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Rhinoplasty In Michigan

“Closed” Rhinoplasty—a rare art in the modern world  
An experienced plastic surgeon’s viewpoint by
Dwight V. Galloway M.D.

Rhinoplasty, or cosmetic nose surgery, is one or the first plastic surgery
operations, started over one hundred years ago by Dr. Jacque Joseph in Berlin. He
was well known and many came to learn from him but he was very secretive and did
not show what he was doing or explain it. Although the techniques are now well
known “closed Rhinoplasty” is still an art and must be learned over many years after
being taught by an expert. Most present surgeons use the open technique as it is
much easier to understand even though it takes almost twice as long to perform,
often gives an operated look, and leaves much more scar tissue in the nose. I was
taught the closed technique in residency at the UCLA medical center in the 1960s
when that was the standard method. This leaves much of the delicate tip structures
and the character of the nose intact and addresses only the undesired
characteristics. For severely twisted and deformed noses (like with cleft lip patients)
the open technique is well worth the problems and I use it for them. Both the open or
closed technique can be done either under local or general anesthesia and I have
done well over 500 under local anesthesia. However with the present medical
system in either the hospital or surgicenter, the price and risk is the same for general
or local anesthesia so now you will have no pain and less anxiety and I can
concentrate only on the operation without worry that I am hurting you. My intention is
to change what you do not like about your nose so the final result will look natural
and not like a “nose job”.

Rhinoplasty if considered one the most difficult operations to master and there is
a whole society of “experts and learners” that meets at most of our national meetings
where only that one operation is discussed year after year. Many text books have
been written on the subject. The steps of the operation are not hard to teach or learn
but deciding what to do and how much in each nose, takes about 5 years to learn.
The biggest problem is that you need to reexamine enough patients after about
2 years to see how the skin, bone, cartilage and scar have healed and matured
in relation to what you started with and what you did. The other factor to consider
is that it is well documented in the literature that about half of the rhinoplasty
candidates have a fixation on their nose and correcting the physical part of the
nose does not eliminate the way they feel about themselves. If you decide to do

rhinoplasty you have to accept the unhappy patient even when you think you have
done your best. Most plastic surgeons just “do not do noses”. The other half with the
improved self-image and happy smile makes it all worth it, at least to me.

The nose is in the center of the face and there is no way to hide it. The most
common complaints are (1) the hump, (2) the bulbous and wide tip, (3) too big and
(4) the tip “pulls down when I smile”. Some are so self-conscious they cover it with
their hand or do not smile and stay away from social situations. Curing that is what it
is all about.

After the surgery there will be a tape and aluminum splint on the nose for about a
week to hold the bones, cartilage and skin in place until they are stuck together. It
takes about 16 days for the bones to get solid and I have you push them together for
about 3 weeks to be sure they do not spread apart. You will be instructed how to do
that on the day the splint is removed.

I take many before and after photos to help me decide what to do and record the
results at various stages after surgery. I usually use the computer and Photoshop to
help me decide how much to take off and change the angles and do a “choice 1” and
an overdo “choice 2” to emphasize what I am proposing, so that you can have some
input into my decision, and also to follow-up at 2 years after the operation when the
final result is achieved. About 10 percent of noses, like most cosmetic operations,
could stand a revision when fully healed. Sometimes it is the patient and sometimes
me that feels a further touchup is warranted. But you never know if you don’t look
and good photos are a must. Healing and judgment are not always perfect and if a
second operation can make a significant improvement the time and effort to check
and get the photos is worth it. The nose and the chin are related to facial balance but
I do very few chin implants initially since fixing the nose is usually enough.

Abdominoplasty – All about Tummy Tuck’s

Abdominoplasty, what you need to know
An experienced plastic surgeon’s viewpoint by
Dwight V. Galloway MD

Abdominoplasty, popularly known as tummy tuck, has become
one of our most commonly requested and preformed surgeries. It is
the central feature in the “mommy make overs” which helps correct
the most visible damage to your body associated with child bearing.
This means that a huge percentage of the female population are
candidates, something that has always been a problem, but only in
the last 30 years has become well known.
The 2 major problems that need correcting are: (1) the stretched
and excess skin and fat on the abdomen, and (2) the stretched
muscle and midline tissue that give a lower abdominal bulge as
well as low back pain. A mini abdominoplasty does not move the
belly button and in plastic surgeons thinking, is what is really “a
tummy tuck”. The skin above the umbilicus must be fairly smooth
and a less severe overall problem apparent for this to be the best
solution. It takes only about an hour to perform and can be done as
an outpatient. My estimate is that about 10 to 15 percent of women
would need only the mini, though in the past I did a much greater
percentage than that. The part of the stretched midline tissue,
actually called a “rectus diastasis” that is causing the low back pain
can be repaired through this much more limited operation.

The full abdominoplasty removes all the skin and fat from the top
of the pubis to just above the umbilicus and goes from mid lateral to
mid lateral on each side. For weight loss cases this incision goes well
around the back and in extensive cases a “total body lift” goes all the
way around, like a belt. The upper skin and fat from the umbilicus to
the breast bone and ribs is stretched and flattened up to allow this
tissue to stretch down to the pubis. You generally walk bent over for
about 3 weeks. We also repair the ”rectus diastasis” and cure your
low back pain and allow you to do sit ups again. Liposuction is
usually done on the flanks to help narrow the waistline but is
probably dangerous to do in the upper abdomen as the blood supply
to the lower midline skin and fat comes through that area. (It is safe
to do liposuction for a mini abdominoplasty.) Of major significance on
this operation is the danger of nicotine, usually from smoking, either
just before or after the surgery and even a history of smoking years

before can increase the incidence of skin death and a huge open
wound for 2 to 3 months. If you continue to smoke or are around
smoke from someone else the skin can die. The full abdominoplasty
is by far the most common operation I do today that is so severely
affected by any source of nicotine.
The initial abdominoplasties were usually done for obesity and/or
weight loss with the abdominal skin hanging down on the thigh. This
is still done today and some obesity surgeons do their own cases,
with my blessing since these are very big cases with low insurance
payments. The insurance companies will not cover the routine
abdominoplasties as they call it “cosmetic” and completely deny the
association with the low back pain relief that routinely happens when
the muscles separation is repaired.
Drains and suction catheters after surgery are routinely used by
many plastic surgeons. Only about a third of us do not. I have not
used them in over 40 years and have used what are now known as
“quilting stitches” or “tension stitches” during that time, 20 years
before they had a name. It is a well published and l know as fact that
seromas and hematomas are essentially eliminated by this method,
though they are very common i.e. 30%, with the drains system. It
takes some extra time and work to place the sutures but we have
become very efficient in their placement and can do a complete full
abdominoplasty with rectus diastasis repair in about 2 hours. The
drains are usually the patient’s major complaint after operation.
The position of the resultant scars has changed over the past 30
years. Initially in the 1950s the Bikini bathing suit was very low but
went across the hips and we tried to place the scar where it could be
covered by the suit. Then in the early 1980s the one piece bathing
suit and exercise and running garment left the hips exposed and
these scars stuck out and were unacceptable and we placed our
incisions much higher and more confined to the abdomen. Now we
are back to the low suits with very narrow bands, so we are back to
1970, but placing the central incision thru the pubis. These scars are
usually not thin hairlines and require coverage by clothes, or possibly
a tattoo. The lower central skin is numb after the operation and
usually the nerves grow back and sensation returns over a one-year
period. All the sutures are buried and dissolvable except some in the
umbilicus which are placed so there are no suture marks on the skin
but are all in the umbilicus itself. I try to make the umbilicus small and

vertical, as it was before the children stretched you out. Every one
need a belly button to feel human but it should not be obvious or ugly

Full abdominoplasties can be done on an outpatient basis to
save money or even in a well-equipped office based surgery or
surgicenter. I have done them in all those places in the past. However
an overnight stay in the hospital offers so much more comfort, safety,
and convenience that I only do it that way now. This is a big operation
and under general anesthesia with an indwelling urinary catheter
and an intravenous fluid replacement, things that are placed by the
anesthesiologist while you are sedated or asleep and offer significant
advantages to being continued overnight rather than you being at
your home with your family. There are so many advantages to the
overnight stay that I feel that is the way to go. I have asked numerous
patients if they could have gone home the day of surgery and nearly
all have said no. I include the cost of the overnight stay in my cost
quote.

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