Health: Facing Facts
People say You’re only as old as you feel. Nowhere is that truer than among the boomer generation, which coined another phrase: 60 is the new 40. Now if only our faces could keep up. They can, with help from cosmetic specialists and the latest developments in their field.
Rhinoplasty is one of the most-requested cosmetic plastic surgeries. Think about it: If you don’t like your nose, you can’t hide it with makeup or mitigate its prominence by accentuating some other feature. But nose jobs have come a long way from the days when everyone’s ‘new nose’ looked the same.
new, but natural
“Rhinoplasty is probably our third most common facial procedure after face-lifts and neck-lifts,” says Dr. William Huffaker of St. Louis Cosmetic Surgery. And it stands to reason that people don’t really want others to notice their nose, says Dr. Scott Walen, SLUCare plastic surgeon. “They don’t want their nose to be a distinguishing feature.”
“There are social, cultural and personal reasons for wanting to change the appearance of the nose,” Walen says. “Some patients want to change a part of the nose because there is a hump or the tip is large. In many cases it’s a good idea because it has the potential to increase self-confidence.”
Rhinoplasty patients tend to be female and younger than patients pursuing other types of facial cosmetic surgery, Walen adds. Some patients are driven by the simple desire for improved air flow through the nostrils. “That tends to be an issue for patients who have had trauma to the nose in the past or who have had a previous rhinoplasty,” he explains. “In the past, rhinoplasties sacrificed function for cosmetics, but that isn’t the way things are done now.”
Not only are today’s noses more functional—no more narrow aquiline structures that constrict air flow—but the procedure is all-around easier on patients. “Rhinoplasty is not a very painful procedure,” says Huffaker. “There is a little numbness at first, but I rarely find it necessary to pack the nose. Patients have to wear a small splint for a week.”
Cost and downtime are two major considerations. In the St. Louis area, rhinoplasty costs range from $2,500 to $10,000. But in some cases—improved airway function, for instance—insurance may pick up part of the tab. Airway function can be improved, of course, without changing appearance. “Commonly we take cartilage from the nose, ear or rib and place grafts into key positions that stent the airway open,” Walen explains. “If the grafts are placed properly, there is no evidence on the outside.”
But as long as they are undergoing surgery, patients often will request cosmetic improvement. “Definitely there is a group of patients who want to change both,” Walen says.
the ideal nose
Turns out, regional differences can affect the kind of nose a patient requests. “Cosmetic surgery in the Midwest is interesting,” says Walen. “Patients want surgery, but they don’t want it to look ‘too done.’ They want to look rested and refreshed, natural and maybe a bit younger.”
Today’s technology allows potential surgery candidates to see what a new nose would look like and to have input into the artistic process, too. “At the consultation, we perform computer imaging to try to approximate appearance after surgery,” Huffaker says. “Years ago, a slightly turned-up nose similar to Sandra Dee’s was popular. Now a straight dorsum is considered best.”
The bottom line, the physicians agree, is working closely with the surgeon to be sure the two of you are on the same page. “We listen carefully to be clear about the patient’s goals,” Walen says. “The actual surgery has its own challenges and art, but the real art is in the diagnosis and treatment plan.”
We may never find the fountain of youth, but who cares? We have the next best thing: the face-lift.
change on demand
“The number of surgical lifts is growing steadily,” says Dr. Mike Nayak of Nayak Plastic Surgery. One reason? “With the prevalence of cellphone pictures, people are more aware of how they look from all angles—and they often don’t like what they see.”
Face-lifts are not one-size-fits-all, points out Dr. Michele Koo. “Anyone who has jowls or looseness in the neck, or a loss of fullness and volume in their cheeks, would benefit from a face-lift,” she says. “But the procedure should be tailored to the specific area of the face that is troublesome to that patient.”
The face-lift can remedy a host of problems. It can smooth deep wrinkles around the eyes, cheek and neck, remove excess skin that creates jowls, and eliminate a saggy cheek or a ‘gobbler’ neck, Koo says. But, of course, the quality of the result depends on the quality of the practitioner.
In general, today’s face-lifts aim for a fuller appearance than the face-lifts of yore, which often resulted in a recognizable ‘tight face’ look. “In the 1970s, it was all about tightening,” Nayak says. “We still use that terminology in talking about face-lifts, but today, tight does not equal young. If you look at a pretty 30-year-old woman, her neck is not tight. It is supple.”
Koo warns about doing too much. “Less is more when it comes to facial rejuvenation,” she says. “I try to replace the skin and underlying tissue to its original position, creating soft curves and restoring volume rather than yanking and pulling so tight it distorts the normal anatomy and the natural facial landmarks that make each person unique.”
keep it real
“Find a plastic surgeon who really understands your cosmetic goals and can deliver that result,” recommends Koo. The technology of plastic surgery—scalpels, needles and thread—has not changed but standards have, Nayak adds. “We are gaining more of an aesthetic understanding. Patients have areas that have shrunk and areas that have grown, and we want to restore their relative proportions.”
A full face-lift may cost $9,000 to $19,000, Nayak says, but it’s the recovery time that often is the deal breaker. “To do the best procedure I can, I tell my patients the recovery time will be two to three weeks.” That’s why some patients opt for downsized procedures that won’t interrupt careers. “Nowadays I try to perform mini face-lifts under local anesthesia in the office,” Koo says. The results, she says, “are a rested, rejuvenated look versus a ‘done’ look. My patients want the change to be soft and subtle, not obvious.”
Recent technological developments such as neurotoxin injections, ultrasound therapy and CoolSculpting offer skin-tightening and removal of fat tissues, which are among the benefits of a face-lift, but they can’t replicate the outcome of a surgical face-lift, Nayak says. “These technologies can make some very modest improvements in the jawline and neck, but they work primarily on the skin and fat layers. They can’t change anything deep,” he says.
Most facial plastic surgery procedures require an advance withdrawal from the piggy bank. But you may be surprised to learn that some may qualify for coverage from Uncle Sam and his medical plan.
“The over-arching principal of insurance coverage revolves around medical necessity,” says Dr. Gregory H. Branham, professor and chief of the division of facial plastic and reconstructive surgery at Washington University School of Medicine.
There are three categories of plastic surgeries, he says. “Some are almost always medically necessary and covered. Then there are some that are always considered cosmetic and not covered. But there is also a gray zone, hybrid cases with some portions that are covered and some that are not.”
A good example of that is when a necessary deviated septum surgery is combined with an optional rhinoplasty, or ‘nose job.’ “When you have a deviated septum and sinus problems, those are medically necessary, functional issues,” Branham says. “You have to meet the clinical guidelines, but by and large those are covered without a lot of questions. A patient who needs functional work, however, might ask, ‘While I’m here, can you take this bump off my nose or make the tip smaller?’”
In those cases, the bills will be shared. “Insurance will cover the medical portions of the surgery, and the patient will be responsible for the cosmetic portion,” Branham says. In such cases, the physician is required to provide “appropriate documentation,” says Dr. Scott Walen, SLUCare plastic surgeon. “Quite often photos are required.”
timing is everything
While nearly all acute injuries are covered, don’t wait too long to have something fixed. “If you come to the emergency room with a broken nose or facial fractures, those surgeries are covered when you receive treatment,” Branham says. But if you break your nose playing basketball, don’t decide years later that you want to eliminate the bump that was sustained.
“If you broke your nose as a child but nothing was done at the time, and you decide later in life to have it fixed, insurance coverage can depend on your circumstances,” Branham says. “The insurance company is going to look at whether you are having functional problems.” Breathing problems due to an old fracture could qualify, he says, but wanting to fix a lumpy nose from a third-grade tumble would not.
“We do a lot of cancer reconstruction. Those patients sometimes are very self-conscious about their appearance,” Branham says. “Insurance companies don’t squabble much about those.”
Dr. Michele Koo adds, “While facial rejuvenation for aging is not covered, rebalancing to restore symmetry may be covered for patients with Bell’s palsy or hemifacial atrophy.” Occasionally even a nonsurgical cosmetic therapy is covered as a medical necessity. “An injectable filler was approved years ago for facial lipodystrophy in patients who were HIV-positive and taking anti-retroviral medications,” Branham says. “They would get thinning in their face, and insurance covered the procedure.”
But be forewarned: New or rarely used procedures may not be covered. “There are situations in which we have to see when new technologies or treatments switch over from experimental or investigational and become a mainstay of treatment,” Branham says. “One of the things that insurance companies consider in their definition of medical necessity is whether the treatment would be generally practiced by a prudent professional: Is it the standard of care?”
Often the physician or patient must appeal an insurance company rejection, he says. “We will get passed to the insurance company’s medical director, who requires a lot of documentation. This is routine for practicing physicians now.”