Subj: Potential revision surgery
Date: 04/21/2000
To: zideb01@popmail.med.nyu.edu
Dear Dr. Zide:
I was referred to you by Diane from NH, on whom you performed a revision on her navel from a previous tummy tuck. She had wonderful things to say about you and encouraged me to consult you about my problem.
I had unfavorable results from facial surgery performed 3 years ago and would greatly appreciate your reviewing my pictures and operative reports to determine whether some improvement may be possible. I realize it is difficult to form an opinion without the benefit of an examination of my face, but this seems like a good place to start.
I had a full facelift and lower blephroplasty on 11/24/97 followed by a rhinoplasty 8 weeks later on 01/28/98. The results of the facelift at 8 weeks was favorable, however, I experienced severe swelling after the rhinoplasty. All areas undermined in the facelift and lower bleph seemed to stretch and the tissue has never returned to its previous integrity, as is apparent in the photos.
I have attached a series of photos to this message. I appreciate your taking the time to review my material and look forward to hearing from you.
Sincerely,
Lucille M. Iacovelli
(operative reports attached)
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Subj: Re: Potential revision surgery
Date: 04/22/2000 1:13:47 PM Eastern Daylight Time
From: zideb01@popmail.med.nyu.edu (Barry M. Zide M.D.)
I know both attending surgeons very well,so you must have been done as a
clinic patient at the hospital .In some of tour pictures your head is down
so it's hard to say what the problem really is .I might have done your nose
differently,but it's not bad.I guess I would have to see you. Have you lost
a lot of weight?
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Subj: Re: Potential revision surgery
Date: 04/24/2000
To: zideb01@popmail.med.nyu.edu
zideb01@popmail.med.nyu.edu writes:
> >you must have been done as a clinic patient<<
Yes, I was.
>>I might have done your nose differently,but it's not bad<<
I actually like the way my nose turned out, since I did not want it to look very different. However, I did not expect that cutting off my nose would spite my face in such an unattractive manner..
>>Have you lost a lot of weight?<<
No, I have gained almost 20 lbs over the past 2 years and weigh more than I ever have in my life at 135 lbs. My weight never fluctuated more than 5 lbs over the past 25 yrs.. I was 118 lbs at the time of my surgery.
Dr. Zide, I know you will have to examine me to properly evaluate the situation, but here's my take on what happened:
The facelift involved a sub cutaneous and extended sub SMAS dissection, executed by hydrodissection under high pressure. the newly forming adhesion of the facelift were "broken" or compromised from severe swelling after the nose job.
This tissue never returned to its previous state and I am now left with a loose "sack" of SMAS and skin which is no longer attached to the underlying muscles of expression. Thus, the distortion of my smile and other facial animation. Please note the platysma and parotid fascia has stretched and because it still maintains the firm quality characteristic of this tissue, with animation, it pulls downward rather than upward when I smile. I can "feel" the lack of attachment to the deeper muscles. Where the lower face would normally pull upward with smiling, it pulls downward or opposite than it did before the swelling of the rhinoplasty. It is difficult to describe or visualize without the benefit of examination.
Things like swallowing and chewing cause pain in the r. platysma area. Actually there is constant pain of some degree present in that area. I do not have any motor never damage. The drooping corners of the mouth are caused by a profound laxity of all the lower face due to the permanent stretching of this tissue.
Dr. Zide, it is my belief that two things caused this damage: 1.) the rhinoplasty was performed too soon after the facelift and 2.) the use of tumescent technique in the facelift causes changes in the mechanical properties of the skin and SMAS that does not occur with conventional dissection. Therefore, the insult of the subsequent nose job caused swelling that ay not have occurred with conventional dissection.
Unfortunately, I did not take pictures of my face during the period of severe swelling. My first instinct was to put a compression bandage under my chin and/or wrap my face in a similar manner as it was after the facelift. However, my surgeon emphatically told me NOT to do this! On the second day my neck was swelled out to the degree that it was wider than the rest of my face, with the weight of the edema pulling down the corners of my mouth and giving my head a triangular appearance, with my neck forming the base of the triangle. (No exaggeration!)
I do have sensory nerve damage and could probably sustain a dissection of my face without benefit of anesthesia. Once again, this is in all areas in which hydrodissection was used. They did not take any pre-op photos smiling, so I had to rely on snap shots for comparison. The earliest picture I have after the rhinoplasty in which there is still some residual swelling is 3 1/2 weeks later. I will send these to you, if you would like to see them.
I have yet to find a surgeon who uses this high pressure introduction of anesthetic solution to dissect tissue planes in facelifts. They all say it creates so much distortion as to make the rearrangement of tissue difficult to judge. When I explained my theory to the surgeons who operated on me they snickered and said it was impossible. A few surgeons whom I have consulted said they thought the of the distortion was due to inappropriate vectors of tension. I agree it gives that appearance, however, that is not the etiology of my condition.
There isn't much written about tumescent technique used in facelifts, and nothing about the physiological changes of the tissue. I was able to pull up one article about some cases of palperbal cutis laxa after rhinoplasty that was published in French. I am having it translated now, but think it probably will describe the hyperelastosis is due to swelling of the eye area with the tissue sustaining permanent stretching. Does this not make sense? Now, to carry logic one step further, doesn't it seem all the more probable for a facelift that has had only 8 weeks to heal would be susceptible to permanent stretching from the insult of another facial surgery?
I have given this much thought and research. I never received an explanation as to what happened or why. . I was repeatedly told I had a "better than average" result and my facelift would have healed like this with or without the rhinoplasty. In the same breath I was told I must have BDD to think I don't look better after the surgery than before. To this, I can comment that it does not take a rocket scientist or a plastic surgeon to see my face is sagging and stretched more AFTER these operations than before.
I would be interested in making an appointment to see you if you can maintain an open mind regarding my case and not discount my theory simply because you have never seen or heard of anything like this before. If things are as I believe, there will be limitations to be considered in a revision surgery and I would want us to be on the same wavelength as to what is wrong as how to correct it.
Thank you for taking the time to read this! I appreciate it more than I can say.
Best regards,
Lucille Iacovelli
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Date: 04/24/2000 12:06:26 PM Eastern Daylight Time
From: zideb01@popmail.med.nyu.edu (Barry Zide)
I don't buy all the theories .the only thing to do is go forward. Have you
seen Dr. Feldman. You should because he was the attending
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Subj: Re: Potential revision surgery
Date: 04/24/2000
zideb01@popmail.med.nyu.edu writes:
>>I don't buy all the theories<<
What would be your guess as to the laxity?
>>the only thing to do is go forward<<
I agree... however doesn't the nature of the problem influence the strategy for correction?
>>Have you seen Dr. Feldman. You should because he was the attending<
Yes, I have. He said he has nothing to offer.
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Subj: Re: Potential revision surgery
Date: 04/25/2000 12:06:26 PM Eastern Daylight Time
From: zideb01@popmail.med.nyu.edu (Barry Zide)
I haven't seen the problem yet
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Subj: Re: Potential revision surgery
Date: 05/04/2000
zideb01@popmail.med.nyu.edu writes:
>> I haven't seen the problem yet<<
I'm confused by this answer, Dr. Zide. Have you seen all the pictures posted in my hotmail account, or just the picture file I attached to my previous e-mail? The problem is most evident with animation, however it is very noticeable in all the post op pictures. (pictures attached)
I did go back to see Dr. Feldman through the resident's clinic. The first time they said I looked fine, even though I obviously did not. I also have persistent pain in the platysma on the right side. I wrote to Dr. Feldman and he responded by saying something may be possible to improve my appearance in repose, but I would never have my "old" smile back. I then made several attempts to meet with him and because this had to be handled through the resident's clinic, I was stonewalled at every attempt. When I called his office I was told he would not communicate with me except through the clinic, which was impossible. I told his secretary I was willing to pay his full consultation fee if he would see me as a private patient, but was told that once operated on in the clinic, he will not accept you as a private patient.
Quite frankly, I find the operation of the resident's clinic at Mass General to be lacking in organization. the left hand doesn't know what the right hand is doing and at this point, I don't want any of their hands touching my face again!
I was told that you were the best facial plastic surgeon in NY. I have read many of your papers and think you are brilliant. I respect the fact that you do not agree with my theories regarding the etiology of my poor results. I am convinced that my case is more complex than it appears and cannot be appreciated without the benefit of an examination. If you and I can come to some agreement that the laxity of the lower face is more pronounced than before the facelift, then I would like to make an appointment to see you.
Dr. Zide, I really appreciate your time and help more than I can say.
Sincerely,
Lucille Iacovell
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Subj: Re: Potential revision surgery
Date: 05/05/2000 9:25:11 AM Eastern Daylight Time
From: zideb01@popmail.med.nyu.edu (Barry Zide)
You definitely look different,and I don't know how to explain it
