I'll avoid making this post too technical and boring. Simply speaking, piezosurgery is a technique which first came out of Europe (Italy), and utilizes ultrasonic energy to manipulate bones. The technique is completely atraumatic to soft tissue (skin, fat, muscle, cartilage), and will selectively manipulate only bone. Thus, piezosurgery techniques are directed toward the upper third of the nose, which is mostly bone (ie, humps, bumps, crookedness).
If I'm not using piezosurgical techniques, I'm using some combination of fine rasping, tiny chisseled osteotomes, and finely-burred drills to reshape and reposition the bones of the nose. These techniques offer great control, but they are mostly performed without looking at the bones directly (ie, the skin is overlying the bone). They are moderately traumatic to the bone or skin. By using ultrasonics (piezosurgery) to maniuplate bones, I am directly staring at my manipulation as it's being performed. Further, I have control to a level of fractions of a millimeter. Lastly, my patients experience minimal trauma at the skin level, and my post-operative swelling curves are drastically reduced. My need for post-operative nasal packing is practically none
Piezosurgical ultrasonic rhinoplasty also offers me options to reshape bones and sometimes avoid nasal fracturing altogether. When I do need to fracture the bones for distinct repositioning, I can do so leaving certain segments of the bone still attached for a very stable and precise modification. Alternatively, I can mobilize the entire segment of bone, but leave the internal lining intact (periosteum) so the bone will not collapse inward.
In summary, I love my piezosurgery techniques and feel very happy with my rhinoplasty results consequently. Bone manipulation is only a small segment of what ultimately gets performed during a typical rhinoplasty. Internal functional work, middle vault reconstruction for stability/symmetry/aesthetics, fine and nuanced tip work, and skin adjustments, all contribute to the aesthetically pleasing balanced nose. Rhinoplasty is a surgery designed to last a lifetime, and as with many things - every detail matters.
[This blog is also a part of Dr. Sparano's series "Rhinoplasty NJ".]

From series Hair Transplant NJ:
Many patients considering hair transplantation have concerns about the "size of surgery." While it still stands, the greater the number of follicular unit hair grafts placed, the greater the general visible result, it is not always the necessary route to success. Often there are cost considerations, continued hair loss considerations, compliance with hair-preserving medication considerations, and time-to-placement considerations (which will be explained below).
The nature of hair transplantation has changed since the time I began training over 12 years ago. Because we were primarily performing strip surgery (i.e., harvesting hair grafts from a linear strip excision at the back of the scalp), we were trading any given result for a long linear scar. While great attempts are made to minimize the visibility of any associated scar, to completely avoid scar in the region is impossible. Thus we were trading a result for a scar, and wanted to maximize the said result usually with larger surgeries consequently.
Currently I use a robotic hair transplatation technique called robotic FUE or rFUE (ARTAS). With this technique I completely avoid the introduction of a linear scar at the back of the scalp. While the technique does necessitate shaving the back of the scalp to short 1.2 - 1.4mm length hairs, there are no other visible sequelae to the technique once the hair grows over the harvest region 10 days later. As a result, smaller surgeries have become more acceptable and even commonplace.
There are times when a patient is not wishing to afford the expense for a large 2,800 - 3,200 graft case. Instead, we sometimes agree to perform a smaller surgery of 1,400 - 1,600 follicular units, focusing on building a healthy and natural frontal and mid-scalp frame to the face. We leave open the option of a secondary procedure at any point in the near or distant future, dedicated to the crown perhaps, also of a smaller or intermediate nature. Because we are not introducing a long, linear scar each time, this is a perfectly acceptable pathway assuming the patient is a surgical candidate with an available donor supply. A good example of this is demonstrated in the picture above. This person had a 1,400 graft robotic hair transplantation focusing on the frontal "frame" and midscalp. We decided to leave his crown alone for a potential future date. This kept the hair tranplant cost down, the day of surgery short and simple, and I would argue optimized success for this patient.
Surgeons who are regularly performing >3,000 follicular unit FUE cases sometimes neglect to speak about growth yield. In my practice we are very conscious of growth yield (i.e., the amount of hair growth by 12-14 months post-surgery, given our pre- and intra-operative photographs and operative reports). I personally believe there are certain factors which start to compromise hair graft survival once the transplant exceeds a certain threshold. This threshold is different between patients because of variables which affect the time-out-of-scalp duration for harvested hair grafts. For certain patients the harvest may take longer due to certain scalp laxity or skin rigidity variables. Also for certain patients, it is more difficult to place grafts WHILE we are still harvesting in other areas, because of inherent limitations in positioning considering where the grafts are meant to go. While we optimize our hair interposition storage and chilling techniques, we focus on careful consideration of every variable to maximize growth success.
The cost of hair transplantation should not be overlooked as a relevant item herein. Many patients lose their hair in their mid-20s through mid-30s. Often, this is not an age demographic with adequate disposable income for a large surgery. While we can certainly offer a large surgery, and propose realistic associated discounts, there is nothing wrong with performing an intermediate-sized surgery to create a natural and pleasant result, with the option of secondary or tertiary surgery in later years.
The overall point here, is really to say robotic hair transplantation with robotic FUE has opened the door to smaller and intermediate procedures as perfectly viable options for certain individuals. We of course would never suggest a surgery too limited in size to create a clear visible enhancement. We have learned however, great growth yields translate to happy patients with small-, intermediate-, or large-sized hair transplantation, so long as the goals of surgery are clearly defined and make sense.

An insert into Dr. Sparano's Rhinoplasty NJ series:
When it comes to fixing the crooked nose, there are various tricks a facial plastic surgeon can employ. The nature of this discussion can indeed be detailed and extensive, but I'll try to keep things simple. There is no doubt that crooked nose "deformity" is one of the more difficult aspects of rhinoplasty. Patients seeking repair of this issue, should definitely research their surgeon and ideally work with someone very steeped in rhinoplasty experience, especially with challenging and revision (secondary) noses. I am a facial plastic surgeon with a dedicated niche subspecialty interest in rhinoplasty. It is a true clinical passion of mine!
Mildly crooked noses can often be fixed by commonplace rhinoplasty techniques, including that of a skillful septoplasty (i.e., straightening the midline internal structure of the nose known as the septum). These techniques include careful tip reshaping with PERFECT symmetry and balance of forces; careful midvault restabilization; and CONTROLLED osteotomies (repositioning) of the bones.
Moderately crooked noses often require additional, specialized grafting at the middle segment of the nose, with use of autologous grafts called "spreader grafts." These can be carefully designed to manipulate the middle and lower segments of the nose to create a midline appearance. They are sometimes purposefully asymmetrically placed to create a symmetric appearance. Designing and securing these is an intricate skill which requires experience, or else the nose will take on a wider appearance. At times the full grafts aren't necessary and I use a technique called "spreader flaps." At other times I use spreader grafts with an overlay of upper lateral cartilages to accomplish the desired effect without a "ridgy" appearance.
Severely crooked noses require an array of techniques, each carefully performed with accuracy and intricacy, so that no tensile forces are left unto the nose potentially creating postoperative drift. I am a big believer in getting the front-most aspect of the septum fixed to the midline nasal spine, but in a way where it's attached to bone (and thus stable), and not fibrous tissue (and potentially unstable). With the most severe of circumstances, I utilize a technique known as extracorporeal septoplasty. This is a very complex procedure in rhinoplasty of the crooked nose, but a very powerful one. During it, I remove the entire septum as a single unit of cartilage attached to bone. This allows me to study the complex, 3-D defortmity of the structure and to manipulate it with control. I will often drill down and/or remove certain culprit segments, always preserving as much as I can. I can attach my desired spreader grafts directly to the newly designed STRAIGHT septum with perfect control. Then I replace the entire structure to refortify the nose. The nose becomes rebuilt around this strong midline structure. This is a longer and more complicated operation, but indeed a helpful one for the correct indications.

CoolSculpting NJ. Many patients ask, "Does CoolSculpting work?" "Is CoolSculpting right for me?" These are fair questions. In this blog we'll cover a few areas of relevance: candidacy for CoolSculpting; efficacy of CoolSculpting; cost of CoolSculpting; how we do CoolSculpting.
Regarding candidacy, CoolSculpting is a a very effective way of treating softer, "pinchable" fat. Thick-walled fat, with extensive fibrous nature, tends not to fare so well with CoolSculpting. Assessing appropriate fat for treatment is something Dr. Sparano performs at consultation.
Regarding efficacy, we typically see results very colinear with published reports on Coolsculpting. That is, in a treated zone, patients can expect to see about a 21 - 25% fat reduction. Given the ease of treatment, the lack of associated downtime, and the relatively affordable expense, we feel quite content with this level of fat reduction for a given treatment. We call CoolSculpting an "additive procedure." By this we mean it is not a treatment which needs to be repeated multiply for a result. Instead, with each treatment a patient experiences the result, and then if an additional fat reduction is preferred, one can elect to do additional treatments after an adequate duration of time (we recommend waiting at least 4 months following initial treatment).
Regarding cost of CoolScultping, our practice has prided itself on offering CoolSculpting at the lowest allowable marketed price. This is because it is not a surgical procedure performed by Dr. Sparano. Instead it is a simple technologic procedure we want to encourage eligible patients to consider. Call us for our everyday low pricing!
We perform CoolSculpting after conducting a consultation assessing candidacy. We do not wish for patients to elect for treatment if an unlikely response is anticipated. We have great success with our CoolSculpting results. On the day of treatment, Dr. Sparano marks all patients and generally applies the device. We believe this optimizes potential for treatment success. Treatments are performed in a private room, on a comfortable spa bed, and with a television available, movies available, and a secure internet access line for work or simple online engagement. After treatment, patients are free to do what they wish, as there is no true "downtime" after CoolSculpting. The first week usually involves some swelling. We typically see onset of contraction (ie, the tissue getting "skinnier" or reducing in size) beginning 3 weeks after treatment, and progressing through 6-months after treatment.
Call us to schedule your complimentary CoolSculpting consultation.

Healthy Skin NJ

This post is meant to focus on a single component of skin transformation - skin stabilization. Dr. Sparano and the very talented, well-read, and researched skin care specialists at Skin Sense Spa (the division of Dr. Sparano's practice exclusively focused on skin health and beauty), conduct their practice by way of a multi-component skin transformation pathway. One vital component - that of STABILIZATION - is a necessary one for healthy and beautiful skin. A very simple truth - healthy skin is beautiful skin - centers on this very principle.
Skin stabilization involves the correction of aberrant cellular processes, and resumption of regulated, controlled, healthy function on a cellular level throughout both the epidermis AND dermis. Through the careful delivery of stimulation agents, DNA repair agents, and anti-oxidants, inflammatory processes of the skin can be calmed, with subsequent cellular transformation.
At Skin Sense Spa, we believe we have a very invested staff, who've committed hundreds of hours of study, research, careful commitment to outcomes, and honest, careful reflection on results. Two of our specialists - Sue Liedel and Natalia Starosolsky - are especially impressive, with an unyielding interest in their patients' skin health and beauty. We believe they're of the best aetheticians in New Jersey!
Through a calculated and customized approach to each respective patient, stabilized skin shows the following changes:
- Damaged cells are shed and replaced by healthier cells.
- The epidermis thickens.
- Dermis has greater turgidity.
- Skin barrier function improves.
- Keratin production increases.
- Pores unclog.
- Inflammatory conditions improve (eg, acne, rosacea, folliculitis).
- Melanocytes become less likely to become hyperresponsive to sun exposure and other irritants.
- Skin becomes better prepared for subsequent steps focused on complete skin transformation.
Our practice offers complimentary consultation for an engagement offering something much more than the typical NJ medical spa. We aim to educate on healthy skin, and offer services which can treat the gamut of skin appearance, always creating improvement through health. We suggest our patients not waste money or time on non-medicinal components of skin care, or on haphazard delivery of care. Like many other things, skin health is a blend of art and science. Come meet us and let's get started!

Kybella NJ

Kybella does work... ...if you're a candidate! There are various ways to treat the neck. Each respective treatment targets different aspects of the aging neck anatomy. Kybella specifically targets fat under the chin. We have great success treating this area with Kybella in our practice. We believe there is a skill to its delivery - both in terms of amount of product used, its spatial delivery, and angle of threading of product to manipulate delivery around the muscle bands which can obstruct its efficacy. Most patients require 2-3 injection sessions, and a minority requires 4. In our practice, we offer a guarantee, of sorts, to our patients. Because each patient is assessed by Dr. Sparano before treatment, all patients receiving Kybella have been approved for candidacy. If after 2 treatments patients do not feel they have noticed a response, we offer submental liposuction at the same price as a third Kybella injection. At the time of this writing, now at least 1.5 years into use of Kybella, we are proud to say we have not elected to transition anyone to liposuction for inadequate response. Dr. Sparano is a facial plastic surgeon offering Kybella in NJ, at great prices, and with great efficacy. Consultations are complimentary. 

I recently read an article about Nina Vaca, a middle child of 5 by 2 immigrant parents from Ecuador, who embraced entrepreneurial endeavors to turn her family’s travel agency business into a $200 million staffing company – Pinnacle Technical Resources.

Vaca’s “perseverance, work ethic, family, and faith,” served as the backbone for her eventual success. But her true grit stemmed from dealings with her father’s murder when she was 17-years-old, leaving the family in fiscal distress. Vaca grew up fast and worked tirelessly to sustain the family business after high school, deferring on college by necessity at the time.

Vaca noted how after founding her company in 1996, the financial crisis of 2001 devastated her business. Her response, “In the darkest moment, you find your greatest strength. Failure has never been an option.” Considering her adolescence and young adult years, it is not surprising she at that time bought out her partner and aggressively diversified her client portfolio.

Her company grew steadily and successfully, despite the offsetting economy. It grew, she claims, from nothing short of “tears, sweat, and building,” and because she was able to get people to “believe in” her. This, to me, is the most important segment of the article. When asked how she thinks of leadership, and what advice she could offer others herein, her response: “The number one thing is to have credibility. Have you ever followed anyone that you don’t trust? 3.3 seconds and they know who you are. You must be credible. Do what you say and say what you do.”

This is something I’ve thought much about. The presence or absence of CREDIBILITY, is something that works itself into my life so frequently, and forms the focal point for many decisions I make on a weekly basis. Yet, it is so infrequently discussed or overtly noticed. I can recall 10 important decisions I’ve made over the prior 60 days that have been based exclusively on my (sometimes preconscious) measure of another person’s credibility. Yet, what exactly is it?

An established sense of credibility I believe is something which becomes earned across time and experience, but equally, is a reflection of one’s nature and general predisposition. Professionally, one cannot become credible without committing to and achieving a certain expertise. Presenting the intricacies of that expertise to non-experts, can be the grey area which separates those whom seem credible from those who do not. The capacity to bridge the gaps affording credibility, usually has to do with the life experiences that have shaped one’s nature, one’s level of insight, and often how one “was raised.”

The article on Vaca concluded with her saying, “It is not enough to want something in life. It is important to prepare yourself. You need to prepare yourself to receive.” That is definitely true. But ultimate success across many aspects of life requires even more. Usually, CREDIBILITY is too a necessary ingredient. Its own recipe is complex, but has as much to do with the rollercoaster ride of life, as with the focused dedication to the mastery of a trade.

I would never want to sound like a “blowhard,” but I write this mostly to answer a recurrent question from many patients. My practice offers unique and interesting, but divergent areas of surgical subspecialty. I am often asked how I ended up where I am, and doing exactly the kind of work I do. I always answer the same way, although a bit abbreviated from what I’m about to write, I’m certain. In answering, however, it has become clear that hearing this from a patient’s perspective is helpfully revealing of the mindset, approach, and even personality-type of the surgeon they’re amidst building a relationship with.

I established an interest in medicine early during my intermediate school years. By medical school, I knew I wanted to pursue surgical medicine. My first 8 weeks of medical school was spent exclusively committed to Gross Anatomy. The anatomic intricacies of the head and neck region seemed extremely more interesting than that of any other anatomic region of the body. I knew then I wanted to focus on head and neck surgical medicine. The subspecialty field of Otolaryngology – Head and Neck Surgery was inviting in this regard. Various research and extracurricular endeavors during medical school helped confirm this as the correct discipline for me.

I subsequently secured an Internship and Residency position in what I believed at the time to be the best Head and Neck surgical training program in the country. That was at the University of Pennsylvania in Philadelphia. I cannot overstate the respect I have for my mentors there, and my privileged training experience. The surgical volume of advanced disease and therapy was outstanding, and the standard of excellence expected and maintained was equally impressive.

During residency, I found myself attracted to distinct anatomic surgery, and to cancer surgery. By “anatomic surgery,” I specifically mean surgery focused on reshaping with exact attention to detail, distinct anatomic structures for the sake of doing so purely (eg, rhinoplasty), or for the sake of functional improvement (eg, temporal bone surgery). My residency experience, however, offered such an advanced and unrivaled training experience with endoscopic sinonasal techniques, I knew I would not abandon my newfound knowledge and skillset. (Nor did I want to; I really loved complex sinus surgery and brain tumor work through the nose.)

Near completion of residency, I decided to advance my training further, and found a perfect Fellowship program that would allow me to hybridize my interests. In fact, there was no other program exactly like it in the country. I placed all of my “eggs in one basket” and applied only to this program. I was fortunate enough to secure the spot in what would pave the way for a double board certification.

My Fellowship was an accredited one by the Amercian Academy of Facial Plastic and Reconstructive surgery. It was at the University of Michigan, which at the time was also a top-5 program in the country. My mentors there were Drs. Lawrence Marentette and Shan Baker. My experience with Dr. Marentette was a special one. Dr. Marentette had one of the busiest skull base tumor practices in the world, and he was adept in the minimally invasive open approaches to this extremely complex disease entity. Skull base tumors are by nature some of the most difficult tumors to operate on because of their location along the frontal part of the brain, around the eyes, between the eyes in the nose, or at the very center of the skull itself. This experience satisfied my interest in performing advanced cancer surgery, and allowed me to blend in my advanced endoscopic techniques learned at PENN for a comprehensive surgical armamentarium. I also directed a large portion of the facial trauma program while with Dr. Marentette.

My time with Dr. Shan Baker was spent mostly learning the intricacies of facelift/necklift surgery, rhinoplasty, eyelid surgery, facial implants, fat transfer, and other surgical and non-surgical enhancement techniques of the face and neck. Dr. Baker and the University of Michigan also afforded a very rich and advanced experience with Mohs skin cancer reconstructive surgery. Dr. Baker, and his textbooks, are internationally renown for the arts of Mohs reconstructive surgery, nasal reconstruction, and deep plane facelift surgery. Skin cancer reconstruction was always an interest of mine. However it was not until right in the middle of my Fellowship, that I realized it was a true clinical passion.

After completing Fellowship training and completing both sets of Boards examinations, I was ready to start practicing. For me, this was a harder decision than deciding what to practice. I thought about returning to academic medicine at PENN, Michigan, or in New York City. The shortest version of a very long story is that I found a supportive university setting hospital at the Jersey Shore University Medical Center that would allow me to continue to do my cancer surgery, my skull base tumor surgery, and my advanced sinonasal surgery. Otherwise, I wanted to commit myself to my clinical passions inherent to facial plastic and reconstructive surgery.

Overall, I am lucky. I have started a practice which allows me to focus on isolated areas of anatomic challenge and disease burden. I love the idea of doing 15 things as good or better than almost everyone, and never doing 16. My training was a special one, which I worked hard to earn, but appreciate. It lives with me every day, and forms the foundation for which I mature and improve as a specialized surgeon targeting excellence in outcomes. Simply speaking, my goals are to be nothing short of the best possible rhinoplasty surgeon; facelift surgeon; necklift surgeon; skin cancer reconstructive surgeon; sinonasal surgeon; eyelid surgeon, etc. I pay very much attention to behaving as a conscientious doctor, and as a friend to my patients.

By now, many have read, seen, or heard of Malcolm Gladwell’s book Outliers: The Story of Success. In the book, Gladwell demonstrates how innate talent, and even genius, are not the necessary roots of success. Instead, success is often a derivative of a series of circumstantial subtleties that together can shape good fortune.

For example, the book begins with Gladwell demonstrating how most of the elite and accomplished Canadian hockey players are born in the first few months of the calendar year. The youth hockey leagues determine player eligibility by standard calendar year cut-offs. At a young age, children born earlier in the year on average tend to be bigger, more developed, and better coordinated than children born later in the year by laws consistent with natural development. Consequently, at a very young age these children are identified as better athletes, and are thus coached better and selected for preferred positions, teams, and leagues, etc. Gladwell calls this phenomenon “accumulative advantage.” In this case, Gladwell is demonstrating how success was as much dependant on the organization of the selection process to identify talent, than on the athletes’ natural talent itself.

Among the many interesting sociologic phenomena identified in the book, is a recurring theme Gladwell calls the “10,000-Hour Rule.” Gladwell cites many examples to support his claim that greatness requires an enormous time commitment. He talks about how the Beatles, by quirky circumstance, performed live in Germany over 1,200 times from 1960 to 1964, amassing more than 10,000 hours of playing time there. This time shaped their talent into a sound that was like none other by the time they returned to England.  Similarly, Bill Gates benefitted from the 10,000-Hour Rule after gaining access to a high school computer in 1968 at the age of 13, and spending 10,000 hours programming on it. The idiosyncratic circumstances that allowed for this, were in large part responsible for the birth of his future success. In the book, Gladwell notes his interview with Gates, who basically agrees that without that unique access to a computer at a time when they were not commonplace, his magnanimous success would have been less likely.

I personally believe in the validity of the 10,000-Hour Rule, and to an extent, even quantifiably. That is, reaching 10,000 hours committed to a specific task or skill is a key to excellence. This in many ways has shaped my professional career, and has structured my solid belief in core competency. I prefer to focus on 10-20 clinical, medicinal, anatomic challenges with a commitment to something approaching mastery. In addition to reading, and lecturing, listening, and studying, and critical self-examination of outcomes and results, comes the direct need to put in time, and more time – 10,000-hours worth. This is one of the reasons I truly believe a facial plastic and reconstructive surgeon is often best equipped to precisely control and predict the anatomic challenges of facial cosmetic or reconstructive surgery. A focus on the face alone “shrinks the world” tremendously, and combined with a diligent and rigorous work ethic, true excellence can be achieved.

The real challenge, of course, is meeting the 10,000-Hour Rule professionally, while at the same time  being a great dad, husband, son, friend, and guitar player.

Have you noticed how certain stars have seemingly flawless skin and very high-arched brows? Cindy Crawford and Halle Berry are notable examples. The question is always asked, is that the gift of pleasant genetics alone, or is there some help from Botox? (Although Cindy Crawford has admitted to the benefits of Botox enhancement.)

Many people know Botox can do wonders for facial wrinkling. The precise effect Botox can have on the brows is less understood. It used to be the case that any conversation of Botox with regard to brow consideration, centered on the fear of “brow droop.” This is no longer a great concern. Instead, precise brow positioning, degrees and location of peak brow elevation, and amount of associated lateral brow forehead movement without the dreaded “spocking” sign, are topics of pre-Botox conversation.

The anatomic region of the lateral brow has a few different muscular complexes working on it. Thus, careful injection manipulation of each respectively can create sometimes subtle, and sometimes significant brow architectural changes. This is part of the art and fun in Botox sculpting.

A nicely elevated lateral brow with a soft peak can form a nice feminine frame for the underlying eyes. The eyes can be made to appear more bright and youthful.

As with all aspects of elective facial surgery and enhancement, the key is in the the communication with your surgeon!