I recently saw a patient who came in because I did a facelift on one of her childhood friends and she liked what she saw: a more youthful look without looking “pulled.” She had a facelift about 7 years ago and feels that it helped a little but the skin of her lower face is “wrinkley” with some excess skin under the neck and cheek folds. She sought out a few opinions of other doctors and the suggestions ranged from fillers to implants to a revision facelift. My first inclination was to suggest another facelift. This would help the jowls and extra skin under her neck. What concerned me is that when listening to this lady, she was more distressed about the way the skin hung around her mouth and narrowing of her cheeks. As a surgeon, facelifts are more interesting and fun for me to perform, plus this patient was basically asking if a revision facelift would be the best solution without specifically stating it. However, I felt that a facelift wouldn’t be the best initial solution for her concerns. I suggested that we first try Sculptra to restore volume to her face and fill out the deflated cheeks and areas around her mouth. A facelift can be performed later to lift the drooping facial skin and muscles.

This is really about deciding priorities. I categorize facial aging into 5 categories: skin changes, dynamic muscle action, loss of volume, gravity and loss of elasticity. Everyone experiences all 5 as they age. It’s more a matter of what should be addressed and in what order. For this patient, I feel it is volume first (high volume fillers with longevity – Sculptra) then combat gravity and loss of elasticity next (facelift). 

 The face ages in 5 ways: skin, muscle action, volume loss, gravity and loss of elasticity. When the question is to fill or lift the face, both the doctor and patient need to determine the best treatment plan per the patients priorities. Steven J. Pearlman, MD, FACS

New York, N.Y.

There is much buzz in the media and on the internet about non-surgical or alternative less invasive procedures instead of facelifts. These treatments include fillers, neurotoxins (Botox and Dysport), and devices such as lasers and radiofrequency machines. Many of these procedures can help restore a more youthful look, but none really lifts the face. You can follow this link to my website for a more comprehensive discussion of the 5 ways the face ages: 

1. Skin changes
2. Dynamic lines from muscles underneath
3. Loss of volume
4. Effects of gravity
5. Loss of tissue elasticity

To treat these aging causes, treatment needs to be targeted to the cause. Of course, most patients experience all 5 in some capacity. I then break down their priorities by need, time frame, importance to them, time off to heal and cost.

Targeted treatment for each or some combination is really what is best: 

1. Skin changes             Lasers and peels for the skin
2. Dynamic lines            Botox or Dysport to relax muscles
3. Loss of volume          Facial Fillers (Juvederm, Restylane, Radiesse, Sculptra, Fat)
4. Effects of gravity       Surgery
5. Loss of elasticity        Surgery

Fillers, Botox and Lasers can go far to make someone look younger, but to lift a drooping jowl, treat a “turkey neck” or low brow, nothing works like a surgical facelift or browlift.

Don’t get me wrong, my new techniques in facial fillers are really getting beautiful results. Now that I target cheeks and the mid-face with fillers, entire faces light up. But this is not a lift. There is a doctor in New York advertising a “insert letter here” lift (I am leaving out the letter as not to offend); but all he is doing is placing many syringes of facial filler deep in the face and under the skin. It’s not a lift but volumizing the face.  Fillers are a good thing, but more is not better. Plump is good but so is lifting.

Lasers and RF machines don’t really lift the face either. Most reports have been disappointing and based more on subjective findings instead of objective long term results.

So, for comprehensive facial rejuvenation, all 5 areas of the face need to be examined and treated.

Steven Pearlman, MD, FACS

New and better ways to use facial fillers for facial folds and anti-aging

New York City, NY – As I perform more and more facial filler treatments, I am using less and less in the nasolabial folds and more in the mid-cheeks for a more youthful appearance.

Most patients seen in consultation for treatment with fillers point to their nasolabial lines and folds. The nasolabial folds are the lines and folds that go from next to the nostrils to the corners of the mouth. They are caused by the facial muscles inserting into the skin at that fold. Smiling, laughing, living creates the folds and etched lines in the overlying skin. Add this to sagging of the cheeks over this fixed line of attachment. The cheeks drape over the fold creating a mound that exaggerates the fold.

When patients with nasolabial folds are examined, most have both the fold and the mound. As explained above, the mound is partially draping of the skin and underlying fat/muscle over the fold. A third contribution is age related loss of volume in the mid-cheek.  If we just fill the nasolabial fold below, patients might appear almost like a rhesus monkey. What most patients really need is refilling of the mid-cheek area, and then only a little filler is necessary for the nasolabial fold. By re-inflating the cheeks, the nasolabial mound and fold are lifted up and out creating a natural, more youthful facial appearance.

If you want to simulate what this looks like, just smile. Mid-face fullness might be one of the reasons why people look better when they smile.

Which fillers do I use? For first timers and those who need a little filler, I prefer 1 to 2 cc of Juvederm Ultra Plus. A little more, Radiesse and for the most volume and longest lasting result, Sculptra.

Steven J. Pearlman, M.D., F.A.C.S; Facial Plastic Surgeon

The fastest growing selection of facial fillers is the HA fillers. One of the first to be FDA approved and widely used was Restylane followed by Juvederm. Along with Restylane there is Perlane, a thicker version and Juvederm Ultra Plus; a thicker version of Juvederm. Historically, Captique and Hylaform were early contenders but these fell by the wayside as not measuring up to Restylane and Juvederm. New to the market is Hydrelle; the first HA to have local anesthetic right in the syringe. Many of us now combine HA with local anesthetic to reduce the discomfort on injection. This saves a step. However, will Hydrelle stand up as a filler? The presentation on new fillers compared Hydrelle to Captique, which really couldn’t hold a candle to Restylane or Juvederm.

An exciting new pair of HA fillers are Prevelle Silk and Prevelle Shape. These also have local anesthetic. According to the new technologies seminar, Prevelle Silk has the smallest HA particle size. This may work well for treating very fine lines in the skin, especially around the mouth. Right now, the HA options of Restylane and Juvederm can be used, but when injected too superficially, the clear gel may be visible as a bluish bump within the skin called the Tindal effect. A smaller particle should reduce this potential side effect. For really small, superficial lines, the best stuff out there right now is Cosmoderm, but there is a rumor going around that Cosmoderm and Cosmoplast might be dropped from production due to low sales from HA competition and high production costs. I will definitely try Prevelle Silk since it will fill a needed niche in facial fillers.

Next week I will expand on fillers (no pun intended) to discuss Evolence, Radiesse and Sculptra.

Runway Cheeks^TM

The “must-wear” look for fall.

New York is still buzzing from the recent fashion shows in Bryant Park. So what did I see? That fashions are always changing but one thing remains the same: beautiful models. What do all these models have in common?  Spectacular cheekbones. Regardless of the trend for more “quirky” fashion faces what has remained the same for decades are those angular cheeks; they frame the face and create highlights that distinguish beauty and frame the face.  Structured cheeks are also a sign of vitality. Great cheekbones highlight the eyes, too, adding overall balance to one’s facial features. Cheekbones are the foundation of a drop-dead gorgeous look.

Patients seeking celebrity cheekbones are fast on the rise. Not long ago, it required a surgical procedure with insertion of cheek or malar implants. This is still a feasible operation for those who desire permanent results. However, with the myriad new facial fillers, I can create stunning cheeks without surgery.

The fillers that I use to create Runway Cheeks ^TM are hyaluronic acid: Juvederm Ultra Plus and Perlane, or calcium hydroxyl appetite: Radiesse. The procedure is performed in-office and takes just about 20 minutes. There is minimal discomfort and little-to-no bruising. You can go straight out to lunch, back to work, or shopping on Madison Avenue directly after.  So, if you want to look like you just stepped off the runway, this procedure is your dream look and the right option for you.

Around the same time that Botox^® was first being used for wrinkles, my friend Dr. Sydney Coleman was modifying the once little-known technique of fat transplantation to create what is considered to be one of the most dynamic contributions to cosmetic surgery for that entire decade. Despite controversy over the longevity of fat transplantation, Dr. Coleman expounded upon the concept of facial deflation with aging. Few surgeons ever considered this third dimension of facial aging: that we lose facial volume as we age. From the first time I saw Dr. Coleman lecture on facial fat transplantation, it became evident that facial volume loss is significant in many of our patients. However, performing fat transplantation correctly to get longevity is akin to a surgical procedure and may be accompanied by significant post-treatment swelling. As I started to perform fat transplantation, I realized that the evaluation of facial volume is necessary in all patients.  With the new Millennium, so came new fillers to the market. With so many available fillers we have long lasting products that can be taken out of a box instead of surgically removed. The process of facial volume restoration is now much simpler. We can treat facial lines, wrinkles, folds and even restore significant volume loss without a surgical procedure.  So, which filler to choose? Firstly, are we treating lines, folds, crevasses or volume? Treatment differs for each. The more superficial the wrinkle, the thinner the filler required. Longer lasting (thicker) fillers often leave lumps. The filler needs to fit the treatment; here are my current choices for facial fillers.  

• Superficial etched or “stiletto” cut lines. These can be along the corners of the mouth, smile lines around the mouth (naso-labial folds) and around the eyes: Cosmoderm, Restylane Fine Lines (not FDA approved so I don’t carry this yet), and Juvederm
• Facial folds, naso-labial folds and marionette lines below the corners of the mouth: Juvederm, Restylane
• Crevasses (deep folds), same as facial folds only deeper: Juvederm Ultra, Perlane (thicker version of Restylane), Radiesse
• Facial Volume Enhancement, cheeks, hollowing below the cheekbones, jawline, temples and under the eyebrows: Juvederm Ultra, Perlane, Radiesse, Sculptra, fat grafting 

When deciding which filler to choose, an easy guide is: the longer a filler lasts, the higher the price, the longer the healing time and potential side effects.  I purposefully left out the latest filler to be approved, Artefill. I choose not to use Artefill at present. Its predecessor, Artecoll was available in Europe and Canada in the past. Some patients developed granulomas (small lumps under the skin) up to three or four years following treatment. The manufacturer claims that the cause has been eliminated. Since there are so many reliable options already available, I prefer to wait a few years to make sure Artefill is completely safe before using on my patients. If you are being offered this by a surgeon I advise you to research further before consenting to Artefill injections. Remember, all aging still cannot be fixed with injections.

We can relax and fill the face but none of these (nor any existing laser) can really re-suspend sagging facial tissue like surgery. Beware when you are told about a “non-surgical” facelift. A true non-surgical facelift does not exist; it is fancy marketing speak for in-office quick fix procedures that are, in essence, nothing like a facelift in technique or result. Needle injections, lasers and peels can make faces look much younger but they will not lift the face. So, which facelift, short flap, deep-plane, SMAS lift or lifestyle lift is right for you? I will address this in a future blog. 

For those of you who had the kindness and interest to read to the bottom, what’s filling up my life are my new twin girls born October 2, 2007. Certainly not a relaxing undertaking to be sure, but the ultimate definition of “true beauty” as far as I can see.