The facelift (Rhytidectomy) requires tailoring of both the lower face and neck to achieve ideal results. Normal facial proportions change with time; skin, fat and muscles sag and are placed into a lower position. Lines and wrinkles that form after sun exposure and normal aging are caused by thinning of the outer skin and collapse of the inner elastic skin layer.

Although most patients view their necks and jaw requesting an improvement, they are concerned with the term “facelift”. No matter what you call it, smoothing out and naturally contouring these areas is what we want to accomplish.

Facial surgery is more than skin deep. The deeper folds of skin are smoothed, sagging skin along the neck, cheeks and jaw line (jowls) are tailored into a more natural appearance, excessive fat is sculpted away and the underlying supportive facial structures are repositioned to restore and rejuvenate your face. The goal is to reestablish facial harmony and balance.

Your comfort and safety are extremely important; thus, the surgery is performed on an outpatient basis using a light general anesthesia in combination with local anesthetic. This combination affords you a peaceful rest without feeling or hearing noises during surgery. You are given extra oxygen while your heart rate and blood pressure are kept level.

Scars are hidden in the hairline of the scalp and neck as well as within the normal creases of the around the ear, below the chin and within the sideburn making them less conspicuous.

After surgery a light wrap will be placed until the next morning, when Dr. Rosenthal will change your dressing. You will be able to shower before starting a simple regimen of cleaning the scars and covering them. The use of ice and specific medications will also improve your results.

Activities after this surgery are limited to prevent swelling or other harmful side effects. This includes such mundane activities as house cleaning and any sport or activity that would increase your heart rate and blood pressure for 3 weeks. During this time you will be wearing an elastic garment to aide in comfort and decrease swelling. Also, you can plan on being out of work for 10 days-2 weeks, depending upon the work activity.

What we eat is who we become, so a diet rich in healthy foods will improve your results and aide in healing. Stay away from products that increase bleeding, such as aspirin, Motrin, Advil and Vitamin E. Refrain from eating salty foods which will cause swelling; therefore they are limited for 3 weeks after surgery: pizza, Chinese food, pretzels and potato chips, to name a few.

Common Reconstructive Procedures – Chapter 1

Your suitability for breast reconstruction will be influenced by a host of factors. The type of tumor, position of the tumor in the breast, and the extent of the cancer will all be important factors in determining the amount of breast tissue left behind after the mastectomy. Operations that spare the chest (pectoralis) muscle, such as simple or modified mastectomies, usually leave behind ample amounts of skin and fat. This allows for an easier reconstruction than those operations that remove this muscle, such as a radical mastectomy.

One of the main decisions to be made about breast reconstruction is whether to start the reconstruction simultaneously with the mastectomy (immediate reconstruction) or to delay the process for days, months, or even years (delayed breast reconstruction).

In attempting to restore the breast to a shape and size compatible with your wishes and to match the opposite breast, surgeons start by considering the simplest procedure and progress to the more complicated ones as necessary. The controlling factors in this decision will be the amount and quality of the tissue left behind and the position and shape of the opposite breast.

Immediate Breast Reconstruction – Chapter 2

With immediate reconstruction, the breast is removed and simultaneously reconstructed, or at least the beginnings of reconstruction will be carried out. This is done with either an inflatable medical balloon, which stretches the remaining available tissues, an internal permanent prosthesis (silicone gel or saline-filled implant) or with tissue transfer, which will be discussed later on. The main advantages of this technique, if available for you, are in the economy of time due to the reduction in the overall number of operations and its positive effect on your psychological outlook. The period of mourning and depression often experienced with mastectomy is markedly diminished once the breast restoration has begun. Likewise, the sense of loss associated with the mastectomy is shortened, and in many cases not experienced, as the substitute breast has already taken its place. The ability to get on with your life and potentially reduce the overall number of operations also makes this an attractive alternative. Additional procedures may follow to refine the breast shape, exchange implants, alter the opposite breast to give better symmetry, or to build a nipple and areola. Immediate reconstruction allows the plastic surgeon to work with the general surgeon in designing the best and most appropriately shaped breast at the time of the mastectomy.

As the reconstruction starts immediately after the mastectomy, this adds to the overall operating and anesthesia time. However, it does reduce the total number of operations. At the conclusion of these procedures your surgeons will be concerned not only with the healing of the mastectomy site, but also with the progress of the newly restored breast. Despite being a valuable option, not all women are good candidates for immediate reconstruction. Factors such as the size and extent of your breast cancer as well as your overall general health may make immediate reconstruction impractical.

THE RECONSTRUCTIVE PROCESS

Submuscular Permanent Implant – Chapter 4

Recreating the breast mound with a prosthesis (implant) is done by using a silicone envelope or bag. This contains gel or saline to give it shape, form and consistency. Implants come in a great many sizes and shapes, from the very small to the very large, to simulate the shape and weight of the removed breast. A specific type is chosen for each individual to produce a new breast and to match the opposite breast, when possible.

During surgery, usually under a general anesthetic, the implant is placed beneath the chest muscles through the old mastectomy scar. This is done to protect the implant by providing additional soft tissue coverage. Quite often there is sufficient skin, fat and muscle left behind after the mastectomy to allow for this. The operation may take a few hours, but the hospital stay is brief, not usually requiring an overnight stay.

A moderate amount of swelling and discoloration of the chest skin may be present for a few weeks. The final shape of the new mound will take some time – up to a year – before it becomes established. Some women have moderate discomfort from the operation for a few days which is usually relieved by pain medication. Generally, daily regimes can be quickly resumed (three weeks), except for the most vigorous athletic, work or household-related activities.

Despite the best intentions of your doctors, complications cannot always be prevented. The most common complications include infection, bleeding, and scarring (capsule formation) around the newly-implanted prosthesis. This latter problem is not really a complication, but actually a natural means by which the body isolates man-made materials from body tissues. All implants cause some capsule formation, but only those that become very hard or pull on the implant and deform it require further surgery. Your doctor’s knowledge and awareness of these potential complications will help to prevent or control them, should they occur.

In situations when there are inadequate amounts of skin and/or muscle to cover the implant, or when the surgeon attempts to match the opposite breast without operating upon it, another technique known as tissue expansion is utilized.

Tissue Expansion – Chapter 5

Through an incision in the skin, with delayed reconstruction or at the time of the mastectomy, an empty medical balloon is inserted beneath the chest muscles. A separate valve is attached to this balloon, which is placed beneath the chest skin and left undisturbed for a few weeks. The balloon is gradually inflated on a weekly or bi-weekly basis by passing a thin needle into the valve through which a sterile solution is injected. A mild pressure sensation may be felt during this process but the discomfort is brief and most women find it bearable.

The gradual inflation of the balloon continues until it is over-inflated. This ensures that sufficient skin and muscle are available to match the larger, opposite breast, or allows the placement of a permanent implant in situations that might require the addition of other tissues, as in tissue transfer. Usually, this over-inflated state lasts from four to six months to allow for stretching of the tissues making up the mound before the second stage is attempted. Difficulty in wearing some clothing and certain physical limitations may be experienced during the expansion.

Stage two involves the exchange of the expanded balloon for a permanent prosthesis similar to that described above for a simple submuscular reconstruction. This may be done under either local or general anesthetic. When necessary, the shape of the breast can be altered during this stage or the crease under the breast can be moved or reestablished. As with submuscular reconstruction, the hospital stay is limited. Activity levels are similar, and post-operative discomfort is usually not severe. The final shape of the breast mound will take many months to finish healing.

In some cases, a permanent tissue expander is placed under the chest muscles. This type of implant requires that only the valve is removed (under local or general anesthetic) when the breast has achieved its desired shape and size. The drawbacks in using this prosthesis include the inability of the doctor to further refine the breast after the expansion has taken place either by altering the position of the prosthesis, repositioning the lower breast crease, or by substituting another implant.

For those women who lack sufficient quantities of tissue despite tissue expansion, or those with poor quality tissues left after the mastectomy, healthy and plentiful skin, fat and muscle from other areas of the body can be transferred to the chest (tissue transfer).

Tissue Transfer – Chapter 6

Areas of the breast that could not be rebuilt by the previous methods can be filled in and/or recontoured using tissues from the upper back, abdomen or buttocks (tissue transfer).

One of the tissue transfer procedures rotates the back (latissimus dorsi) muscle to the mastectomy site. The muscle carries the overlying fat and skin which is maneuvered into its new position on the upper chest. Still attached to its original blood supply, this blend of tissues can build up the hollows created by some radical mastectomy operations. This enables a prosthesis to be inserted, thus reconstructing the breast mound. The transferred portion of muscle and skin does not leave behind a significant deformity or weakness of the back. It does, however, add a scar to the upper back which some women may object to.

The Transverse Rectus Abdominis flap (TRAM) is a blend of tissues taken from the abdomen or lower portion of the belly. This, too, relies on a blood supply still attached to the muscle. Portions of fat, muscle and skin are transferred to the upper chest leaving behind a long lower abdominal scar. Unlike the other procedures, a prosthesis is not always needed if this tissue transfer method is used, as the lower abdomen usually has more than ample amounts of fat and skin to build the breast mound. But do not be misled–more is not always better, and the fat in this region must be firm. Illnesses such as diabetes or vascular disease, and even having had prior operations on the abdomen, can prevent you from being a suitable candidate for this type of reconstruction.

A third tissue transfer method uses portions of tissue from the buttocks. This tissue is reconnected to the chest blood supply using specialized microvascular techniques. This operation is chosen in only a few selected cases and is by no means the usual method for most reconstructions needing tissue transfer.

All tissue transfer procedures are extensive operations and have a potentially higher complication risk. They are, however, extremely valuable, offering alternative methods of reconstruction, especially when simpler operations cannot be performed.

The Opposite Breast – Chapter 7

Even though the breast mound is now restored, the reconstruction is not complete until it resembles the opposite breast. In well-endowed women who have a large or pendulous (droopy) opposite breast, obtaining breast symmetry is more difficult. To achieve a better match with the newly reconstructed breast, the surgeon may reduce the size of the opposite breast, elevate and reshape it (mastopexy), or in some cases insert a prosthesis to enlarge it (augmentation)

Frequently, these operations can be performed in conjunction with either the nipple/areola reconstruction or during further refinements of the breast mound. After these procedures most women have a breast mound of appropriate size and shape and one which matches the opposite breast.

Finally, the breast mound is transformed into a breast with the addition of a nipple and surrounding areola (darkened skin).

Nipple and Areola Reconstruction – Chapter 8

Nipple and areola complex reconstruction is begun some months after the breast mound swelling has diminished and the shape of the breast has settled in. Premature placement of the nipple and areola will cause it to be either too high or too low.

Under either general or local anesthetic, the new nipple is outlined on the peak of the breast mound. Using tissues from this area, the nipple is raised and fashioned. A skin graft is then taken from the upper, inner part of the thigh to form the surrounding doughnut, or areola, leaving behind a fairly inconspicuous thigh scar. The operation is usually performed on an out-patient basis and is accompanied by some tenderness in the thigh donor site for a week or two.

The shape and projection of the new nipple and size of the areola are approximated to that of the opposite breast. However, the color of these structures may not be identical to the original. When this is a problem, tattooing of both the nipple and areola may produce more acceptable results. Sometimes simply tattooing the shape of a nipple and areola on the mound will give the illusion of having a completed reconstruction, although authentic projection is lacking. Alternatively, the nipple is rebuilt and the surrounding areola is tattooed without the use of a skin graft.

A less frequently used method is taking part of the nipple from the opposite breast to fashion a nipple for the new breast. However, the other nipple may be too small to be used, and there is a risk that sensation in the existing nipple will be diminished.

The nipple from the original breast containing the tumor can rarely be used on the reconstructed breast. There is concern that some cancer cells will be transferred to the newly formed breast. Besides, with the available technology, nipple and areola formation has been elevated to a refined art.

Often, two operations can be combined so that the nipple and areola are fashioned simultaneously with the remolding of the opposite breast. The newly fashioned nipple and areola transforms the reconstructed breast to appear more like the original. Unfortunately, though, the new nipple and areola will not have the original nipple’s unique sensitivities.

Sometimes a false nipple can be used. These are made of soft plastic and simply adhere to the peak of the new breast. The false nipple will give an authentic projection under your clothes but, again, will not have the original nipple’s sensitivity nor will it be a permanent part of the breast.

Nipple and areola formation is usually regarded as the final step which completes the reconstruction. Many women see this step as an ending to the struggles, physically and psychologically, which began with the initial diagnosis of breast cancer.

Questions For You and Your Plastic Surgeon – Chapter 9

1. Does breast reconstruction interfere with other treatments (for example, chemotherapy or radiotherapy)?
Both treatments can start fairly soon after the reconstruction; however, a slight delay may be necessary to allow the surgical wounds to start healing. Neither therapy is made less effective by the breast reconstruction.
Radiotherapy for cancer prior to the breast reconstruction can affect the quality of the remaining skin. This may mean you will need a tissue transfer or tissue expansion operation.
2. Does the breast implant cause cancer?
No. Medical research to date does not indicate that the implant causes cancer.
3. Will a recurrence of breast cancer be hidden after the breast is reconstructed?
Normally, a local recurrence is first seen in the skin of the chest or the scar tissue left behind after the operation. Both of these areas can usually be seen or felt by your doctor during your follow-up examinations. Tissue transfer techniques may be a slight hindrance to physical examinations, as new skin and muscle are brought to the chest. Continued follow-up examinations by your physician will help to detect any changes.
4. Will my reconstructed breast feel normal?
The gel or saline-filled implant matches the breast tissue that has been removed in weight, size, and consistency. The breast may remain soft or become firmer than the day it was restored due to capsule formation. Fat within tissues transferred may atrophy or become thinner causing a change in breast consistency. Keep in mind that breasts normally feel slightly different from side to side and from woman to woman.

The new breast skin will feel normal to the touch, but some areas may feel numb. This is due to the mastectomy which removed or cut many of the nerves leading to the breast. Likewise, the new nipple and areola will look and feel normal to touch, but lack in most sensitivities.
5. Will the new breast look exactly like the one which was removed?
No, it would be almost impossible to exactly copy the removed breast, but in many cases a close match can be obtained.
6. Is the recovery period lengthy or painful after reconstructive surgery?
Depending upon the method used, various physical restrictions may be placed upon you. In general, no strenuous activities can be performed for at least three weeks from the time of the reconstruction to allow for initial healing to take place. Most women notice some stiffness and soreness in the operated areas, which is short-lived and usually relived by mild painkillers and local therapy (e.g., stretching). When combined with the mastectomy, the sub-muscular implant or tissue expansion reconstruction does not cause additional discomfort. Tissue transfer may cause additional discomfort in the donor site.

Any further limitations, as well as individual information on what to expect after the operation, should be fully discussed with your surgeon before the reconstruction.
7. Do I need nipple and areola reconstruction?
The final stages or finishing touches are entirely up to you. Many women are very satisfied to have just the breast mound, while others feel that the nipple/areola transforms the mound into a visual breast. There is no need to make this decision until the breast has settled in.
8. Is it always necessary to alter the opposite breast?
Once again, you are an active participant in the decision to operate upon the other breast. In many instances uplifting, reducing, or enlarging this breast will allow for better symmetry between the two breasts.
9. With immediate reconstruction, is the hospital stay prolonged over that of the mastectomy alone?
The recovery time is usually about the same; however, this will depend upon the type of reconstruction and if there are any associated complications.
10. Is the breast implant easily broken or damaged?
Both the gel and saline-filled implants are surrounded by a strong silicone envelope. Under normal conditions they do not break. In the rare case of the implant leaking, rupturing or deflating, it may be substituted for a new one, usually without affecting the previous results.
11. Does capsule formation around the implant or expander have any effect on the reconstruction?
Every man-made prosthesis is surrounded by scar tissue. This is the body’s way of isolating it. In some cases the scar tissue becomes overabundant causing the implant to feel harder than normal. If firmness or distortion of the breast becomes a problem, then the capsule can be surgically broken.
12. What is the most common type of breast reconstruction?
The placement of an implant below the chest muscles after the mastectomy can give very pleasing results if there are adequate healthy tissues present. Individual selection for this and every other type of restoration procedure is critical. The options available for your particular situation should be thoroughly discussed before the reconstruction takes place.
13. Will I ever view the reconstructed breast as my own?
Studies show that within months of the surgery women begin to assimilate their new breast into their own body image and soon thereafter feel it is their own.
14. Do my expectations about the breast reconstruction play a role in my satisfaction level?
Definitely. Having a realistic idea of what to expect and knowing that the new breast will never be an exact duplicate of the one removed will assist in your satisfaction.
15. Are most women pleased with their results and if given the opportunity would they do it again?
The vast majority say that they would undergo either immediate or delayed reconstruction again. Having the ability to wear normal clothing and not constantly being reminded of the cancer, by a flattened chest, has helped them adjust to the mastectomy.
16. Will I still be able to have a breast reconstruction if I did not consult a plastic surgeon before my mastectomy?
The availability of breast reconstruction does not depend on the length of the interval between the mastectomy and your decision to have reconstruction. It is determined by your health and the quality and amount of tissues remaining after the mastectomy. A discussion with your surgeon beforehand, however, will enable planning of the breast reconstruction and possibly allow for immediate reconstruction.
17. Is breast reconstruction available from the National Health Service?
Yes. If you have had or are going to have a mastectomy as cancer treatment, you are entitled to a free breast reconstruction from the National Health Service. Alternatively, if you prefer, there are surgeons who will do reconstructive surgery privately.
One must be responsible for one’s own well being. I hope that I have assisted you in your quest and that you will continue to seek out those answers that will benefit your recovery.

If you feel young but your face is telling a different story, then a “Facelift out of a Bottle” using Juvéderm,

Radiesse and Botox will amaze you. Refresh, lift, tone and brighten your appearance while you maintain your personal identity. Why not look on the outside how you feel on the inside?

Fillers have revolutionized facial contouring with little or no downtime. Juvéderm and Radiesse are synthesized products that plump up, support and reshape the face, lasting from several months to over a year. The results can be so remarkable that Dr. Rosenthal refers to his procedure as “a liquid face lift”. While Juvéderm smoothes out lip lines and restores lost volume around the mouth, Radiesse restores or improves the cheek bones and arch to lift, smooth and contour hollow areas. The combination of Radiesse and Juvéderm is a perfect match for non-surgical facial rejuvenation and enhancement.
Botox is another wonderful non-invasive rejuvenating procedure that is used to create a “pretty” and relaxed upper forehead. Dr. Rosenthal can transform a tense and wrinkled forehead into a smoother and attractive one. He accomplishes this by balancing the many muscles in the upper face rather than leaving you with a frozen appearance. This creates a rested and tension-free appearance.

Be confident and comfortable with yourself. Even though beauty starts from within, let Dr. Rosenthal and his caring staff help you care for the outside.

Who is not a bit frightened or perhaps very concerned prior to having surgery? Even when the surgery is cosmetic or elective in nature, the threshold for anxiety is imposing. Having some control over the procedure will allay much of your anxiety and contribute to a smooth and enduring outcome.

Look at the surgery as an adventure, into an unknown land that requires a guide to prevent you from getting lost and to assure that the expedition will be advantageous. So let us delve into some of the ways that you can facilitate a positive outcome.

Choosing a surgeon is always the inaugural event which will make the experience less bumpy. Look for a physician who has the knowledge, experience and skill-set to perform the surgery that you are interested in. But as crucial to whom you pick, this individual must be able to communicate the benefits, potential risks and expected outcome of the procedure and have a plan to make the event as stress-free as possible for you. Communication is paramount in all walks of life, but especially critical in order for you to trust that you will be well taken care of. Once you establish a mutual respect, trust that your surgeon will look after you and let go of your desire to direct the show.

Make a list of questions that you wish to be addressed during the initial meeting. Come prepared by researching your surgery in advance. For example, there are numerous websites on line that will greatly assist you in this quest. A word of caution regarding second hand information from friends, as their experience may be influenced by a host of factors which are unrelated to you.

Once you have chosen your surgeon, the date and the place your surgery will take place, your participation is even more integral to a successful outcome. Your state of mind influences how your body will deal with the physical part of the surgery. The immune system, which is the part of the body that fights to prevent infections and helps in the healing, is influenced by your overall health and how positive you are. Take care of yourself physically and mentally-stay positive and optimistic. Surround yourself with similar minded individuals. The mind is an extraordinarily powerful weapon that will protect and assist you in the healing process.

Let’s now discuss a few of the factors that you have a tremendous ability to affect.

Traveling far distances within a few days of surgery is not ideal. Prolonged sitting causes the blood to pool in your lower legs which may increase the risk of blood clots. Likewise, there are a host of herbs, vitamins, and medicines, such as birth control pills or blood thinners, which either increase or decrease your ability to control bleeding or clotting.

To be on the prudent side, you should discuss what medications, herbs and vitamins you take with your surgeon prior to surgery. However, in general over, the counter herbal products should be discontinued two weeks prior to surgery and after surgery, as they may influence your body chemistry or affect how you tolerate anesthesia. Many of us take baby aspirin daily to assist with circulation. Discontinue the aspirin for two weeks on either side of the surgery, unless you are taking it under the supervision your physician. There are a number of other products: Motrin, Advil and Ibuprofen, vitamin E, fish oils, flax oils, cold remedies containing any of the above and alcohol that must be discontinued two weeks before and after surgery.

A word of caution is in order for those who partake of tobacco use. There are not many habits that are so destructive to the healing process than smoking. Numerous toxins, additives and nicotine bathe each cell of the body causing irreparable harm. The carbon monoxide that is inhaled affects the oxygen content of the blood, a vital component of healing, causing the areas operated upon to fall apart. Your lungs are compromised by the smoke increasing your risk of complications. You would not consider sucking on your car exhaust before or after surgery, so it is necessary to discontinue cigarettes weeks before and after surgery.

A few basics that will make the process smoother for you.

1. Stay away from crowds a few days before surgery to prevent your catching a cold.

2. The night prior to surgery eat a meal that is easy to digest, like pasta.

3. Stay away from salty foods for two weeks after surgery to decrease swelling.

4. Wear comfortable and loose fitting clothing to the surgical facility.

5. Get all of your prescriptions filled in advance of the surgery and learn what order and how often to use them.

6. Have a few bags of frozen peas or corn that you can transfer to baggies. Apply the peas/bags wrapped in a thin towel to the area that was operated upon for 10-15 minutes 4 times a day for a week to keep the swelling down.

7. If you have no pain after surgery, use Tylenol every 6-8 hours for the first two days to prevent discomfort. Or use the prescribed pain medicine given to you by your surgeon.

8. If possible, keep the area operated upon elevated. This will diminish swelling.

9. Minimize your activity for the first week to keep your blood pressure from rising.

10. Refrain from sports or heart rate elevation for a few weeks after surgery to allow for optimal healing.

11. Have low salt food at home for the week following surgery to minimize swelling.

12. Books on tape or movies you can enjoy at home will take away from your boredom.

13. Expect bruising, some bleeding and perhaps discomfort for the first weeks after surgery.

14. Be realistic; you will not be able to resume your normal daily routine for days to weeks afterwards. Plan for this.

15. Healing is controlled by your body. Having a positive outlook will assist your body in the mending process.

16. It helps to have your mind, body and your spirit balanced.

17. Your destiny is yours to take control of. By being informed and prepared for the surgery you will improve upon the outcome. No one can predict the ultimate result of surgery but you are positioned to significantly improve upon and influence your fate.