Face Reconstruction Without a Transplant: Prof. Dr. Suleyman Tas on the Microdissected Prefabricated Flap

1) You are a doctor whose education has been filled with major achievements, who has performed many operations both abroad and in Turkey, and who has pioneered several firsts with the new methods you use. What drew you to this profession, and what were the reasons that guided you toward it?

I've always had a nature that tries to do the best it can. That's why my years of education and work have always been filled with achievements and top placements. At the same time, my imagination was the most important factor that pushed me forward, challenged me, and helped me develop myself. Perfection and beauty were always a philosophy that caught my attention, and through this my interest in art began at a young age with the charcoal drawings I used to make. Because of my interest in mathematics and science, solving problems and making flawless analyses always excited me. This aptitude earned me third place in Turkey at the Tubitak Olympiad during high school. But because the feeling of helping people made me incredibly happy, I wanted to go to medical school and become a doctor, so I enrolled at Istanbul University Faculty of Medicine. The plastic surgery operations I witnessed in my fourth year of medical school affected me deeply - I realized that these demanding operations, which touch people's lives and souls and require aesthetic perception and skill, had to be my profession, and I chose plastic surgery as my specialty.

2) What do you see as the main source of your success?

I would say it's my imagination, the patience to follow through on the roadmap I set out for realizing my dreams without ever giving up, aesthetic perception, the ability to help people and empathize with them, and manual dexterity. By imagination, I mean the pleasure I get from always thinking ten moves ahead, like in chess. This allowed my personal development to happen much faster than expected - faster than I myself expected.

3) What is your philosophy in aesthetic operations?

It's the same core philosophy that underlies medicine itself: "primum non nocere" - first, do no harm. Whatever I do, I constantly ask myself how I can perform this operation without harming any tissue, even at the cellular level. My ability to make these operations better every day comes from this philosophy of being "atraumatic." "Atraumatic" is a Latin-rooted word meaning not traumatic, not harmful. When you perform an operation this way, it genuinely stops being just an operation - it turns, in an instant, into a work of art of the highest order, becoming more vivid, meaningful and almost spiritual than ever before. You know how people say something is "like poetry"... That's exactly my philosophy: making the operation, in every sense, like poetry.

4) What is plastic and reconstructive surgery, and which operations does it cover?

"Plastic" comes from the Latin for "to give shape," "reconstructive" means "to repair again," and "aesthetic" means "to aim for what is beautiful." So in a sense, every type of operation falls within the domain of plastic surgery in one way or another, but we can describe the operations we as plastic surgeons specialize in as reconstructing any kind of tissue defect and performing aesthetic surgical procedures. We cover a wide range spanning all age groups, from congenital conditions such as cleft lip and palate to facelift surgery.

5) There are situations in which aesthetic operations are needed for health reasons rather than simply for a youthful appearance. Beyond people who need nasal surgery for health reasons, for example, it's said that breast reduction surgery can help prevent breast cancer and is also important for posture-related issues. What are your thoughts on this? Which operations can provide health benefits for a person?

Of course, aesthetic surgical operations also have secondary benefits. These range from the person finding the operated organ more beautiful and no longer having it interfere with their life by reaching the size they desired, to making peace with that organ - even, in a psychological sense, no longer "allowing" cancer to develop there. In breast reduction operations, because the tail of the breast - the region where cancer develops most often - is removed, we also reduce the person's risk of developing cancer.

6) What are the aesthetic operations you perform most often and that are most preferred?

In Turkey, the most commonly performed aesthetic surgical operations, in order, are: rhinoplasty, breast implants, liposuction (fat removal), hair transplantation, fat injection, eyelid surgery, facelift, and prominent ear surgery. We perform all of these operations.

7) Do aesthetic operations carry complications or risks?

Like any operation, aesthetic surgical procedures carry risks, and complications can develop. What matters most is setting and managing expectations correctly.

8) Can a person undergo more than one aesthetic operation at the same time?

Of course - we call these combined surgeries - but everything has a limit. Our bodies have a certain wound-healing capacity, and if procedures are performed beyond that capacity, healing takes much longer; your capacity is directly related to your age and health. For that reason, in my clinical practice, I don't combine more than 2-3 operations at a time.

9) Using the "Microdissected Prefabricated Flap" technique - which entered the medical literature and was applied for the first time by you, and which involves creating transferable tissue through advanced microsurgery - you performed a face reconstruction on a patient whose face and neck had been extensively burned. Could you tell us a bit about this method?

This was my dream, and having made it a reality makes me very happy. In a patient who had already undergone 12 operations and had no option left besides a face transplant, this is a technique that shows it's possible to create a face from the patient's own body that is even more advantageous and beautiful than a transplanted one. You have to sit down and dream up something like this. Isn't that how science itself - not just medicine - advances? We exist only as far as we're able to push the boundaries. I can actually explain the technique I developed like this: imagine a tree, with roots, a trunk, branches and a flower. You want to move the flower from the right branch to the left branch. If you simply pluck the flower and glue it onto the other branch, the flower dies. But if you can trace the vessel that feeds the flower all the way down to the root of the tree and isolate it, then you can place that flower wherever you want. What I did was find that vessel and identify exactly what it feeds. In this way, I created a transferable "flower" that could be moved onto a withering branch that had none.

10) Where did the idea for developing this new method come from?

Face transplantation is a wonderful achievement in terms of how far science has come, but if you examine it as someone who understands its technical details, it's a technique with enormous drawbacks. Someone else's skin is transferred to you, but skin doesn't behave like other transplanted organs - it's the most antigenic organ, meaning the one where rejection is seen most. To prevent this, the body's immune system is suppressed with many drugs, which in turn causes infections, requiring many antibiotic and antifungal treatments. In the long term, this can lead to organ failure, and in the short term it can cause the patient to be lost to severe infections. But beyond that, a patient who needs a face transplant really only needs a skin graft - yet due to technical limitations, the facial muscles and nerves are transplanted along with it. That means the muscles and nerves in your face are removed and replaced with someone else's. Once nerve transfer is involved, the absence of the face's minute movements produces a "mask face" appearance; and if rejection occurs, because the transplanted face extends down to the bone, wounds can form that expose the bone directly. So in my view, rather than such a risky operation, it makes more sense for the patient to wear a silicone face. These drawbacks always made me think there had to be another way.

11) Can we say that this method will become a new alternative to face transplantation?

Absolutely. Our own tissues are the most natural and beautiful source for a new face, and the method I developed for transferring and creating them serves this purpose in the best possible way.

12) What are the benefits of this new technique you apply in face reconstruction? 13) With this method, is there any risk of rejection in the transfers?

First of all, because the patient's own tissues are transferred, rejection isn't an issue at all, so there's no need for all the medication given to suppress the immune system or prevent infection. Because it only involves a skin graft, it doesn't disturb the healthy muscles and nerves, so there's no mask-face appearance either. Since it requires no donor, there's no need to wait for years - the face is formed on the patient's own body within about 1-2 months. So it eliminates every drawback of face transplantation. The only disadvantage of the technique I developed, I would say, is that it's painstaking and requires advanced microsurgery, because every vessel within the tissue bundle has to be carefully isolated one by one, the organ it feeds identified, and the direction of the vessels changed - it's a bit like looking for a needle in a haystack, but it isn't difficult for an experienced surgeon.

14) Could this method be developed further in the future and become a ray of hope for treating other conditions?

Of course. For single-piece, large-volume skin grafts, this method is currently the only solution. It's the only method that lets you decide the size and thinness of the flap, as well as the number and length of the vessels it contains. For this reason, I believe that in the future, face reconstructions will be performed using this method alone.

15) Rhinoplasty is at the top of the list of the most frequently performed aesthetic operations, and new methods are being developed for it all the time. Could you tell us about the "Closed and Atraumatic Technique" you apply in rhinoplasty?

My experience in microsurgery taught me a great deal - you realize that something you see as a single substance, molecule, atom or electron actually has its own world inside it, and that there's a great deal you can do without disrupting how that world functions. In essence, that's about figuring out how to operate without hurting so much as an ant. My word for this philosophy is "atraumatic." "Atraumatic" is Latin-rooted for "without causing trauma" - done without hurting anyone. That's why I perform closed rhinoplasty: when I open the nose, things happen that I can never undo, such as scarring at the tip of the nose or the cutting of the vessels, nerves and lymphatic bundle at the nasal tip. So for an operation to be performed under the atraumatic philosophy, it first needs to be done with a closed technique - though that doesn't mean every closed technique is automatically atraumatic. The philosophy doesn't end with the incision; we continue applying it throughout the rest of the operation, preserving all the structures of the nose and reaching the targeted shape without disrupting their primary structures or their relationship to one another. When done this way, the nose looks as if it was never touched at all, as if it had always looked that way - and I think that's extremely important. The reason people have recently started noticing an obviously "done" look is that an operation not performed under this philosophy leaves the nose looking caught in between - and that in-between look is what other people notice.

16) What new applications and improvements might the future hold for rhinoplasty?

Progress happens every day, and there's no end to it. We're the ones driving it, and my dream is that one day, forget about the operation itself - we'll even be able to see, while a child is still in the womb, how their future nose will develop, its psychology and its direction, and perhaps we'll be able to address these things at the genetic level.

17) Is psychological support needed before rhinoplasty?

Even something like exam stress can keep many young people from performing as well as they could, sometimes forcing them to spend another year preparing for the exam. In the same way, if you're not psychologically ready before an operation - if you're going through a period of high anxiety or depression - your body may not respond properly to wound healing afterward, and problems can follow one after another. That's why we have a psychologist at our clinic, so we can prepare our patients psychologically and provide the necessary support after surgery as well. With this feature, we are the only clinic in Turkey to offer it.

18) People considering rhinoplasty can feel some anxiety about the recovery period. What can you tell us about this?

That's completely natural - it's a process they haven't known or experienced before. As a professional team that lives through this process every single day, I should say that once every step of this story has been laid out and explained to them clearly, they'll be freed from this anxiety.

19) What should patients pay attention to after rhinoplasty?

Recommendations vary depending on the procedure performed. In general, though, we ask patients to avoid wearing glasses, taking any impact to the nose, or sleeping face-down for about 2 months. Strenuous sports should be restricted for the first 4-5 weeks. Patients can generally return to their daily personal and work life once the splint is removed - that is, on the 7th day after surgery.

20) What method do you use for a nasal hump?

We take a completely patient-specific approach. Depending on the case, we may reshape the hump without removing it, rasp it down, hide it internally, or remove it entirely. When we do remove it, we use what we call micromotor instruments to do so with precision.

21) What is a non-surgical nose job or nose filler procedure? How does it differ from other operations?

Nose filler is not a surgical operation. What we call hyaluronic acid is a gel that is also normally found between the cells in our own bodies. This substance is produced in a laboratory and injected into the area of the nose where volume needs to be added, giving it a more attractive appearance. It's generally preferred for cases requiring only minor touch-ups, or as an alternative to a risky operation such as revision rhinoplasty when an improvement can instead be achieved with filler - it's applied as an injection after the injection site has been numbed. It's temporary, of course, but there are types that dissolve over periods ranging from 6 months to 4 years, so a more attractive appearance can be achieved with just a small injection.

22) What can be achieved with nose filler?

Irregularities or depressions on the nose can be camouflaged, crookedness can be camouflaged, and fullness and lift can be given to the tip of the nose.

23) Can nose filler be applied to noses that have already been operated on?

Of course - if another operation is considered risky, the desired aesthetic result can be achieved by turning to filler instead.

24) What other filler procedures are performed alongside nose filler?

Of course, filler isn't a procedure limited to the nose - it can also be injected into other hollow or sunken areas of the face to restore fullness and a more youthful look. These include facial wrinkles, hollow cheeks, and under-eye hollows. It can also be injected into the lips to achieve fuller lips, or into the chin to improve the facial profile in people with a recessed chin.

25) What differences are taken into account when performing rhinoplasty on women versus men?

It's absolutely different - the whole spirit of the work is different, from start to finish! When shaping a woman's nose, the angles and techniques used aim for a feminine look, whereas in a man, the angles and techniques used aim for a masculine look. So rhinoplasty for women and for men is a completely different undertaking. In a man, the nose is a symbol of good looks and strength, while in a woman it's a symbol of beauty and elegance.

26) Do seasonal conditions matter for recovery time in facial aesthetic procedures? Which season is most suitable?

In the past, when bleeding control couldn't be managed as well as it can today, it was considered appropriate to perform operations in winter in order to avoid the heat. But nowadays, there's no more "winter or summer" to this - if anything, colds and flu tend to come up more often in winter, and that leads to postponed operations. In short, there's no longer a best season for this; it's most appropriate whenever the patient is healthy and can set aside one week for us, both physically and psychologically.

27) Could you tell us about the "Antihelixplasty Technique" (Proximally Based Dermo-Fascioperichondrial Flap) that you developed yourself for prominent ear surgery?

After seeing the complications that occurred with existing techniques in prominent-ear patients - sutures opening, sutures coming loose, infection, sensitivity in the ear, shape irregularities in the ear - I developed this flap technique to eliminate these problems, and thanks to this technique, we no longer encounter the issues I just mentioned. In this technique, the ear isn't pulled back with stitches. Instead, the tissues behind the ear are used to lay the ear back, so the ear is repositioned through entirely natural means. I have been using this technique since 2009. In 2012, we won an award for this technique in a competition organized by the Turkish Society of Plastic Surgery, and in 2013 it was published as a scientific article in one of America's most prestigious plastic surgery journals. I also plan to write a book on this subject in the near future.

28) In our society, prominent ears are often a source of teasing, especially for children of school age. At what age should prominent ear surgery be performed on children?

In my view, prominent ears are a serious social problem - they can become the source of self-confidence issues that begin in childhood and grow with the person for the rest of their life. It makes a great deal of sense to have the operation before these issues even arise. That's why we recommend performing this operation before children even start school, at around 5-6 years of age. That said, there's no age limit for this procedure - it can be performed at any age.

29) For people who have already had prominent ear surgery but whose ears have opened up again, is another procedure possible?

Patients who have previously been operated on with other techniques and whose ears have opened up again also come to me frequently. In these patients too, we use the flap technique, as it's the most reliable method, and we achieve successful results.

30) Today we see that men are turning to aesthetic surgery just as much as women. Which aesthetic surgical operations are performed most often on men?

Of course, there's no such thing as this being a "women's thing" or a "men's thing." Apart from functional operations, everyone undergoes these operations from a cosmetic standpoint to feel better about themselves, so men have just as much right to them as women do. For men too, rhinoplasty comes first, followed in order by hair transplantation, prominent ear surgery, gynecomastia surgery (male breast reduction), and liposuction (fat removal).

31) Hair transplantation is today one of the operations especially popular among men. Could you tell us a bit about the methods you use?

We use the FUE technique, the most current and most recently developed method, in which hair follicles are extracted one by one and transferred one by one to the areas where they're missing. Because this procedure can be performed under local anesthesia, the patient doesn't need general anesthesia either.

32) Is it possible to achieve healthy, thick hair after a hair transplant?

Of course, but it depends on the extent of the missing area and the number of hair follicles that can be taken from healthy areas. If our reserve is sufficient and the bald area isn't too extensive, excellent results can be achieved. If the missing area is very extensive, then it makes more sense to perform the hair transplant over several sessions.

33) Migraine pain is something many people complain about. What methods do you apply for migraines?

For migraines, we first have the patient evaluated by neurology and confirm the migraine diagnosis, because tension-type headaches, depression and other neurological conditions can be confused with migraine. Once the migraine diagnosis is confirmed, we determine the character of the pain and start with Botox injections. If, with Botox, the patient no longer experiences the pain attacks they used to have and the pain stops, then we either renew the Botox injections every 6-8 months, or, if the patient wants a permanent solution, we perform what we call migraine surgery. In this operation, the nerves responsible for triggering the pain are identified, small incisions are made, and the points where they are compressed are released. For the right patient, it's a simple, gratifying, and result-oriented operation.

34) After a certain age, people often experience significant weight gain. Who is a candidate for liposuction?

Liposuction is not a weight-loss method. It should be performed on patients with a normal or near-normal body mass index - that is, patients who are not overweight. Liposuction is body-contouring surgery: if you're not carrying excess weight but want your body to be more shapely, more contoured, and your muscles more defined, then you're the right candidate. In liposuction we now also use the state-of-the-art VASER technology, which liquefies the fat before it's removed, so we don't see the post-operative irregularities and skin sagging that used to be a concern.

35) At what ages does facelift surgery produce healthier results?

Facelift surgery is an operation we prefer to perform in the 40-65 age group. At more advanced ages, it depends on the patient's overall health. But the healthier the patient is and the earlier it's performed at the onset of aging, the better the result will be.

36) Can all signs of aging be eliminated with aesthetic procedures on the face?

Technology in aesthetic surgery has advanced very quickly, and what we're able to do has grown enormously. This effort to defy the years has allowed us to achieve results that satisfy both us and our patients a great deal. There are many separate procedures available for every type of aging sign, and we can group all of them together under facelift surgery. Through this operation, we can help a person look closer to their younger years and, in turn, feel happier - but completely erasing all signs of aging simply isn't something that's possible at this time.

37) What kinds of changes can be made to the lips with lip aesthetics?

Our approach to lip aesthetics is quite different - we don't consider the overdone, puffy lip look you see on the street to be aesthetic. We aim for lips that are fuller and more attractive but whose movement isn't restricted. The lips are the feature women care about most and perhaps spend the most time on in their daily makeup routine. The situations we usually address are differences in volume between the upper and lower lip and asymmetries between them. Because patients often complain that the upper lip is thinner than the lower lip, we generally add volume to the upper lip, though of course a fuller lower lip may be desired at the same time. For this, we commonly use two approaches: hyaluronic acid injection into the lips, and fat injection into the lips. Hyaluronic acid injections in the lips last for about 6 months and need to be repeated. If a permanent result is requested, then fat injection into the lips is performed, and with this approach a fullness that lasts a lifetime can be achieved. About two-thirds of the injected fat is gradually absorbed within the first two months, while the remaining one-third stays permanently. For that reason, either three times the amount the patient needs is injected so that the remaining portion provides the fullness they want, or the procedure is divided across several sessions.

38) Could you tell us a bit about chin implants?

Chin aesthetics is one of the important elements of the facial profile. When you consider that one of the reasons people seek rhinoplasty is how their profile looks, chin aesthetics takes on an even more important role. When the chin is recessed or protruding, we intervene on the chin to achieve a better profile. If the chin is recessed, we perform augmentation with a chin implant or fat injection; if the chin is protruding, we perform genioplasty, which sets the chin back.

39) Is it possible to get rid of under-eye bags without an incision?

Yes - with what we call the transconjunctival approach, it's possible to get rid of under-eye bags without any external incision at all. This procedure, which we can perform when there isn't excessive skin sagging, involves entering from behind the eyelid to remove the herniated under-eye fat pads, achieving a more attractive transition between the eyelid and the cheek.

40) What has been the most challenging case you've handled in aesthetic surgery?

Every case is very important to me and takes a great deal of effort, because we try to engage deeply with each one and bring out the best result for everyone. When you factor in post-operative support as well, we're really setting out on a long journey together with our patients.

41) What are the most common misconceptions you encounter from people about aesthetic surgery?

Of course, there are many. For rhinoplasty: the fear that the nasal tip will droop afterward, that the nose will become crooked again, or that breathing problems will develop. For breast implants: the fear that the implant will rupture, or that it will prevent breastfeeding. In reality, these are all things that shouldn't occur in a surgical procedure performed correctly and by the book.

42) What look do people who want aesthetic surgery request from you most often?

An aesthetic look has to be personal to each individual. Everyone's face, nose, eyebrows and eyes are different, and they should be different. That's why we don't think it's right to plan a result by showing pictures of celebrities. Our patients tell us which points bother them and explain what they're looking for. Then, together with them and within the bounds of medical knowledge, we carry out a simulation tailored to their own face. This way, our surgical plan takes a shape that's personal to them and to their own face.

43) What should new techniques in aesthetic operations focus on most?

At this point, they need to focus at the cellular level - on increasing both the capacity and the speed of cellular healing.

44) It's an undeniable fact that physical appearance carries a great deal of weight in social life. Which professions do your patients come from most often?

We have patients from every profession. I would say doctors, lawyers, teachers and private-sector employees make up the majority, in particular.

45) What advice would you give to people wanting aesthetic surgery about the difficulties they may encounter? What should they pay attention to when choosing where to have their operation?

I strongly advise patients who want this operation not to rush their decision under any circumstances. Even to patients who come to me for a consultation, I recommend meeting with at least three doctors and then moving forward with the one they feel most comfortable and at peace with. Because when a decision is well researched and thought through carefully from every angle, there's no chance of ending up unhappy with it.