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, NY

The best candidates for facial plastic surgery are motivated individuals who are healthy, inherently happy and looking to enhance their appearance.  Of course, health comes first. Cosmetic surgery is still surgery. It inevitably involves anesthesia of some sort, be it local, twilight or general. That means patients need to have normal healing, clotting and must be medically able to tolerate surgery and anesthesia. There are well established pre-surgical testing requirements that have been set forth by the national Anesthesia society. For a young healthy person, it has been shown through studies that doing a stack of tests are not necessary. Age, sex and medical status standards determine what each potential patient needs to deem them safe for surgery and anesthesia.

I have turned away a number of patients seeking facelifts who are on medications for heart conditions and/or have heart stents. This is because they cannot safely be off blood thinners for the necessary amount of time to heal normally from surgery. Some have begged me, or their primary care doctors, to take them off the blood thinners or operate on them anyway. Of course, I said no. This decision is really up to your primary care doctor. It is not worth looking good if there is a chance that you may have a heart attack, or worse.

Cosmetic surgery is to make patients look better and to improve self image and self confidence. However, no matter how good you look after, if you have a poor sense of self image, surgery may not help. The best patients are those who are happy yet look to improve features that may detract, such as a big nose or jowls. Fixing this aesthetic flaw then restores or enhances self esteem. I often see personality changes that far outstrip the cosmetic changes, but this is as a result of, not a reason for cosmetic surgery.

Over 15 years ago, I performed a rhinoplasty on a friend (at his insistence). He was extremely affable and a great person, plus the #1 salesman in the country for a large international corporation. So, he certainly didn’t lack self confidence. After surgery, his professional confidence spilled over to his social being. He finally asked out the girl he admired from afar for years. They are now married with two children. I didn’t make that much of a physical change, but the psychological change far outstripped what we did for his nose. He was able to apply that great personality to his social life.

In reviewing some articles on patient selection for facial plastic surgery, they said that an educated patient is part of the criteria to be considered a good candidate. But given the media attention to cosmetic surgery and enhanced beauty, too much is not good either.  Airbrushed celebrities and models don’t help give accurate accounts of what they really look like. Actors can also take off months to hide and heal before appearing back in public (as they don’t have 9 to 5, 52 weeks a year jobs to get back to right away). The internet is full of excellent information, forums and blogs, but not all of these are helpful. Sometimes too much information is not good. Details of a surgical procedure can sometimes be daunting and confusing to patients; especially when highly respected surgeons even differ. How can a non-physician make a choice? Also, unhappy patients tend to be more prolific on the internet than happy patients.

Cosmetic surgery is an amazing way to enhance one’s appearance for healthy well motivated patients. It’s always a good tool to research your options but beware of misleading information from the internet. Steven J. Pearlman, MD, FACS

I am a firm believer that teaching helps me reach more patients than I can actually touch.  In fact, one of the oldest definitions of physician is teacher.  Residents and fellows seek out information from many sources. In order to be a useful resource for residents and fellows, it is important that I stay ahead of the game in terms of patient education and advances in the field.  Last, but certainly not least, I firmly believe it is my responsibility to educate consumers. We are in an era of information, sometimes more information that we know what to do with. Patients should be educated about treatment options available to them as well as detailed information about the procedure(s) they are interested in, including the expected results and recovery time, whether the procedure is surgical or applied.  An informed patient is the best kind of patient.  If you have any questions related to this blog or would like to make a comment, I welcome you to do so.

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.