March 22nd, 2010
Non-surgical facelift, can you get away with it or do you need the real thing?
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:
- Skin changes
- Dynamic lines from muscles underneath
- Loss of volume
- Effects of gravity
- 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:
- Skin changes Lasers and peels for the skin
- Dynamic lines Botox or Dysport to relax muscles
- Loss of volume Facial Fillers (Juvederm, Restylane, Radiesse, Sculptra, Fat)
- Effects of gravity Surgery
- 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
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March 16th, 2010
Who is a good candidate for facial plastic surgery?
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
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March 9th, 2010
Athletic faces: facial fillers, broken noses, septoplasty, rhinoplasty
New York, N. Y. ,
Two weeks ago I saw a lady that I first treated 14 years ago as a promising college varsity soccer player. She was referred to me by the school’s athletic trainer for a broken nose. She was happy with a straighter nose and went back to playing with a face guard for the rest of the season. She came back to see me three weeks ago for a long overdue follow-up. In addition to getting a professional degree, she went on to play for the national team of her ancestral origin and is now slowing down her athletic career. She is looking to fix a deviated septum that often occurs with nasal fractures as well as a few other cosmetic changes for her nose. She also appears prematurely aged due to eyelid changes, small bags under her eyes and narrowing cheeks. I am leaving out specifics to protect her privacy, although she did consent to allowing me to tell her story.
It is very common for the septum and nasal bones to be pushed over when a patient breaks their nose. The nasal bones should be fixed within two weeks, but a septum needs to heal for 6 to 8 weeks before addressing it surgically. A number of other changes can occur in the nose from trauma that isn’t addressed by a “closed reduction” (simple straightening of displaced nasal bones). I will go into broken noses in a future blog.
As a long time athlete, she demonstrated what I see in these individuals of both sexes. Lean bodies are often associates with prematurely hollow cheeks. This was first recognized in devoted marathon runners. I was quoted in New York Magazine on Yoga Masters suffering the same consequences. Having little body fat, they often lose their facial fat even faster than the rest of us do as we age. I have discussed facial fillers to combat facial aging in past blog posts as well as on my website. To treat this lovely patient, I used Restylane under her eye “bags” to camouflage aging changes of her eyelids and Juvederm in her cheeks to restore a more youthful facial appearance. She is extremely happy with these treatments and may consider Septoplasty with Rhinoplasty in the near future.
Steven J. Pearlman, MD, FACS
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February 24th, 2010
Septoplasty Part II
Fixing a Deviated Septum
New York, NY - Fixing a deviated septum is usually performed from inside the nose by a closed or endonasal approach. Crooked bone and cartilage is moved, removed and/or straightened. There should NOT be any changes to the way the nose looks or any “black and blue” whatsoever. As I tell my septoplasty patients, your mother couldn’t tell that you had surgery 3 days later. On the other hand, if you have a deviated septum it might be the ideal time to have a rhinoplasty if you have been thinking about it. Your surgeon will be operating in the neighborhood. Also, with modern rhinoplasty, often cartilage from the septum is used to strengthen the nose as we re-model it. Because of this, I suggest that if you are considering rhinoplasty and have a deviated septum, they should be performed at the same time. Other than the convenience of going through only one operation and one recover period, the fact that I often use cartilage from your septum to strengthen the nose during rhinoplasty is reason to do them together.
Please make sure that your surgeon looks inside your nose and checks for any causes of nasal obstruction; those that exist and those that may inadvertently occur during rhinoplasty. Based on Bernoulli’s Law of air flowing through a column, a minor asymptomatic deviation or other cause for obstruction can become more significant if the nose is narrowed. A rhinoplasty surgeon should be well versed in sinus surgery and all the associated consequences of functional nasal surgery.
A common misconception is that if you have or your doctor finds a deviated septum then you get a free or discounted nosejob. This might have been the case years ago. Insurance companies paid well and freely for nasal surgery. Doctors would call it a deviated septum and old nasal fracture or other creative names. Insurance companies got wise to this. Rhinoplasty is a cosmetic procedure and really isn’t the responsibility of your medical insurance company. Unless you broke your nose within the past year or so and have good documentation of a significant new deformity, don’t even think about it. There are some doctors who still add inappropriate codes to get higher reimbursement and others who will “throw in” a rhinoplasty if you have a deviated septum, but they aren’t necessarily the best surgeons. Be careful, you may get what you paid for: discount surgery.
There usually is some cost savings from doing a Septorhinoplasty together. Part of the operating room and anesthesia fees may be covered for the functional aspects of surgery. The functional portion of the Septorhinoplasty may also be covered by your medical insurance and may mean no or little additional cost beyond a cosmetic rhinoplasty for the functional (septoplasty) procedure. This depends on your insurance coverage.
This is the nose that you will have for the rest of your life. You want it done once and done right. You should find the best surgeon you can, one who specializes in noses and does what is necessary to get a great nose. Steven J. Pearlman, MD, FACS
Posted in Home, Rhinoplasty | 1 Comment »
February 16th, 2010
Septoplasty – Deviated Septum Part I
New York, NY
What exactly is a deviated septum? How do I know if I have one? How did it happen? Will it change the way my nose looks if I have my deviated septum fixed, even if I don’t want to? Maybe I have one and no one knows? Will it get me a “free” or discounted nosejob?
These are just a few of the many questions patients and non-patients alike have when it comes to the elusive deviated septum. I will attempt to answer the above questions and more. My answers just kept on going and going so I am going to divide this into two parts.
The definition of a septum is a dividing wall. The nasal septum divides the two sides of the nose. The front 2/3 is made of cartilage and the back portion derived from two different thin bones. The septum sits in a groove of the bone that is above the palate of the mouth. When any or all portions of this structure are crooked, it is a deviated septum. We usually don’t even know when it became crooked. Maybe from falling on your face as a child, during sports or maybe even while you were being born; unless you can pinpoint a specific episode when you got hit in the nose followed by bleeding and a subsequently reduced airway.
Many people have crooked nasal septums and don’t know it. If there is no blockage of breathing or exacerbation of sinus and allergies then there is no need to worry or ever treat it. Many people have asymptomatic mildly deviated septums. The most common problem a deviated septum can cause is nasal blockage. If one side of your nose tends to be more blocked than the other, it is a high probability that you have a deviated septum. Other structures in the nose that can also contribute to blockage are called turbinates. These are curly bones that are covered with skin (mucosa) and tissue that swell with blood to warm and humidify the air we breathe. By the time air gets to your lungs it is 98% humidity and body temperature; most of this occurs in the nose. The turbinates work by swelling alternately, one side than the other. So, if one side is blocked then it alternates but you get good air through both together there really is no problem, just a normal nasal cycle. This cycle is even more evident at night, the “downhill” nostril swells. This is obvious when you turn over and the open nostril switches sides. If one side is almost always blocked, that means there is a fixed obstruction; a deviated septum or other abnormal structure such as a nasal polyp. Allergies, colds and other conditions that cause the inside of the nose to swell will also cause obstruction. This obstruction can be worse if there is also a deviated septum. A deviated septum is diagnosed by a careful examination of the inside of the nose. Sometimes a CT scan helps delineate the back of the septum and can demonstrate possible associated sinusitis. Deviated septums can even be a cause of chronic headaches.
Sometimes a deviated septum may be asymptomatic. However a mild deviation can become a problem if the nose is made narrower in cosmetic rhinoplasty. This is why every rhinoplasty candidate should have the inside of their nose examined. If you see a doctor for a rhinoplasty and they don’t look inside your nose, it can lead to breathing difficulties after. Cosmetic rhinoplasty should go hand in hand with functional nasal surgery. It might not be necessary to address the septum, but it is important to make sure that it is not crooked; otherwise rhinoplasty may cause breathing difficulties. It amazes me that when I see patients for revision rhinoplasty with breathing issues how often they report that their prior surgeon never even looked inside their nose!
Steven J. Pearlman, MD, FACS
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February 11th, 2010
Topical vitamins, health and anti-aging for skin care and facial aging
New York, NY - If you told me as recently as 2 months ago that I would be blogging based on a question from my Facebook Fan page, I would have thought both you and I were crazy. Well, here it is; I had an inquiry from Pauline, a lovely lady from Charlottesville, VA about vitamins and skin tightening. This came as a response to an article in Natural Health Magazine February 2010, where I was quoted on the benefits of topical vitamins for skin rejuvenation.
We have long known about the beneficial effects of various vitamins on anti-aging. The most well documented is Retin-A, a vitamin A derivative. Technically, Retin-A is only FDA approved for the treatment for acne. However, people have been using this for decades for more youthful appearing skin and it is probably the single best anti-aging topical treatment you can use at home for facial aging. Retin-A has been demonstrated to reverse the signs of aging right down to the cellular level. There are potential side effects though; dryness, redness and sun sensitivity. So, use it at night and use daily sunscreen (as everyone should do so already). Other Vitamin A preparations are also available that have moisturizers or modified retinoids that may be less irritating and better tolerated by your skin.
Vitamin C is an antioxidant that is effective in fighting aging skin. Anti-oxidants combat the formation of free radicals. What does all that mean? Ultraviolet (UV) radiation from the sun penetrates the skin and causes the formation of free radicals. Free radicals damage the skin cell membranes, enzymes, surrounding fluid and proteins making the skin age prematurely. Vitamin C neutralizes some of this damage. It is also a necessary building block for a number of the enzymes that make collagen for our skin. UV exposure also depletes the skin of Vitamin C making it less available for the skin cells. Oral vitamin C is good for overall health, but little gets to the skin so topical is helpful as well. Unfortunately, you can’t chop up vitamins and smear them on your skin. The vitamin C molecules need to be of a specific size and associated with certain carriers that enhance skin penetration and absorption. This varies from product to product.
Pauline also asked about Vitamin D. Vitamin D has been a hot topic lately, as it was even featured in the New York Times Science Section last week. Vitamin D is made in the body from sunlight and also found in fish and fortified milk. There are well documented health advantages from Vitamin D for many disease processes as well as overall health. What is not known is if we really need to take supplements other than what we get naturally from food and sunlight. Active healthy patients have higher Vitamin D levels. But is this from outside sources or do healthier people produce more Vitamin D themselves?
When it comes to vitamins taken orally, nothing beats a balanced diet and good hydration for healthy skin. The #1 thing I recommend for overall health is adding Omega 3 fatty acids. These are the highest in fish but can be obtained from a number of other sources such as flaxseed oil or even oral supplements.
Here’s to a healthier you. Steven J. Pearlman, MD, FACS
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February 3rd, 2010
The Little Baby Face Foundation
Pro-bono reconstructive surgery for children around the world born with facial defects
New York, NY. I am thrilled and honored to have been added to the medical advisory board for the Little Baby Face Foundation. The Little Baby Face Foundation provides pro-bono reconstructive surgery for children from around the world with facial deformities. Over 100 children have been treated since its inception. All surgical, medical and dental care is donated without fees by the medical advisory board members. Each child also undergoes a full medical evaluation including exams, scans, X-Rays and other diagnostic tests. All non-participant physician costs – such as diagnostic tests, hospitalization, travel to and from New York, including hotel costs for the family – are covered by the foundation.
This foundation was founded in 2002 by Dr. Thomas Romo. Tom is a gregarious giant of a man when it comes to measuring heart. Having participated in Face to Face, a pro-bono program from the American Academy of Facial Plastic and Reconstructive Surgery, I, like Dr. Romo, have travelled around the world offering pro-bono reconstructive surgery for needy children. With familial and personal responsibilities back home, it is difficult to do this very often. Through this foundation, we bring the patients to us so we can treat them year-round.
A short list of some of the procedures that are offered are: Atresia (malformed ear canals), Bite, Jaw and Dental Abnormalities, Cleft Lip and Palate, Microtia (malformed ears), Eyelid Deformities, Malformed Faces, Nasal Deformities, Vascular Lesions, Bone Anchored Hearing Aids, Dental Implant Surgery, Distraction Osteogenesis, Orthognathic Surgery and Temporal Mandibular Joint Surgery.
To quote Winston Churchill, “We make a living by what we get, but make a life by what we give.”
If you are more interested in this foundation and want to know more about us or how to help, please visit the website http://littlebabyface.org/.
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January 7th, 2010
The perfect eyebrows
New York, NY:
The perfect brow is club-shaped centrally then tapers along the tail with the center portion beginning 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. Aestheticians commonly use the “pencil trick”* to guide them in eye shaping. The skin portion between the brow and the eye should be smooth and have a youthful fullness, with little excess skin and no over-hang of the skin. This leaves a nice platform to apply eye shadow without flaking or cracking.
Center
- Peak of brow
Tail of brow
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. There are a number of non-surgical as well as surgical techniques to rejuvenate an aging eyebrow. Eyebrows can be elevated non-surgically by the use of expertly placed Botox. Not only can brows be lifted, but shaped as well. Crow’s feet can also be smoothed. Sometimes it’s more a deflation of the eyebrow instead of drooping. In that case, fillers such as Restylane or Juvederm can be used to restore youthful fullness that mimics a browlift but actually doesn’t lift the brow.
When is surgery necessary? When there is significant wrinkling and redundancy of the eyelid skin, which may be due to excess skin or drooping of the eyebrows. If the brows are in good position and the overhanging skin doesn’t extend far beyond the corner of the eye, a blepharoplasty is the best solution. When the excess skin goes well past the eye, that means that the brow has dropped; a browlift is more helpful. Another way to tell if it is the brows or eyelids that are the problem: if you look worried, sad or angry it’s more likely due to a brow problem. 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.
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December 16th, 2009
Revision Rhinoplasty Specialist reports on a comprehensive study
New York, NY:
Revision rhinoplasty can be a frustrating situation for the patient, which is why it is even more important for surgeons to understand why people seek revision surgery. In October, Drs. Yu and Kim, residents from New York Presbyterian Hospital presented a study at the annual meeting of the American Academy of Facial Plastic and Reconstructive Surgery on revision rhinoplasty that we conducted on my patients. Our goal was to present why patients seek revision rhinoplasty. Prior articles in the medical literature all discussed these findings from the doctor’s point of view. There are many scholarly articles on this subject, but they all looked at what the doctor thought was important. We decided to survey 104 consecutive patients seeking revision rhinoplasty to see what their concerns were, before I chimed in with my opinions. This unique study is to parallel trends in modern medicine and to focus on the patient’s point of view.
104 consecutive patients filled out a comprehensive questionnaire that asked questions about their noses from top to bottom and functional (breathing) complaints. They were also asked to identify their top three reasons for seeking revision rhinoplasty. The most frequently cited concerns were tip asymmetry, crooked middle third of the nose and irregular upper (bony) third of the nose. The three top concerns differed a little with difficulty breathing cited as the second largest concern with tip asymmetry still first and crooked nose third.
Breathing problems was a very common finding. 62% of patients reported nasal obstruction and 71% were found by the surgeon (me) to have blockage of the nose.
At the end of the survey, we asked why patients didn’t go back to their original surgeon and 57% indicated that since the surgery was not successful, they would not go back. 23% reported that their original surgeon was not receptive to their concerns. For the other 20%, surgery was either too long ago, their doctor is no longer in practice or they moved. Therefore, surgeons must be aware that good communication and understanding patient concerns are of the utmost importance in addressing revision rhinoplasty. Steven J. Pearlman, MD, FACS
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November 30th, 2009
Treating Crows feet and more with Botox
Treating crows feet comes with relative ease since the arrival of Botox
New York City, NY - One of the first areas to show the signs of aging is the crows feet area. These are the lines that are adjacent to one’s eyes. We all have some lines when we smile but and the lines remain when the smile is long gone, it may be time to do something about them. Maybe this is why oversized sunglasses are so popular; for the younger set sunglasses can help prevent lines and cover them in the older set.
Thank goodness we have Botox. Years ago, we used to inject collagen filler into these lines. Unfortunately, this skin is so thin and delicate, that no fillers are really useful and can leave behind both lumps and serious bruising. While many very popular creams and lasers are touted to remedy crow’s feet, if the cause isn’t addressed (overactive underlying muscle) all these treatments will be ineffective. Botox relaxes the thin circular muscle around the eye called the orbicularis oculi muscle. The skin is less compressed with smiling and squinting so most of the lines go away. However some lines will always remain. If you push your cheek up to simulate a smile, a few lines still form from the skin being bunched.
As an experienced Botox physician, we can extend treatment to adjacent areas. The tail of the brow can be raised in many patients creating a “Botox browlift.”
Browlift with Botox only
Deep lines under the eyes can also be treated… however they should be treated with caution. If a patient has a weak eyelid, the eyelids can become droopy. Also, the orbicularis muscle may be the only layer left holding back lower eyelid fat from pouching out. If you have early “eye-bags” then you might not be a candidate for treatment within this area of the eyelid. I caution all patients who are treated in this area of the eyelids and find that about 1 out of three do not repeat treatment under the eyes.
Some patients even have lines extending down their faces from and below the crow’s feet. Now that we are getting into the mid-face area, Micro-Botox is a better solution. Very tiny amounts are used to help the superficial lines but not change the smile.
Lastly, relaxing the muscle needs help with the overlying skin. Quality skin products such as TNS and rejuvenating eye creams work very well with Botox beneath. Many of the popular over the counter creams make amazing claims but produce little results.
Steven J. Pearlman, M.D., F.A.C.S.
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