implants, which are made from the same material used in chin implants, can be placed through incisions in the mouth or just below the eyelashes of the lower eyelids, or during a face lift procedure. The results can be stunning, with great accentuation of one’s inherent facial beauty.

Risks
Risks are identical to those encountered with chin implants.

Otoplasty (Plastic Surgery for Protruding Ears)
        This surgery is done on protruding ears to change their size, position, and configuration. Protruding ears frequently cause psychological problems in young children in spite of efforts to camouflage them with longer hairstyles. Ears reach adult size by age five or six, the surgery can be done any time after that.
         This operation is designed to correct ears that project outward too far from the head. Such ears usually have a cup-shaped appearance and are referred to as "outstanding ears." There are a number of other ear deformities such as lop ears and Stahl’s ears that can also be corrected by a qualified plastic surgeon.
         Children are usually not aware nor sensitive to this problem until they begin school when they are exposed to the ridicule and laughter of their classmates. This can have tremendous emotional and psychological impact on a child. Surgery is, however, for the child and not the parent. The child should want the correction or else emotional problems could result.
           In children the procedure is done under general anesthesia, and in the adult it can be done under local anesthesia and mild sedation. The object of the surgery is to reshape the cartilage and to reposition the ear backward toward the head to a more normal position. This is done in a number of ways depending upon the problem.

Surgery
             Incisions are made in the skin on the back of the ear so they are not seen. Portions of cartilage are shaped or removed and the remainder remolded as necessary to achieve the desired contour. Permanent sutures are frequently placed in the cartilage under the skin to insure the proper shape.
             Bandages in the shape of large earmuffs or a turban-type dressing remain over the ears for up to one week after surgery. For several weeks after removal of the dressing, the patient will wear a small, elastic headband or tennis sweatband when sleeping to avoid trauma to the ears. Mild swelling is present for seven to ten days after surgery.

Risks
           Both ears are rarely identical; therefore, symmetry is sometimes not possible. The previously mentioned risks of infection and bleeding are very unusual. Following surgery there is no change in the patient’s ability to hear.

Precautions
• Numbness of the skin is usually experienced for one to two months following surgery.

• Protect the ears from cold weather throughout the first winter.

• Do not wear clothing items which pull over the head for the first month. They can catch the ear and tear the cartilage sutures, causing recurrence of the original deformity.

• Avoid contact sports for a few months..
           All these facial procedures are intended to make the face more attractive to the patient in the culture he may be a part of. As with teeth straightening with braces, facial procedures are often important to the wellbeing of the person and should be considered in the same light.