May 11th, 2010
It’s wedding season, why not get freshened up.
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.
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April 23rd, 2010
Heidi Montag: too much, too young
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.
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April 14th, 2010
New York, NY
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.
- 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.
- 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.
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April 6th, 2010
Role reversal or just an early Mother’s Day?
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
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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
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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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