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. One would think that Hollywood celebrities would have access to some of the best plastic surgeons and dermatologists, yet why do so many get such bad results? I am asked this question all the time by patients and don’t really have an answer. I have been recently quoted in USMagazine.com, CNBC.com, Hollywoodlife.com and Star Magazine (see below) about Kate Gosselin and David Spade. Both have peaked eyebrows most likely from poorly performed Botox.

Over 10 years ago when we started treating areas other than the frown lines, Botox was injected in a “V” pattern up the forehead to smooth out horizontal brow wrinkles at the same time as relaxing furrowed brows or the “angry 11’s.” This left the sides of the foreheads with fully functioning muscles and patients sometimes got what we call the Mr. Spock or Jack Nicholson look. This was then treated with a few small dots of Botox to relax these remaining muscles. From that, we learned over a decade ago to include those latter areas into our original treatments. Very rarely now do we get results like those seen in these news stories.  So even if these celebrities had unusual reactions to the Botox, it certainly could have been corrected within days by a little more Botox.

I was quoted in Star Magazine (above) that David Spade had an over-done browlift. This was only part of the quote. I really said that he more likely had Botox and the reaction explained above. If he really had a browlift then it was certainly pulled way too high for a male. The male brow should be without a peak. See my article on the ideal brow. Steven J. Pearlman, M.D., F.A.C.S.

New York, N. Y.

1. Doctor, do you have to “break” my nose? The technical term for this is osteotomy.

In most cases, yes. Osteotomies are necessary in the majority of rhinoplasties. They do not make the nose less stable nor do they make the results less predictable, they actually improve the results in rhinoplasty. This takes about 2 minutes in a two hour operation.

The reasons why I perform osteotomies are two-fold. First, when a hump is removed from the nose it’s like slicing off the top of a pyramid. That leaves a gap called an open roof. If the side walls aren’t closed down then the upper part of the nose has a flat-top and may even look like railroad tracks. I sometimes see this in patients seeking revision rhinoplasty. Secondly, osteotomies are performed to narrow a wide nasal bridge.

The only difference is that the black and blue around the eyes may last a few days longer to get a better looking nose for the rest of your life. Sometimes patients have seen other surgeons who promise that they don’t “need” to break the nose. Maybe they use a euphemism such as “micro-osteotomies” which is really the same thing. What you see on TV is usually dramatized and not as violent as it really is. Using very sharp osteotomies makes a clean cut with little trauma, just like having quality carving knives in the kitchen; there is less tearing and damage to the surrounding tissue.

2. Doctor, can you just remove the “bump?”

Sometimes just the bump can be removed without touching the rest of the nose. However, most of the time even large noses are in balance. That means the nasal tip is usually a little large as well. Removing a hump without narrowing the nasal tip will make the nose look out of balance and un-natural, exaggerating the size of the tip. Another scenario is when there is a mildly drooping tip as well; again, a larger but balanced nose. Removing a bump alone will make the nose appear longer. The bump breaks up the profile. Raising the tip will restore a normal appearing nose.

This is one of the best reasons for using computer imaging for rhinoplasty. I can demonstrate to patients the potential changes from just removing a bump vs. minor reduction of the entire nose to maintain, even improve balance. Most of the time, more natural results can be achieved when the entire nose is addressed. Even if it means a millimeter off here and two millimeters off there, such small changes in multiple areas will yield more beautiful noses.

In summary,  “breaking” the nose in rhinoplasty yields superior results in most cases. Bumps alone can be removed, but more beautiful noses are created when the entire nose is addressed.  Steven J. Pearlman, M.D., F.A.C.S.

New York, NY. This week I was quoted in an article on plastic surgery as graduation gifts in Crain’s New York. I won’t hassle you with the link since it will prompt you to sign up and create a password etc (even though it’s free). To summarize, it talks about high school students getting cosmetic surgery, mainly rhinoplasties as graduation gifts. These aren’t really the surprise type of gifts that we usually associate with graduations. These are usually more like parents who are giving in to their teenagers who likely have wanted this surgery for a number of years; and now the parents have finally given in. High school graduation is a very good time for this surgery. As long as there is 3 weeks between surgery and going off to college, they are meeting people with their new nose, and often new confidence. Of course it takes a full year to see the final nose, but even at 3 weeks the nose is looking better than prior to surgery.

Graduation is a transition for educational, emotional and even physical maturity. Why not start out on the right foot? It has been proven in numerous psychological studies that improvement of facial appearance goes a long way in instilling and building confidence. What better time than when a teenager is moving on to a new environment about to make new friends and wants to put their “best face” forward. For more information on teenage rhinoplasty, please see my prior blogs.  Steven J. Pearlman, MD, FACS

New York, NY. Eyebrows frame the face and have been one of the most visible and changeable hallmarks of facial beauty over the past century. I recently wrote an article on The Perfect Brow for the prestigious beauty website Inwithskin.com. Beauty is defined by magazines and movies and not Plastic Surgeons. So when I want to demonstrate what the perfect brow looks like to a patient, I usually say “let’s look at a plastic surgery textbook” and then open a fashion magazine and flip through the ads and editorial pages.

Makeup artists and aestheticians have long understood what makes the perfect brow. The brow is club shaped centrally then tapers along the tail. The central portion of the brow begins at a vertical line drawn upward from the edge of the nostril. The tail extends to a line that runs from the corner of the nose through the corner of the eye. The height of the brow should be equal at both ends; typically at or just above the rim of the eye socket. Generally, in women, the brow should arc delicately with the highest peak between the corner of the iris and the corner of the eye. The male brow should rest on or at the rim of the eye socket and is more horizontal in shape.
The skin of the upper eyelid should be smooth and have a youthful fullness, with little folding or wrinkling. Makeup artists love this since it leaves a nice platform to apply eye shadow without flaking or cracking.

All the above is well and good for teens and models, but as we age, the brow may flatten and droop as well as deflate. Before even considering cosmetic surgery, a skilled makeup artist can often shape your brows to restore a youthful arch.

How can we change the brow?

 Eyebrows can be elevated and shaped non-surgically by the use of expertly placed Botox. Crow’s feet can also be reduced. Sometimes it’s more a result of flattening of the eyebrow instead of drooping. In that case, fillers such as Restylane or Juvederm can be used to restore youthful fullness. Using a filler to repair deflated eyebrows may work just like a brow lift but actually doesn’t lift the brow.

Eyelids or eyebrows?  If you look worried, sad or angry it’s more likely due to a brow problem; looking angry often responds to a quick Botox treatment.

If you look tired, it’s usually more from the eyelids. Another way is to pull out photos of yourself from your mid 20′s, and check where your eyebrows once were and maybe still are.

When is surgery necessary? When there is significant wrinkling and/or  folding of the eyelid skin and your eye shadow won’t stay without flaking. Wrinkling of the eyelids is due to either aged skin, drooping of the eyebrows or both. If your eyebrows are in good position and the overhanging skin doesn’t extend far beyond the corner of the eye, a blepharoplasty (eyelift) is the best solution. When the excess skin goes well past the eye, we call that lateral hooding.  Hooding means that the brow has dropped; a brow lift is more helpful. Remember, when it comes to a youthful eyebrow/upper eyelid complex, its’ about shape not height.

Steven J. Pearlman, MD, FACS

New York, NY. I have been fortunate to be featured in the media for two of the most expressive features on the face over the past 2 weeks: lips and eyebrows. This week I will discuss what makes lips beautiful and what doesn’t. On May 4^th, Hollywood Life revealed Megan Fox’s new lips. Way overdone, as are a number of other celebrities. While some may look good, most unfortunately don’t; such as Melanie Griffith, Elizabeth Hurley, Priscilla Presley and a host of others.  When it comes to lips, bigger is not necessarily better. I was quoted about classic beauty when natural lips ruled. Clara Bow, Gloria Swanson and Carol Lombard all demonstrated well formed upper lips with a cupid’s bow, the true power of beauty. Their lower lips were an appropriate 1 ½ to 2 times the size of their upper lips as it still should be for celebs and patients alike.

As we age, a number of things occur to the lips. They deflate; the cupid’s bow of the upper lip flattens and the lip loses the nice bow shape. The border of the lip loses the nice ridge that defines the lips. To properly restore lip shape, only a half cc of hyaluronic acid filler is necessary, either Restylane or Juvederm. I place the filler just like you do your lipstick. First the lip liner: filler is injected along the border of the lips to re-define the rim and restore Cupid ’s bow. Next the lipstick to fill in the lips: the rest of the filler is placed within the substance of the lips to create fullness to create a soft, subtle pillow. For younger patients seeking bigger lips, I go up to 1 cc. This can be done tastefully for small lips and still look beautiful. The “Cupid’s Bow Lip” technique of mine for lip enhancement was featured in Vogue August 2008.

Actual Before and after lips I enhanced using Restylane, this is what lips should look like: 

Tip of the week: lips can be enhanced using the “Cupid’s Bow Technique” yet still look natural, unlike too many celebrities out there.

Steven J. Pearlman, MD, FACS

New York, NY: 

The goal of pre-wedding aesthetic enhancement is to achieve the ultimate “look” on the day of the wedding. There are a number of treatments we can offer ranging from minimally invasive to aesthetic surgery. This applies to the bride as well as the mother of the bride and the mother of the groom. As I say to all “mothers” the most important individual at the wedding is the bride. Next is the mother of the bride. Third is the mother of the groom and 4th but not least, is the groom.

 For surgical enhancement, I often see brides-to-be right after they get engaged for rhinoplasty consultation. Wedding photos will be a keepsake for the rest of their lives and if they haven’t been happy with the way their noses photograph this is a great time. I typically have half a dozen weddings that I am helping to “prepare” brides’ noses for each summer season. Since the bride is the center of attention. I like to have at least 4 months or more between surgery and the wedding for adequate swelling to go down. It really takes a year to see close to the final “nose” but by 4 months the nose should already look better than pre-op.

 The same guideline applies to mothers of the bride (or groom) seeking a facelift for the upcoming wedding. I think we can shorten this to 3 months, minimum. Most patients will look better at a month, but just in case healing is a little slower, I don’t want to take any chances. Other than the “mothers” we can go down to a little over a month healing. For example, recently I had the mother of the bride and her sister, the aunt, come in for facelift consultations 2 months before the wedding. With creative scheduling I could get 1 ½ months of healing before the wedding but no way would I operate on the mother of the bride with this short period. The aunt had her facelift and looked great by the wedding.

 For blepharoplasty and browlift, the healing is faster. 1 ½ to 2 months is adequate healing time before a wedding, although healing still improves the result for 6 months.

 Many brides are no longer in their 20’s and want the makeup to glide on for their wedding. When it comes to minimally invasive “tune-up,” we have a number of treatments to erase wrinkles and get a stress free appearing bride. Botox smoothes frown lines, crows’ feet and forehead lines. For Botox regulars, I suggest the last treatment 3 to 4 weeks prior to the wedding, just in case they get a rare black-and-blue mark. The same holds for facial fillers to enhance nasolabial folds and cheek enhancement.  Expertly performed Botox can smooth wrinkles yet maintain some facial expression, brides do not want to look flat (or like too many Hollywood actresses) for their photos either.

 For Botox and filler rookies, I don’t like treating brides less than 4 months before the wedding. This way there is a trial period to make sure they like the results. If so, a booster 2 to 3 weeks before will restore their look. For the rare few who are not happy with the results, Botox will have worn off and a reasonable amount of filler will have dissipated.

 The last category is skin care. Everyone should be on a good skin care regimen, with properly selected skin products by a skin care expert, and I don’t mean the counter girl who at a department store who has limited training. For older brides, a series of light office peels can smooth out wrinkles. For any bride, an exfoliating facial with light peel using an alpha hydroxy acid or similar product two weeks before the wedding will leave the best palate for the makeup artist of choice.

New York, NY, It is probably a little too late to be commenting on Heidi Montag’s multiple plastic surgeries. However it is obviously still in the mind of the media and therefore the public since I was interviewed and quoted in the Daily News on Wednesday April 21. I will try to confine my comments to her face since I specialize in Facial Plastic Surgery and don’t venture south of that professionally.

Going from top to bottom:

• Mini-brow lift: From her pre-op photos, I don’t think she really needed a brow lift. The key to the brow is shape and not height. I discussed the ideal brow shape in an earlier blog. Heidi’s brows were a little low but so are many top models and actresses. She did have the proper arch and now has too much of an arch.
• Botox: in the forehead and frown lines. No matter how much a 23 year old frowns, it won’t leave lines. I am not a fan of using Botox when there are no lines at rest to “prevent them” from eventually appearing. I also think that too many actresses get too much Botox. It is disconcerting when watching a TV show or movie and there is no expression in anyone’s face anymore.
• Nosejob revision: This I agree with, as her previous nose was slightly too wide for her slender (and now even more slender) face.
• Fat injection in cheeks, nasolabial folds and lips. Everyone, even children and teens have nasolabial folds. These are a sign of character and expression. Also, fat is good but doesn’t always last in the nasolabial folds or lips.
• Chin reduction: she did have a large chin, this one is a plus.
• Neck liposuction: there needs to be a little fat between the skin and the muscle of the neck called the Plastysma muscle. This cushions the skin and if too much is removed you will be able to see every fiber of neck muscle as she ages. She is also a little young for facial liposuction. The facial fat changes a lot from the 20’s to the 30’s.
• Ears pinned back (otoplasty): I cannot comment on this since her hair covered her ears in all pre-op photos I found.

As for the body stuff, as I said I can’t comment as a professional. But, as a male, I think her breasts are way too big and were more attractive before surgery.In summary, patients benefit from multiple plastic surgical procedures but there really needs to be a limit. Some people, such as Heidi Montag, went way over the line.

I got a taste for teaching facial plastic surgery going back to my residency where I presented at a national meeting in front of hundreds of practicing physicians. One year and two other journal publications later, I was asked by my facial plastic surgery fellowship preceptor and mentor Dr. William Friedman to co-author two chapters for an upcoming textbook in facial plastic surgery.

1. Friedman W.H. and Pearlman S.J., Preoperative Evaluation and Patient Selection for Blepharoplasty. Aesthetic Facial Surgery, Krause, C.J. ed. J.B. Lippincott Company. Philadelphia 1991.
2. Preoperative Evaluation and Patient Selection for Rhinoplasty. Aesthetic Facial Surgery, Krause, C.J. ed. J.B. Lippincott Company. Philadelphia 1991.

I recall a lot of pressure to write something that was befitting sharing authorship with such a respected physician plus the knowledge that it will likely be read by thousands of peers. As a fellow, I rounded daily in the hospital with residents from Columbia Presbyterian Hospital. Thus began my academic career. Teaching is a big responsibility. It requires me to be on top of my game at all times. At rounds, answers to residents’ questions need to be precise and accurate. Teaching in the operating room requires comprehensive understanding of the procedure, background, reasons for all maneuvers and discussion of potential complications (and how to avoid them, of course).

Over the past 22 years in practice, I have authored over two dozen articles in peer reviewed journals (the most recent on revision rhinoplasty) and textbook chapters (the most recent on Endoscopic Browlift) and have given hundreds of lectures on various topics in facial plastic surgery. I now teach my own fellows as well as residents. Currently I have a fellow, Dr. Jason Moche, who is about to graduate. We are working on a combined project looking at revision rhinoplasty. I also have two ongoing research projects with residents on rhinoplasty techniques. So, if you want to find a surgeon who is on their toes and knows the latest about their specialty, look for those who teach.

New York, NY: A few weeks ago, I treated three Baby-boomer moms. What made that day unique was that each was brought in by their daughter for facial rejuvenation. One was the mother of a beautiful teen on whom I did a rhinoplasty and had a fabulous result. The second daughter had prior Botox and the third just found me through “sources” and dragged her mother in for a fix-me-up. Each of these mothers are vibrant ladies in their 50’s and were there for their daughters, now it was the daughters who were telling the moms what they needed.

Each mom had office facial rejuvenation with Botox, fillers and skin care. Botox was used to soften their frown lines, reduce crow’s feet, reduce downturned corners of the mouth; and in one mother smooth the forehead. By individualizing treatment and using only the necessary amount of Botox, each looked smoother yet retained facial expression.

Next, they had Juvederm to restore youthful cheeks. As we age, one of the first things to go is mid-face fat. Nasolabial folds aren’t so obvious in a young adult, but become much more visible when the mid-face gets hollow. When I used to just fill nasolabial folds, patients were happy but not ecstatic. Restoring youthful “apple” cheeks give what I call the “wow factor,” each looked in the mirror after only one cc per side (cheek, nasolabial fold and marionette line) and said exactly that: “wow, this is how I used to look” and could now compare themselves to their daughters. One of the mothers also had Restylane to her tear troughs to camouflage the appearance of lower eyelid bags.

Lastly, each was put on a skin care regimen designed for their face. The core for each of their product selections was TNS, a great skin rejuvenation product that I even use myself on a daily basis. So, mother’s watch out, your daughters are watching out for you too! Steven J. Pearlman, MD, FACS