Ten Plastic Surgery Pearls

I have been a board-certified plastic surgeon in private practice for more than 6 years. Whereas most of the plastic surgeons who read this article have many more years’ experience in practice, I thought I’d share some pearls or tricks of the trade that have proven extremely valuable to me. They cover a range of subjects, from tips you can use during procedures to those that can help you market your practice

Some of these pearls have saved me time and money, and others have prevented complications. All of them, in one way or another, have helped make my patients happier with the results of their procedures or in their interactions with me.

1 – INJECTING NASOLABIAL FOLDS

A couple years ago, my filler rep showed me a trick that I’ve been using on all of my nasolabial fold filler patients.

Take the side of the nostril and the nasolabial fold to make two topsides of a triangle. Make an imaginary bottom base of the triangle and inject a relatively large amount of filler (0.3 cc or more) into this depression—the nostril groove.

This is a very powerful way to reduce the nasolabial fold prior to injecting it along the fold itself. After performing this single injection, I often have patients compare one side to the other. With literally one poke, the difference can be dramatic.

2 – SUTURE THE UPPER EYELID WHEN PERFORMING A TRANSCONJUNCTIVAL LOWER BLEPHAROPLASTY

I perform virtually all of my lower blepharoplasties using a transconjunctival technique. The recovery time is shorter, and there is less bruising.

The first several times I performed this procedure, however, I found the upper lid eyelashes would get in my way. As a fix, I use a 5-0 nylon suture to suture the upper eyelid open, while using a corneal shield to protect the cornea. This ensures that my patient will not wake up without her upper lashes (Latisse or not).

3 – HOW TO AVOID A PIXIE EAR DEFORMITY

One of the pearls of facelift surgery I learned from my fellowship director, Richard Ellenbogen, MD, was to place a nylon suture—I use a 3-0 nylon—between the dermis of the facelift flap and the perichondrium of the ear deep to the earlobe. This provides a stable base to reduce any tension on the actual earlobe, preventing a pixie ear deformity.

4 – BUCCAL LIPECTOMY

I believe this is a very underutilized surgery. When used in select patients, it can dramatically enhance the results of a facelift. I recommend this for any patient who complains about a “chubby” or “bottom-heavy” face.

There are also a select group of patients who present with herniating anterior buccal fat pads. These appear as soft protrusions in the anterior inferior cheek hollow, resembling pseudo-jowls. An obvious sign for herniated buccal fat pads: a slow, oozing-out appearance of the fat after it is manually reduced when you press a finger into the herniation located just anterior to the masseter muscle.

Herniating buccal fat pads can often be reduced or removed during a subcutaneous facelift dissection or via an intraoral incision. When removing the buccal fat pad via a facelift incision, dissect subcutaneously to the area overlying the herniating buccal fat pad. Often, the SMAS covering it has thinned, and the fat can be seen protruding from this area. Gentle, spreading dissection with a tonsil hemostat is usually all that is needed to reveal the buccal fat pad. Carefully mobilize it out of the buccal space and conservatively excise it using cautery.

Conversely, the buccal fat can be excised by an incision in the cheek opposite the first to second maxillary molars. An incision is made near the upper gingivobuccal sulcus; a tonsil hemostat is used to spread the fibers of the buccinator muscle, revealing the buccal fat pad in the buccal space. It is carefully mobilized into the oral cavity and then excised with cautery. Be careful not to cauterize inside the buccal space or anything that isn’t obvious fat, as this space also contains the parotid duct and a branch of the facial nerve.

5 – PROGRESSIVE TENSION SUTURES

Prior to attending a lecture given by Harlan Pollock, MD, FACS, at the annual ASAPS meeting several years ago, I utilized two 15 french Jackson-Pratt (JP) drains for 2 to 3 weeks in each of my abdominoplasty patients. Even so, my clinically evident seroma rate (necessitating percutaneous drainage) was approximately 20%. After utilizing progressive tension sutures—essentially, suturing the Camper’s fascia and Scarpa’s fascia of the abdominoplasty flap to the anterior rectus fascia—my seroma rate has decreased to approximately 2%. While the procedure adds maybe 10 minutes to each surgery, it is well worth it. I continue to use one drain (although now only 10 french) and leave the drain in place until the output is less than 35 cc per 24 hours, which is typically 3 to 6 days.

Further, I understand that most plastic surgeons that utilize progressive tension sutures do not use drains at all. Progressive tension suturing has virtually eliminated postoperative seromas after abdominoplasty in my practice, has made my patients happier with their postop course, and saved me hundreds of dollars in spinal needles and seroma catheters.

6 – EXTERNAL ULTRASOUND AND MECHANICAL MASSAGE

I believe that most of the laser-based devices that plastic surgeons buy are not good investments. These devices often cost more than $100,000, have hundreds of dollars in disposable costs per treatment, and even have annual maintenance/repair plans that can put you back $12,000 per year.

I have tested and used several lasers in the past 6 years, and even purchased two that I use regularly in my practice. That being said, my best investment in this area is my cellulite treatment device. It combines a mechanical deep tissue massage with external ultrasound, and cost me less than $25,000 5 years ago.

In addition to cellulite treatments, my aestheticians use this device for many types of postoperative patients. I combine both the ultrasound and massage for improving swelling in postliposuction, facial fat grafting, and facelift patients. This has proven extremely valuable, especially when confronted with a patient who is distraught by excessive postoperative swelling. Recently, I’ve begun using the ultrasound for patients with early capsular contractures.

I have never needed to have the machine serviced and never signed up for an annual maintenance contract. It may be the only device I have purchased that has truly paid for itself—and then some.

7 – BOTOX TO THIN THE JAWLINE

This simple procedure has brought a small but constant number of patients into my office. Although masseter hypertrophy is more common in the Asian population, I have been seeing it more frequently in Caucasian patients as well. Botox injections to the masseter muscle are a very simple, effective treatment for reducing masseter muscle hypertrophy, thereby thinning the jawline. I learned it from Los Angeles-based plastic surgeon Charles S. Lee, MD, FACS, after he presented his technique at an ASAPS meeting several years ago.

Typically, I have the patient clench his or her jaw, allowing me to palpate the masseter muscle between two fingers. I ask the patient to relax; followed by injecting a total of 25 to 40 units of Botox into the mass of the muscle, typically using a 1-inch-long 30-gauge needle in three to five separate injections. Pressure is placed over the muscle for several minutes to prevent a hematoma. Most patients notice a distinct thinning of their jawline within 2 months, which lasts approximately 6 months.

8 – HIRE A PHYSICIAN EXTENDER

A good friend of mine, Las Vegas-based plastic surgeon Terry Higgins, MD, once told me that the best financial decision his senior partner ever made was hiring a physician extender to provide injection services for their patients. This allows the plastic surgeon more time to see more consultations, and therefore convert more surgeries. I completely agree with this.

My physician extender (an RN) performs neurotoxin and filler treatments 5 days per week, keeps track of my breast implant consignments, and sees my postoperative patients with me. As a result, I have additional time to see consults for surgery instead of having my schedule filled with injection patients.

Although initially I lost money on her, now I make a small profit off her services, in addition to having gained a nurse who helps me with my patients and office. The main drawback: the amount of time spent training her during her first several months of employment. This, however, has also paid off handsomely.

9 – E-MAIL IS THE FUTURE IN ADVERTISING

Five years ago, I added an aesthetician to my practice as a means of generating revenue and retaining patients. We used a mailing list of patients whom we could invite. At that time, we went to the local print shop, printed out 150 postcards, and hand-addressed and mailed each of them—at a significant cost. Later, I received an e-newsletter from the plastic surgery practice of my friends, Beverly Hills-based plastic surgeons Steven Svehlak, MD, FACS, and Daniel Yamini, MD, FACS. It looked slick, professional, and attractive. Since then, I’ve signed up with the same e-newsletter service they use, which costs me less than $30 per month to send an e-newsletter to our mailing list of more than 500 people.

Many practice consultants emphasize internal advertising, or advertising to your current patients. It’s much easier to keep a person in your practice than it is to attract a new one into the fold. E-mail is definitely the easiest and least expensive way to do that.

10 – NEVER REGRET TURNING DOWN PATIENTS FOR SURGERY

The best piece of advice I received during my 6 years of plastic surgery training came from Grand Rapids, Mich-based plastic surgeon Bradley P. Bengtson, MD, FACS: “You never regret turning a patient down for surgery.”

To this day, I can think of several patients on whom I operated but now wish I’d never taken into the OR. I can’t think of a single cosmetic surgery patient, however, whom I regret turning down for surgery. Usually, the person came to me with unrealistic expectations. Some of these same patients came back to my office months later, upset with the results that they received after going to another surgeon.

I am often relieved to have followed Bengtson’s advice.

I hope these tips and tricks will help you in your practice. If you have any pearls of advice you would like to share, please contact me at and we will publish them in a follow-up article.

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Anthony S. Youn, MD, is a board-certified plastic surgeon in Rochester Hills, Mich. He can be reached at (248) 650-1900.