Aging of the face is inevitable, over time the skin begins to loosen on the face and neck and the facial bones and fat atrophy. As the facial volume declines, the skin is pulled towards gravity. Crow’s feet appear at the corners of the eyes. Fine forehead lines become creases and then, gradually, deeper folds. The jawline softens into jowls, and beneath the chin, another chin or vertical folds appear at the front of the neck. Heredity, personal habits, the pull of gravity, and sun exposure contribute to the aging of the face. As the aging population grows, it is obvious why rhytidectomy has become the third most desired facial plastic surgical procedure. Dr. Cole's specialty is the deep plane extended lift also known as a technical lift. The deep plane facelift avoids the problem of the tight overfilled look of many modern facelifts. The main tenet of the deep plane facelift is that it lifts only under the muscle layer, leaving the skin attached to the muscle layers, so it can never look tight. It also lifts the cheeks by releasing the tethering points of the face in the deep plane so that addition of fat or filler is unnecessary. The deep plane facelift avoids the problem of the tight overfilled look of many modern facelifts.

What is a Deep Plane Facelift
‍The “deep plane” is the term used to describe the anatomic plane that exists between the SMAS-platysma complex (which is muscle and fascia) and the deeper layer of muscles responsible for facial expression. The deep plane facelift focuses on release and movement of muscle and fat layers instead of skin pull and removal. The extended deep plane facelift that Dr. Cole uses incorporates release of the ligaments tethering the deep plane layer to achieve tension-free movement so that no tightness can be created by the facelift procedure. There are four ligaments that are released with corresponding natural lifting throughout the face and neck.The first ligament released is the zygomatic ligaments that tether the cheek so that drooping cheeks can be elevated superiorly. This restores the cheek shape and volume recreating the heart shaped face of youth avoiding the need to add filler, fat or cheek implants to the face. It also will improve the nasolabial folds (creases from our nose to the corner of the mouth), and hollowing and shadowing seen under the lower eyelids by restoring volume that is lost by gravitational descent associated with aging.

When the procedure is performed with a combination of mild sedatives, local anesthesia, and a mild intravenous anesthesia ("twilight sleep"), the patient will experience little discomfort. More advanced facelifts will require general anesthesia.

Your surgeon begins the incision in the area of the temple hair, just above and in front of the ear. Next it continues under the earlobe and follows the back of the ear and blends into the hairline. The skin is gently lifted as the surgeon repositions and tightens the underlying muscle and connective tissue. Some fat may be removed, as well as excess skin. For men, the incision is aligned to accommodate the natural beard lines. In all cases, the incisions are placed where they will fall in a natural crease of the skin for camouflage. The type of facelift required depends on the specific deficit each person. Newer more advanced lifts address multiple areas at mid face, jowl and neck simultaneously.  

In all cases, the incisions are placed where they will fall in a natural crease of the skin for camouflage. After trimming the excess skin, the surgeon closes the incisions with fine sutures and/or metal clips. This will permit precise surgery and avoid shaving hair in the incision sites. Depending on the extent of the surgery, the process can take from two to four hours.

Actual placement of incisions varies from patient-to-patient and is dependent on the surgeon's judgment for that patient.

Following the surgery, the surgeon will apply a dressing to protect the entire area where the incisions have been made. Typically, our patients enjoy one night’s accommodation in the hospital where nurses provide overnight care and supervisio (additional fees may apply). Some swelling and bruising are expected after a facelift, but much of it will diminish within the first week or two.

Often, the forehead and brow show the first signs of aging. The primary contribution to the overall laxity (sagging face) is bone and fat volume loss. Sun, wind, and the pull of gravity all affect the face, resulting in frown lines, wrinkling across the forehead, and an increasing heaviness of the eyebrows. Even people in their thirties may have faces that look older than their years. Others may mistake your appearance as tired, angry, or sad when this is not how you actually feel. As a result, many people have opted for a procedure known as a brow lift. Based on variations in how men and women age and on new advances in medical technology, different methods are used to perform this procedure.

The main difference among the various options for forehead and brow lifting consists of the placement of the incision. The newest approach is endoscopic surgery. Several small incisions are placed just behind the hairline and a scope is used to assist in the surgery. In the right patient this procedure could result in a faster recovery time. Other techniques use longer incisions to lift the brow and forehead and the location is determined by your surgeon after examining you and discussing with you the various options. While all the various procedures will usually raise the brow and smooth the forehead, some can even lower a high hairline and improve facial balance and harmony.

A brow and forehead lift typically takes between one to two hours to perform. It is most commonly performed under IV sedation or twilight anesthesia. Brow lifting and forehead lifting are related but somewhat different procedures. The difference lies in the goals of the procedure. A brow lift acts to raise the position of the brow to give a less tired appearance and sometimes improves sagging eyelids. Depending on the patient the primary goal of a forehead lift is to elevate brow position and smoothing the forehead.  A forehead lift may involve movement of the brow or possibly surgery on the upper eyelids for an optimal result.  There are many types of brow lifts.  Certain brow lifts bring a high forehead down to normal forehead height, other lifts raise eyebrows to the standard height. Finally certain brow lifts done in office, under local anesthesia raise the tail of the brow or lateral brow.  Brow lifts in men use the eyebrow hairline itself to camouflage the elevation.

At times, brow lifting is done along with upper eyelid surgery or a facelift for an optimal result. A consultation with Dr. Cole will help you best determine which type of procedure is best for you.

You will experience a certain amount of swelling and bruising in the 10-day period following surgery. In some patients, this condition may include the cheek and eye area as well as the forehead. You will be advised to keep your head elevated in order to reduce swelling. Cold compresses may further reduce swelling. As the incisions heal, you may experience some numbness as well as itching, both of which should diminish with time. The sutures are usually removed within 7–10 days following surgery. If bandages have been used, they are removed in 1–3 days. It is important to follow the advice of your surgeon on resuming normal activities. For most patients, the recovery time should not exceed two weeks, but patients may still be advised to avoid strenuous activities for longer periods. Any prolonged bruising can be camouflaged with standard make-up techniques.

A neck lift, or lower rhytidectomy, is a surgical procedure that improves visible signs of aging in the jawline and neck. A neck lift can only be performed surgically; nonsurgical rejuvenation treatments cannot achieve the same results, but may help delay the time at which a neck lift becomes appropriate.

If you feel like your upper face is still pleasing, but you have excess wrinkling of the neck skin, a double chin or "turkey wattle" and jowl lines, a neck lift may be a good solution for you.

• Excess fat and skin relaxation in the lower face that creates jowls
• Excess fatty deposits under the chin
• Loose neck skin
• Muscle banding in the neck, which created abnormal contour

As a restorative surgery, a neck lift does not change your fundamental appearance and cannot stop the aging process.

Dr. Cole may also recommend additional rejuvenation procedures that can be performed in conjunction with a neck lift. in many cases, buccal fat pad removal is performed to improve the jawline and remove any jowl-like appearance.

Additional procedures that can be performed in conjunction with a neck lift are: a brow lift, to correct a sagging or deeply furrowed brow; fat transfer, to add fullness to the lips and cheeks and reduce the appearance of wrinkles; or eyelid surgery, to rejuvenate aging eyes.

Every year, hundreds of thousands of men and women choose blepharoplasty to improve the way they look. Droopy eyelids can make you look older and can also impair vision. Blepharoplasty corrects these problems and also removes puffiness and bags under the eyes that make you look worn and tired. This procedure cannot alter dark circles, fine lines and wrinkles around the eyes, nor can it change sagging eyebrows. Though blepharoplasty is often performed as a single procedure, your surgeon may also recommend a brow-lift, facelift, or skin resurfacing to achieve the best results.

In upper eyelid surgery, the surgeon first marks the individual lines and creases of the lids in order to keep the scars as invisible as possible along these natural folds. The incision is made, and excess fat is removed or repositioned, and then the loose muscle and skin are removed. Fine sutures are used to close the incisions, thereby minimizing the visibility of any scar.

In lower eyelid surgery, the surgeon makes the incision in an inconspicuous site along the lash line and smile creases of the lower lid. Excess fat, muscle, and skin are then trimmed away before the incision is closed with fine sutures. Eyelid puffiness caused primarily by excess fat may be corrected by a transconjunctival blepharoplasty. The incision in this case is made inside the lower eyelid, and excess fatty material is removed. Usually there are no sutures involved in the lower eyelid in the conjunctival procedures. Under normal conditions, blepharoplasty can take from one to two hours.

A more refreshed look is often the result when eye bags are improved with blepharoplasty.

Immediately after the surgery has been completed, your surgeon may apply tiny sterile bandages. This is not done for transconjunctival blepharoplasty. It is not crucial that the eyes be covered. However, an ointment to prevent dryness of the eye area may be used. A certain degree of swelling and bruising is normal. Cold compresses, as well as head elevation when lying down, will enhance healing and relieve discomfort. Your surgeon will prescribe medication for discomfort.

For a week and a half following blepharoplasty, you will clean the eye area (the eyes may feel sticky, dry, and itchy). Eyedrops may be recommended. Your surgeon will also list activities and environments to avoid in the weeks immediately following surgery. Permanent stitches will be removed in three to six days after surgery. Self-absorbing stitches will dissolve on their own.

The risks of blepharoplasty are fairly minimal but include poor healing, persistent fat or loose skin and muscle, dry eyes, and very rarely, visual changes or loss. In a blepharoplasty, the eyelids heal remarkably quickly and scars are usually quite inconspicuous.

A large number of people are now opting for a more youthful appearance with lip enhancement. There are several options to help you achieve fuller lips. You can opt for lip injection done using natural or synthetic fillers. These fillers can last for several months and you will need regular retouches to keep them full. Or, you can opt for a more permanent solution with a surgical procedure. It is important to learn about the procedures and what to expect so that you are fully prepared.

You can consider lip enhancement if you have one of the following conditions:

• Your lips are thin and they tend to disappear when you smile
• Your lips have become less full and thinner due to age
• Your upper lip was elongated so you smile with more bottom teeth showing
• You are self-conscious about the appearance of your lips
• Having a lip enhancement would help balance the shape of your face

There are several surgical procedures and your surgeon will explain all the options. The procedure recommended may be based on the recovery time frame and your personal aesthetic goals. In some cases, the surgeon may conduct two, or even more, procedures to achieve the best look for you. Lip enhancement surgery procedures include the following:

• Dermal Graft — This is a permanent lip augmentation procedure. A dermal graft can be taken from the thighs or deeper layers of the skin. This graft is then surgically positioned on the lip lining (under the mucosa) so as to achieve plumpness.
• Lip Implant — Lip implants are inserted by making tiny incisions on the corners of the lips. Natural or synthetic materials are used depending on the desired results.
• Lip Lift — If you have a longer distance than desirable between your nose and upper lip, then lip lift surgery could be an option for you. To get the upper lip fullness, an incision can be made right under the nose so as to shorten the skin and then the lip is pulled upward. There are other lip techniques which can be used to shorten the upper lip so as to expose the teeth. If your lip has a downward turn, the surgeon can make incisions on the sides. The incisions allow for extra skin to be removed. Sutures are normally used when conducting a surgical lip lift. The sutures can be removed after 5 days, or as your surgeon directs.
• Vermillion Advancement — Vermillion advancement is a procedure that involves making an incision along the borders of the lips. A strip of the skin is removed outside the lip border. The rest of the skin along the border of the lips is pulled to achieve fullness.

Injectable lips fillers are substances that are injected directly into the lip. There are several types of filler materials that provide lip enhancement.  The fillers will differ in terms of their composition and thickness or firmness. Most of these products will dissolve slowly over several months. The fillers can be injected in the office using topical anesthesia creams or local anesthetics. Natural body fat can also be injected as a filler. For this procedure, a small amount of fat is removed from your body (typically through a small incision inside the belly button), processed, and then re-injected into the lips. Some fat will be reabsorbed following the procedure, but the remaining fat will typically be permanent.      

Once the procedure is done, it is good to have someone take you back home. Local anesthesia may be used during the procedure and you may not be in the best shape to drive yourself home.

If the lip enhancement procedure involves the use of hyaluronic acid fillers (like Juvederm® or Restylane™), you can go back to activity immediately. With grafts or implants, it may take about two weeks for a patient to recover. It is best to discuss beforehand how much time you need to recover so that you can take time off work. At a minimum, you may be away from work for at least three days. It is also advisable to keep off rigorous physical activity for some time after getting injections or surgical implants.

Before the procedure, ensure that you prepare your home for your recovery by undertaking the following:

• Having comfortable pillows
• Have plenty of non-alcoholic drinks and soft foods such as yogurt, pudding, and jello, because you may experience discomfort when chewing - avoid high-sodium foods like canned soup, this can cause swelling.

Smokers are normally advised to stop smoking a month before the procedure, or some surgeons may have stricter policies regarding smoking. On the day of the procedure, please ensure that you wear loose fitting clothes. This way you will not pull your clothes over your face.

Rhinoplasty (plastic surgery of the nose) is the most commonly performed procedure in facial plastic surgery. The name is a blend of the word, “rhino” (nose) and “plasty” (to mold or shape). The eyes are the focal point of the face; however when the nose has an undesirable appearance, attention is drawn to it. Rhinoplasty is by far the most artistic procedure in facial plastic surgery, and Dr. Cole believes that the ideal outcome in rhinoplasty is a natural-looking nose with balance and harmony, enhancing the beauty of the eyes and lips.

Many undesirable features of the nose may be improved through cosmetic surgery. Noses may be made narrower, straighter, longer, or shorter. Humps may be removed and the shape, size, angle, and definition of the tip of the nose may be altered. Breathing problems, such as those caused by a deviated septum may be corrected at the same time as the cosmetic changes. The art of rhinoplasty is in obtaining the desired changes, while maintaining a natural appearance and function of the nose. Nasal plastic surgery may be performed for strictly cosmetic reasons (cosmetic rhinoplasty), for strictly breathing reasons (functional septoplasty), and more commonly for a combination of both (septorhinoplasty). Rhinoplasty may be performed at any time after facial growth has been completed, age 15–16 for women and age 16–17 for men.

Achieving facial harmony by implantation of synthetic materials to the face is now easily achievable by surgery that can oftentimes be performed without creating a visible scar.  This type of surgery can help patients who are born with facial deformities, patients who have suffered from trauma resulting in changes to the bones of the face, and those who simply desire a more aesthetic facial appearance due to aging changes. When looking at someone’s face, we see the skin, which is merely a “tarp” reflecting the underlying bony structure of the facial skeleton.  As we age, our facial bones change with a predictable pattern.  Thus, an aged facial skeleton will result in the overlying skin appearing aged.  Addressing this aging process requires rejuvenating the underlying bony skeleton, which can result in positive changes to the overlying skin.  

Facial implant surgery can usually be done without creating a visible scar.  In some cases of chin implantation, an external incision under the chin is necessary but hides well.  Your facial plastic surgeon may elect to perform the surgery under local or general anesthesia based on your preference and what the surgeon feels is appropriate.  Augmentation of many regions of the face is possible, including the periorbital region, the cheek, the chin, and along the jawline.  For placement of an implant along the tear trough or cheek, an incision can be made inside the eyelid to prevent a visible scar.  Alternatively, an incision can also be made through the skin of the lower eyelid within a pre-existing wrinkle line.  Oftentimes, your surgeon may be able to combine your implant surgery with a lower-lid blepharoplasty to further rejuvenate the lower-eyelid region.  

Similarly, an incision can also be made inside the mouth for augmentation of the cheek and malar regions.  This can help add volume to your cheek, thereby restoring youthfulness.  For placement of a chin implant, your facial plastic surgeon may use an incision inside your mouth, or under the chin, where the scar will hide nicely.  The incision is usually quite small and heals imperceptibly.  Chin implants are often used in conjunction with a rhinoplasty to help restore harmony to the face, particularly on profile view.

You will likely be discharged on the same day of surgery. Your surgeon will provide you appropriate pain medication and may prescribe antibiotics.  Many surgeons will place a dressing over the implant site to hold pressure on the area.  You will be able to resume normal activity 4 weeks following surgery.

Many environmental factors such as sun exposure, weight gain/loss, stress, cigarette smoke, and alcohol cause changes to occur in the facial skin. These changes result in sagging, fine wrinkles, and pigment changes (splotching). Fine wrinkles are different from sagging skin, and they need to be treated differently.

The most common areas where fine wrinkles develop are around the eyes and mouth. The crepe paper-like skin below the eyes and the lines radiating around and into the lips are examples of these. The skin of the cheek may become crisscrossed with wrinkles. These types of wrinkles are not removed with lifting surgery such as a facelift, or eyelid lift, but they can be significantly improved with a resurfacing procedure. Resurfacing the skin can also improve acne scarring and irregular pigment.

Resurfacing begins by removing the outer layer called the epidermis and part of the dermis. This can be accomplished with deep chemical peels, dermabrasion, or use of a laser. Dr. Cole most often prefers to use the laser because the depth of skin removal can be controlled more precisely. Laser resurfacing may also be safer than chemical peels, which may have systemic side effects. Dermabrasion cannot be used on the fine skin of the eyelids, but the laser can. This is another advantage of using the laser.

The procedure is typically performed in the operating room under sedation using local anesthesia. The patient’s eyes are protected with shields, and other precautions are taken to prevent accidental injury. The laser settings are adjusted, and multiple passes are made over the treated area, removing deeper and deeper layers of skin. Once the appropriate level is reached, the skin is dressed with ointment.

Postoperative care is very important and your surgeon will provide detailed instructions that need to be followed.

Probably no other physical characteristic cries out for facial plastic surgery more than protruding ears. Children, long the victims of cruel nicknames like “Dumbo” or “Mickey Mouse,” are the most likely candidates for otoplasty, but this surgery can be performed at any age after the ears have reached full size, usually around five to six years of age. Even if the ears are only mildly distorted, the condition can lead to self-consciousness and poor adaptation to school. It is often desirable in children to consider this surgery before they start Kindergarten or first grade.

Surgery begins with an incision just behind the ear in the natural fold where the ear is joined to the head. The surgeon will then remove the necessary amounts of cartilage and skin required to achieve the right effect. In some cases, the surgeon will trim the cartilage, shaping it into a more desirable form and then pin the cartilage back with sutures to secure the cartilage.

In other instances, the surgeon will not remove any cartilage at all, using stitches to hold the cartilage permanently in place. After sculpting the cartilage to the desired shape, the surgeon will apply sutures to anchor the ear until healing occurs to hold the ear in the desired position.

A change in shape will not affect hearing. Although the ears’ folds and convolutions do serve to concentrate and localize sound waves, routine surgery to pin back or reshape ears will not produce a noticeable change in hearing.

Soft dressings applied to the ears will remain for a few days. Most patients experience some mild discomfort. If you are accustomed to sleeping on your side, your sleep patterns may be disrupted for a week or so because you cannot put any pressure on the ear areas. Headbands are sometimes recommended to hold the ears in the desired position for two weeks after surgery.

The risks are fairly minimal but include very rare infections, poor healing or possibility of recurrence of the deformity. Normally, there will only be a thin white scar behind the ear after healing. Because this scar is in a natural crease behind the ear, the problem of visibility is usually inconsequential. Anything unusual should be reported to the surgeon immediately.

Everyone has skin lesions or moles that occur naturally or as a result of sun exposure or diseases. In some cases, unfortunately, these lesions are malignant (cancerous), but more often they are benign. In either case, Dr. Cole  has extensive experience in diagnosing the various types of lesions and can treat you effectively. Surgical excision is imperative for malignant lesions, but benign lesions do not have to be removed for any medical reason.  

Moles are growths or lesions found on the skin and they come in various shapes and sizes. Moles can appear anywhere on the skin, from the facial area, as well as arms and chest areas, in groups or by themselves. They can be present at birth or can begin to appear over time.

Concern over the presence of moles on the skin is mainly an issue of appearance for most people. Dr. Cole can remove moles from skin using one of several techniques. If a mole is suspicious looking, Dr. Cole will refer you to a dermatologist or he will biopsy the area to determine if the mole is cancerous and/or should be removed.

The mole removal process, whether for cosmetic or preventive reasons, requires a fair level of surgical skill to prevent unpleasant scarring.  The type and size of mole being removed determines what technique is used. Never attempt to remove a mole on your own.

Scalpel Excision: The most basic type of mole removal is the scalpel excision that can be performed quite simply in Dr. Cole’s office. This mole removal process begins with numbing the area with an anesthetic, cleaning the area to prevent infection and then using a scalpel to remove the blemish. Stitches are generally used with this technique.

Cauterization: If the mole is only slightly raised from the skin, Dr. Cole may choose to cauterize the blemish off your skin instead of using a scalpel. First, the area will be numbed and cleaned and then a cautery needle will be used to burn the blemish at its base. This procedure does not require stitches; the burned skin will heal over time, although it will likely leave a light scar. If a scar persists Dr. Cole can use other techniques to minimize the scars appearance.  

Cosmetic surgical excision under local anesthesia is a great option for those with benign lesions who simply do not like the appearance of their lesion due to location, size, or color. When performed by a skilled plastic surgeon, rather than a dermatologist or family practitioner, the scar can be minimized and the result very rewarding. Some benign lesions can be removed without surgery using lasers or even creams.

• Large lesions, or lesions in sensitive areas, can be removed surgically. Generally this can be performed with local numbing.
• Minor lesions, such as warts, can be frozen off with liquid nitrogen or treated with chemicals such as salicylic acid.
• Non-ablative laser procedures using an Intensive Pulse Light (IPL) system can help with minor sun damage and age spots.
• Lesions that show any signs of turning cancerous, for example a mole that has changed shape or color, are recommended for excision and laboratory testing.

Scars are visible signs that remain after a wound has healed. They are the unavoidable results of injury or surgery, and their development can be unpredictable.

Scar revision is plastic surgery performed to improve the condition or appearance of a scar anywhere on your body. Scar revision surgery will attempt to minimize a scar so that it is less conspicuous and blends in with the surrounding skin tone and texture. Although scar revision can provide a more pleasing cosmetic result or improve a scar that has healed poorly, a scar cannot be completely erased.

Scars may be noticeable due to their size, shape or location; they can also be raised or depressed, and may differ in color or texture from the surrounding healthy tissue. The different types of scars are:

• Hypertropic scars are thick clusters of scar tissue that develop directly at a wound site. They are often raised, red and/or uncomfortable and may become wider over time. They can be hyperpigmented (darker in color) or hypopigmented (lighter in color).
• Keloids are larger than hypertropic scars. They can be painful or itchy, and may also pucker. They extend beyond the edges of an original wound or incision. Keloids can occur anywhere on your body, but they develop more commonly where there is little underlying fatty tissue, such as on the face, neck, ears, chest or shoulders.
• Contractures are scars that restrict movement due to skin and underlying tissue that pull together during healing. They can occur when there is a large amount of tissue loss, such as after a burn. Contractures also can form where a wound crosses a joint, restricting movement of the fingers, elbows, knees or neck.

The type of scar you have will determine the appropriate techniques your plastic surgeon will use to improve your scar and can include:

• Simple topical treatments
• Minimally invasive procedures
• Surgical revision with advanced techniques in wound closure

A facial fracture is a broken bone in the face. The face has a complex bone structure. The facial skeleton consists of the frontal bone (forehead), zygomas (cheekbones), orbital bones (eye sockets), nasal bones, maxillary bones (upper jaw) and mandible (lower jaw). There are many other bones that are found deeper within the facial structure. Muscles required for chewing, swallowing and talking are attached to these bones.

Nasal fractures (broken nose) are the most common. Fractures to other facial bones can also occur. Only one fracture may be present, or there may be several broken bones. Multiple fractures are more likely to occur during a motor vehicle accident or other high-impact accident. Fractures may be unilateral (occurring on one side of the face) or bilateral (both sides of the face).

Some types of facial fractures are relatively minor, but others may cause irreversible damage and can even be life-threatening. That is why it is important to seek proper diagnosis and treatment before serious complications can occur.

Facial nerves and muscles responsible for sensations, expressions and eye movements are positioned near the facial bones. The face is close to the brain and central nervous system (CNS). Fractures may result in damage to cranial nerves, depending on the particular type and location of the fracture. Fractures to the orbit (eye socket) may result in problems with vision. Fractures of the nose may make it difficult for the injured person to breathe or smell. Also, fractures of the jawbones may cause breathing problems or make it difficult to chew, speak, or swallow.

If a facial injury occurs, the injured person should seek immediate medical attention. Complex fractures may cause irreversible damage and can even be life-threatening. Some facial fractures can cause problems with the respiratory system, airway passages, central nervous system or vision.