Facial Plastic Surgeon Helps Repair Self-Esteem

As the dedicated facial plastic and reconstructive surgeon for Yale Medicine Otolaryngology, Yan Ho Lee, MD performs plastic surgeries on the head and neck area for people who have been disfigured by car accidents, dog bites and gunshot wounds. She reconstructs noses for people who were born with deviations (including those where the nose flops to one side), or who need reconstruction after losing bone or tissue in surgery for a skull-base tumor or skin cancer.  She even operates on boxers who have had traumatic hits to the face.

Dr. Lee continues to be amazed at the effect these surgeries to repair conditions and traumas can have on patients’ self-esteem. “Patients become much more confident once we repair these issues, and not just in the way they present themselves, but in their interactions with spouses, friends and families.”

We spoke to Dr. Lee about her work—and its potential for benefits beyond appearance.

I’ve always thought that people who have a setback, like an illness or injury, should still be able pursue their life dreams. In college, I majored in biomedical engineering, because I was good at problem-solving. But I realized I wouldn’t be able to work closely with the people I wanted to help, and I wasn’t seeing results firsthand. In medical school, I learned that facial plastic surgery was one way to help patients pursue and maybe even achieve their dreams.

Unlike general plastic surgery, facial plastic and reconstructive surgery is a subspecialty of otolaryngology-head and neck surgery. I focus on the body from the neck up—everything except the eyes and the brain. The head and neck region contains complicated structures, with spaces and substructures, some of which are critical for all of the senses. It makes this type of surgery part science and part art. We have to figure out how everything can be restored.

Sometimes, I’m just trying to close a small wound, and that may take half an hour. If an injury is more extensive, surgery can take between 3 and 12 hours—or multiple surgeries may be required to repair multiple defects. Unfortunately, some patients have disfiguring tumors or were in a terrible accident, and have many broken pieces of bone and soft tissue injuries. These are complicated 3-dimensional deformities.

In those cases, we use radiographic studies. We’ll order a CT scan, because that shows us the bony structure in three different views, which a computer can then use to create a 3-D image of the entire skull. (Sometimes, we use MRI scans to look at the soft tissue in further detail.)

CT images can be sent to a company that will make titanium plates or other synthetic implants that we’ll use for the reconstructive surgery. For example, if we need to restore the cheekbone and its underlying structures, and there isn’t enough remaining bone, we will ask the company to produce a custom piece that we then actually implant into the patient’s face.

The next step would be to print these molds ourselves. Sending the 3-D images to a company is expensive and can take weeks. If we had our own plates, we could use our molds to pre-bend the plates ourselves, and then sterilize and implant them. That might take less than a day. That’s what we are working toward.

That’s always at the back our patients’ minds. It’s at the back of my mind, too. Our number one priority is to restore function—to get them to the point where they can properly eat, swallow, talk and breathe through their nose and mouth. But it’s also important to restore their appearance. Patients will bring me old pictures, which is helpful because you get a sense of where they’re coming from.

Sometimes patients don’t want to see exactly what they looked like right after an accident. But I want them to have reasonable expectations—and to know that as a surgeon, I may not always be able to restore what they once had. But I can recreate the area that was damaged, and this can be very good. It’s helpful to show them what they looked like at different stages of their treatment. If they had surgery to remove a skin cancer and close the defect, for example, I will show them a picture of how big the defect was before I began the reconstruction. I will also show them pictures of how they’ve healed over time.

Wound healing is important. After surgery, even if the patient looks perfect on the operating table, problems can develop over time, and one of them is scarring. When we make an incision and rearrange the soft tissues, we rely on the circulation to oxygenate the tissues and stimulate healing. We know that diabetes impacts scarring, partly because high levels of glucose affect the nerves and circulation, making it hard for blood to reach the skin to help heal the wound. There are multiple studies that show smoking inhibits wound healing, too. If the blood supply is weak—as it can be in smokers—the incision can be slow to heal or not heal at all.

So, I recommend patients quit smoking as soon as possible—a month or more before surgery. If they are diabetic, I urge them to talk to their doctor about managing their glucose levels. Even the healthiest people should improve their nutrition. This is something we’re still studying, but we do know that good nutrition can help wounds heal. Of course, some surgeries must be scheduled quickly, so you do what you can.

Even if you do all of these things, we monitor surgical scars. If it doesn’t heal properly, we want to catch it early, so we can help it heal better. We might use topical or injectable medications or schedule a revision surgery. Every case is different. So, it’s a constant challenge for me to figure out what’s going on.

Sometimes. We do a lot of rhinoplasties, which are surgeries for nasal obstruction. We try to fix all the deviated parts so the patient can breathe better and as equally as possible from both nostrils. This can have aesthetic benefits. For someone with a narrow nose, it requires us to make the nose a little bit wider, which may be cosmetically pleasing.

Of course, we do a lot of cosmetic surgery. That includes eyelid surgery, facelifts and neck lifts. We use noninvasive techniques and treatments, such as fillers and neuromodulators, including a popular one under the brand name Botox®. (Neuromodulators are usually injected into the muscle; fillers can be injected anywhere beneath the skin.) In general, the goal is to restore fullness to the face, because the skin, soft tissue under the skin, and even bone can change at a certain age. We also use these strategies to reduce wrinkles. These treatments and procedures are important because they help with self-esteem and enhance daily life.

I had a patient who was in a car accident. His nose slammed on the steering wheel and completely flattened. The nose is made up of bone and cartilage, and when cartilage gets crushed or damaged, it can be difficult to reconstruct. First, I performed a closed nasal bone reduction to put the bones back into a normal position. Several months later, to give his nose a better shape, I performed another surgery, using cartilage from his ear. He was just out of college and starting his career, so he was very happy once his nose looked better and he was able to breathe properly.

When people have any disfiguring issue, they can become anxious or depressed, and often there is a period of grieving or adjustment. We know that when people are not suffering from these kinds of psychiatric issues—when they are motivated, and have family support and confidence—they recover faster from surgery. The most important thing is to remind the patients that I’m on their side. No matter what caused the deformity, I’m here to help them. I believe this kind of support goes a long way.