At Advanced ENT and Allergy, we offer both reconstructive and cosmetic plastic surgery for the face and neck, as well as non-surgical procedures such as Neuromodulators and fillers. This area of our practice is led by Dr. Aaron Smith. Dr. Smith practices at our New Albany, Jeffersonville, and Breckenridge locations and sees patients of all ages. As our Advanced Cosmetic and Facial Plastic Surgery services continue to grow, we thought this would be a good opportunity to introduce and explain some of our procedures and areas of focus.
Nasal fractures are the most common facial fracture making up about 40% or facial fractures and third most common bone fracture overall behind the clavicle and the wrist. This frequency is mainly due to the central location and projection of the nose on someone’s face.
In an injury like this, sometimes the nasal bones are fractured, sometimes the cartilage of the nose is fractured and sometimes both are fractured. These types of injuries can end up in long term issues with trouble breathing through the nose. It is important to be evaluated for a septal hematoma as this complication can destroy the septal cartilage and cause the nose to fall in.
Management of nasal fractures may include doing nothing for nondisplaced fractures or re-setting the fracture if displaced. Re-setting is best done within about 2 weeks of injury so this is an important time frame to keep in mind. After about two weeks fibrous tissue forms so that the bones cannot be re-set. Additionally, further reconstructive surgery can be performed months to years later if necessary.
NEUROMODULATORS FOR MIGRAINES
Neuromodulators has been FDA approved for use in people who suffer from chronic migraines, facial spasms and synkinesis (abnormal facial movements).
Chronic Migraines – If someone has suffered from chronic migraines with 15+ headache days, 8+ days associated with migraines lasting at least 4 hours each of those day AND has failed two prophylactic medications for migraine treatment, they may qualify for Neuromodulator injections. Neuromodulator will ease the contractile force of the muscles that cause headaches and likely lessen migraines by doing so. These treatments last for about three months.
Facial Spasms (Hemifacial spasm, Blepharospasm) – neuromodulators is injected into the facial areas of spasm in order to improve symmetry, decrease spasms and improve function.
Synkinesis – Neuromodulators is injected into the precise facial musculature that is being activated when it shouldn’t be (EG: The eye muscles closing the eye while someone is smiling). This improves symmetry and function for those individuals that suffer from facial nerve injury or Bells palsy.
Dr. Smith injects Neuromodulators for both cosmetic and functional indications.
Earlobe surgery can be used to repair stretched or torn ear lobes from trauma, gauging or heavy earring use. The skin lining the tract is removed to create a raw edge and then precisely realigned with sutures. The procedure can be done under local anesthesia in the office in under an hour. Any discomfort afterwards is minimal and usually can be relieved with over the counter medications.
BENIGN SKIN LESION EXCISION
Skin lesions come in all shapes, sizes and names (cysts, lipomas, keloids, dermoids, keratoses). Most of which are benign but can become irritated, infected or painful. They can be unsightly and located on prominent facial areas (eyelids, nose, ear, lip). The main treatment options are by shave or excision which depends on the evaluation with your physician. Sometimes these can be larger and require more complex closure techniques depending on the situation.
Moles (nevi) are small, pigmented lesions of the skin. They can be present since birth or show up years later. The majority are benign (not cancerous) but some have worrisome features that could be cancerous.
Here are the worrisome signs a mole may be cancerous
A – Asymmetry
B – Borders (Irregular)
C – Color
D – Diameter (>6 mm)
E – Evolution (change over time)
Depending on the situation, a mole may be removed from an insurance basis if it is worrisome for cancer or if it is in an area that interferes with our daily lives and becomes irritated/painful. Moles can also be removed from a cosmetic basis if someone believes it is unsightly. There are many ways to “remove” a mole. The main treatment options are by shave or excision which depends on the evaluation of a mole with your physician.
SKIN CANCER RECONSTRUCTION (MOHS RECONSTRUCTION)
Skin cancer excision can leave a large area devoid of skin and soft tissue (hole) following the Mohs procedure (Mohs defect). Dr. Smith specializes in closure of these defects on the scalp, neck, face, nose, ear, lips, and eyelids.
Four main options exist:
Healing by Secondary Intention – This method is mainly dictated by size, location and depth of the defect. The advantage is that no additional procedure is needed. The disadvantages can be a prolonged healing time 4-12 weeks, depressed, white or hypopigmented scar.
Skin Grafting – Skin grafts can be harvested from many locations including the chest, stomach, around the ear, and neck. This skin can then be placed into the defect for repair. Skin grafts do not have their own blood supply and receive nourishment from the underlying tissue; therefore a bolster is used.
Local Flap Reconstruction – In this technique, adjacent skin to the defect is utilized and rearranged into the defect for closure. Frequent types of these flaps are call rhomboid, advancement, rotational, island and bilobed flaps. These are advantageous as they use tissue that is of the same texture and color as the defect skin and they are completed in one stage.
Pedicled local and regional Flaps – These flaps may require more than one stage for completion with a minimum of two stages. They are required for larger defects or defects that require multiple layers for reconstruction like cartilage or nasal lining in addition to skin. The first stage is more involved while subsequent stages are usually more quickly performed with shorter recovery periods. Pedicled flaps fall in this category as skin and tissue are placed onto the defect with a skin bridge back to the origin site to provide blood flow and nourishment to the flap during healing. This skin bridge will then be divided and inset 3-4 weeks after the first stage.
Whether a scar is from acne, trauma, previous surgery, or infections, facial scarring can be life altering no matter the cause. No procedure can fully remove a scar, however, many different treatments ranging from dermabrasion to re-excision exist to reduce the noticeability of a scar or potentially improve functioning. These treatments can significantly impact someone’s life. The different options will be reviewed after a scar is evaluated and the best approach (may be multiple) will be chosen with you.
As many as 29% of infants are born with ear deformities (cupping, Stahl’s ear, conchal crus, etc). Unfortunately, about 70% of those won’t improve and we can’t tell which will be the 30% that will improve on their own. The EarWell device was created specifically created to mold a baby’s ears during infancy to correct these issues. It is best to be placed within the first 3 weeks of life while maternal estrogen keeps hylaronidase levels high and keeps the ear cartilage malleable. It only takes a few minutes to place in the office and treatment lasts 6-8 weeks total.
More information can be found at the official Becon Medical website: https://www.earwells.com/
BLEPHAROPLASTY (EYELID SURGERY/EYELID LIFT)
Eyelid surgery can be done for both functional and cosmetic reasons. The procedure involves a skin incision in the upper eyelid crease with removal of skin, muscle and sometimes fat. Upper eyelid blepharoplasty can be covered under insurance if the skin is heavy enough to cause narrowing of the visual field. Insurance coverage usually requires a visual field examination with untaped and taped upper eyelids that meet the correct criteria. Lower eyelid blepharoplasty is generally considered a cosmetic procedure only where skin, muscle and/or fat can be removed to correct puffiness or “bags” under the eyes.
EYELID TIGHTENING PROCEDURES (Tarsal strip, canthoplasty)
Many reasons (IE: Bells palsy, gaining) can cause turning out of the eyelids (ectropion). Several procedures exist to tighten the lower eyelid to correct this issue. The tarsal strip procedure involves resetting the lower eyelid into a more natural position.
GOLD WEIGHT INSERTION
If the eyelids do not close properly (mainly from facial paralysis), a gold weight can be placed in the upper eyelid in order to achieve eyelid closure and reduce the risk for drying out of the eye.
Facial trauma is unexpected and can leave someone with devastating injuries to the face both in soft tissue scarring and to the underlying boney framework of the face. Dr. Smith trained at one of the highest volume trauma centers in the country, the Elvis Presly Memorial Trauma Center in Memphis, TN. He specializes in fracture management of the nose, cheeks, forehead, orbit, and mandible. Some of these fractures may not be repaired but others require multiple operations. Mandible and midface fractures may require arch bar placement where the jaw is wired shut for several weeks.