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Steven J. Pearlman, MD, FACS Dual Board Certified in Facial Plastic Surgery

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Teaching Facial Plastic Surgery

Teaching Facial Plastic Surgery in Las Vegas

I just returned from Las Vegas where I was lecturing at the 7th annual Multispeciality Foundation course on Facial Plastic Surgery. The first reaction from friends is, “oh, Vegas must have been a lot of partying and fun.” This course is so comprehensive that I didn’t want to miss anything, so I was inside the lecture halls from 7 AM until after 6 PM every day for 4 days straight. At night were dinner demonstrations and meetings with the various laser, filler (Juvederm, Restylane, Radiesse, Sculptra, Belotero) and neurotoxin (Botox, Dysport) vendors to see what’s the latest and greatest.

I gave four talks at this meeting. Three were on rhinoplasty:

  1. spreader grafts for primary and revision rhinoplasty
  2. What causes nasal obstruction other than a deviated septum
  3. Treatment of the complications of rhinoplasty
  4. Wow cheeksTM How to make nasolabial folds look better than just treating the lines. 

I also moderated a half day session on eyelid rejuvenation, including lectures on blepharoplasty, browlifts, Botox and fillers for the eye area.

This meeting has an amazing cadre of lecturers, equal numbers from each of the “core” disciplines of cosmetic surgery: Plastic Surgery, Facial Plastic Surgery, Oculoplastic Surgery and Dermatologic Surgery. Attendees can really see how different specialists approach facial aging and the varying ways that internationally recognized experts from each discipline treat facial aging.

This meeting was a true testament to the organizing committee and founder Dr. Randy Waldman; a long time friend and facial plastic surgeon (in that order of importance) from Lexington, KY. He ran a similar but smaller meeting in Newport Beach, CA for 17 years before this and is a true meeting genius.

Steven J. Pearlman, MD, FACS

Botox New York and Hollywood

Why do celebrities get such bad Botox?

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.

Rhinoplasty, Botox, Fillers Pre-wedding

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.

Browlift, Botox, Revision Rhinoplasty, Neck Liposuction, Otoplasty

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.

Teaching Facial Plastic Surgery in New York

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.

  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.

Browlift and Botox in New York

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

Center

Peak of brow
Peak of brow
Tail 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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