Common concerns
Start from what you noticeYou don't have to know the name of the operation.
Patients arrive describing what they see in the mirror, not what it is called. Each entry below starts from the thing you notice, says what it usually turns out to be, names the operation that answers it — and names the one that does not, because being sent to the wrong operation is the commonest way a face ends up needing a revision.
What you see, and what it usually is
None of this is a diagnosis. It is the reasoning a consultation goes through, written out so you can follow it — and so you can tell whether the clinic you are sitting in is going through it too.
01“My eyes look heavy and tired, even when I'm not.”
What it usually is One of four things, and they are separated before anything is proposed: the brow has descended, the eyelid skin is in excess, the muscle that opens the eye is weak, or your forehead has been doing the lifting for so long that the brow only looks normal because of it.
What answers itIf the brow leads, an endoscopic forehead lift. If eyelid skin leads, eyelid surgery. If the levator leads, ptosis correction. Often two of them together, in an order decided by which leads.
What does notAnother eyelid operation when the brow was the cause. That is the single most common reason a patient arrives here having already been operated on.
Endoscopic forehead lift, in full 02“My forehead lines are getting deeper and botulinum toxin has stopped working.”
What it usually isThe lines are the evidence, not the problem. A brow that has come down is being held up by the frontalis all day; the muscle thickens, the lines deepen, and toxin eventually cannot hold against the work the muscle is doing.
What answers itLifting the brow so the compensation is no longer needed. The frontalis is preserved as a rule — it is the muscle that raises the forehead and brow, and removing it to erase lines costs you the lift.
What does notMore toxin, more often. And a lift that raises the brow too far, which produces the startled look people fear.
The questions about the brow 03“People say my face looks wide from the front.”
What it usually isThe zygomatic arch — the lateral cheekbone — is what widens a face seen from the front. The zygomatic body is what projects in profile. Most faces have some of both, which is why the two are measured rather than assumed.
What answers itEndoscopic malar reduction through a single temporal incision, with the arch and the body reached on two separate dissection planes. Where the anterior body leads, the L-rotation turns it inward on a retained cortical hinge.
What does notReducing bone when what has actually happened is that the soft tissue over it has descended. That makes the face look older, not narrower.
Endoscopic malar reduction, in full 04“My cheeks sagged after cheekbone surgery.”
What it usually isSoft tissue that lost the bony support it was sitting on, or a dissection carried wider than the reduction needed. It is a different problem from bone left behind, and it is told apart by CT plus examination, not by either alone.
What answers itA reading of the last operation first — where the osteotomy ran, whether the segment united, how much of what you see is descent. Then bone, soft tissue, or both, in that order of evidence.
What does notTaking more bone. If descent is the finding, further reduction removes the support that is already failing.
The 2013 revision series, eleven cases 05“There's still a bump after my cheekbone surgery.”
What it usually isThree different things that look the same in a mirror: bone that was never reduced, a fragment that dropped or failed to unite, or soft tissue sitting over a bone that was reduced correctly.
What answers it3D CT to see where the segment actually sits, then a plan addressed to whichever of the three it is. Non-union may need firm fixation added rather than more cutting.
What does notA second operation planned from photographs. A revision is a reading of the first operation before it is anything else.
The questions about malar revision 06“My nose is crooked, or I can see the implant through the skin.”
What it usually isA pocket made off to one side at the first operation, a septum that is itself deviated, or skin thinned — congenitally or by surgery — over an implant that is too thick or set too high.
What answers itRebuilding the pocket correctly, correcting the septum where the septum is the cause, and where the skin has thinned badly, moving to your own tissue with no implant at all.
What does notA larger implant to disguise the problem. Thin skin over more material is the same problem, later.
Revision rhinoplasty, in full 07“My nose was operated on several times and I've been told nothing more can be done.”
What it usually isSometimes true, often not. What decides it is the tissue that remains and its blood supply — cartilage left, skin thickness, scarring, what was implanted before, whether inflammation has settled, the degree of contracture and the airway. Seven checks, not a count of operations.
What answers itThose seven checks, then either a plan built from what remains — rib cartilage or your own dermis where the septum and ear are spent — or a clear statement that now is not the time.
What does notOperating into unsettled tissue because a patient is impatient. That is how the same failure repeats.
The seven checks 08“My nose turned up after the implant was removed.”
What it usually isAn implant that stretched the tissues for years leaves them short when it comes out, and the tip rotates upward until it is supported and lengthened again. It is what the remaining support was always going to do, not a new failure.
What answers itLengthening a contracted nose — a separate operation with its own graft requirements, planned from what remains rather than from photographs of the nose you used to have.
What does notReplacing the implant at the old height. That restores the appearance and the original problem together.
What happens after a removal 09“There's a lump where I had filler or fat years ago.”
What it usually isA semi-permanent filler that hyaluronidase cannot dissolve, a granuloma the immune system built around the material over years, or grafted fat that lost its circulation and calcified. Ultrasound tells them apart; fingers do not.
What answers itRemoval under direct endoscopic view through small scalp incisions for the forehead, glabella and temple, with a second approach for the cheek where needed — the area is dense with nerves, which is why it is done with magnification rather than blind.
What does notAnother dissolving injection when the material is not hyaluronic acid, and forcing a complete removal at the cost of the normal fat and nerve around it.
The questions about foreign material 10“My forehead is too long, or my hairline too high.”
What it usually isA forehead length problem, which is the opposite of a brow position problem — and the two are routinely confused, because both are described as “my forehead”.
What answers itForehead reduction, lowering the hairline through an incision at the anterior hairline. Reported in 641 Asian patients in 2021, mean central excision 16.64 mm.
What does notA forehead lift, which raises the brow and can lengthen the forehead slightly. They are not interchangeable, and choosing wrongly makes the complaint worse.
Forehead reduction, 641 casesEvery one of these is the same mistake, in a different place
Read the ten together and one thing repeats: the operation that fails is almost never done badly. It is done correctly, on the wrong cause. An eyelid operation for a brow. More bone for a descent. A larger implant for thin skin. A dissolving injection for a material that does not dissolve.
That is why the consultation here starts with separating causes rather than choosing a procedure, and why every technique page on this site carries the faces its method does not suit. The most useful thing a surgeon can tell you is which of these ten you actually have.
What each operation does How to test a surgeon's answer One hundred and one questions, answeredThe cause, before the procedure.
A consultation begins with examination, 3D CT and, where the layers have been mixed, ultrasound — to establish which of these you have before anything is proposed. Where the findings say that not operating now is the better course, that is said first.
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