In my busy aesthetic surgical practice, I see many patients desiring to rejuvenate their facial appearance, but they are not sure as to what they need. They ask me if they need. They ask me if they should get Botox or fillers, which is less invasive than surgery, or go with surgery for a more long-lasting result.

What I will share here is my approach, which is integrated from both plastic surgery and dermatology.

The key to successful facial rejuvenation is no different that for any medical problem: accurate assessment or diagnosis of the problem followed by correct treatment. I have defined six key areas to assess.

1. Skin quality – Years of chronic sun exposure as well as environmental and genetic factors can induce fine lines and wrinkles, pigment changes, loss of elasticity and overall complexion problems. Here the treatment is to address the skin with topical agents. Botox, fillers and surgery have really no role here. Our aesthetician can refresh the facial skin using various types of peels and other typical agents. This does require compliance, but the reward is fresher, more radiant and youthful skin. Think of it not as a short-term treatment to fix a problem, but rather as an ongoing maintenance, just as is proper diet and exercise.

2. Dynamic lines – These are wrinkles produced in the skin as a direct result of the contraction of underlying facial muscles. Examples include horizontal forehead lines, vertical glabellar–the area of the lower forehead between the eyebrows–lines, and crows’ feet–the area just outside the eyes, and vertical lip lines. Treatment requires the muscles to be relaxed. Botox is the best way to achieve this. Thorough understanding of facial muscle anatomy and function is required to selectively relax these muscle anatomy and function is required to selectively thee muscles to give a more youthful appearance without producing a mask-like or surprised appearance.

3. Static lines – These are lines produced not by facial muscles but by a combination of loss of facial fat with aging and also stretching of skin and sagging due to gravity over time. Examples of these lines include the nasolabial folds (the lines between the cheeks and the upper lip extending all the way down from the nose to the corners of the mouth) and the marionette (puppet) lines, which are extensions of the nasolabial folds further down the face. Although surgery can be helpful here, a very popular and effective way to treat these lines is to restore the lost volume to the face. This is done with fillers. Examples of fillers include Collagen, Restylane, Juvederm, Perlane and Radiesse. The longevity of the result varies among the different types of fillers used. For a more complete discussion of Botox and fillers, please visit www.epsteinplasticsurgery.com.

4. Loss of facial volume – As we age, even as a small child, there is loss of fat under the skin, which can become pronounced when we are in adulthood. The cheeks hollow and a “tear-trough” may develop under the eyes at the junction of the lower eyelids and cheeks. Fillers work very nicely here, but surgery can improve these areas as well.

5. Sagging of facial structures – Gravity, loss of facial skin and muscle tone result in the descent of important facial features such as the eyebrows, malar area (the prominent part of the cheeks under the eyes) and the development of jowls. In this case, surgery is usually the best option (brow lift, facelift) although Botox can do a nice job of elevating the tail of the eyebrow and fillers can sometimes reduce the depression between the jowls and chins, giving the “illusion” of a smoother, more unified jaw line.

6. Redundant skin – Loss of skin elasticity and gravity as well as genetic factors weigh heavily on the development of redundant or excess skin. This develops over the entire face. During facial surgery, the skin is re-draped over the deeper facial structures permitting removal of the excess skin. Although Botox and fillers have no role in correcting redundant skin, they may be useful adjuncts after surgery to restore lost facial volume and correct wrinkle lines due to facial muscle activity.

Our practice offers the services of myself, a plastic surgeon, as well as that of Elyse S. Rafa. M.D., a dermatologist (both of us board-certified) as well as Irene Maher, an aesthetician. All of us would love the opportunity to meet with you for a complimentary evaluation to help you decide whether you need Botox, fillers or surgery. It’s our job and our pleasure to assist you in the important task of maintaining a beautiful facial appearance.

To your health & beauty,
Dr. Mark Epstein

While doing some grocery shopping tonight (yes, plastic surgeons do grocery shopping – my spouse is a dermatologist so we split the household chores) I saw this month’s Life & Style cover story “Heidi’s New Surgery Disaster.” Being a cosmetic plastic surgeon this naturally piqued my curiosity so I bought the magazine and read it when I got home.

The essence of the article is a story about how Heidi regrets all the surgery she had, about ten or so operations performed at once, at a cost of over $100,000. There is an extensive pictorial showing her multitude of scars, which are portrayed as horrific. I am not writing this blog to defend what was done, but rather to make a few comments on my observations and offer my opinion.

1. No one “needs” cosmetic surgery. Sure, we may see someone with a large hump on their nose and say they “need” to have it fixed, but they really don’t. The purpose of cosmetic surgery, as I see it, is to make a person feel better about the way they look, that is, to make them more comfortable in their own skin. There is other reason to have cosmetic surgery than to make you feel better. Never do it for someone else.

2. Do not let your surgeon “talk” you into having anything done that you are not in agreement with. Heidi discussed having liposuction on her legs, but later expressed remorse that the scars did not justify the results and that her surgeon talked her into it. As her surgeon recently and very unfortunately met a tragic end, we will never know the truth about that.

3. Surgery does not happen without scars. All humans form permanent visible scars when their flesh is wounded. Some scars are less apparent than others. As plastic surgeons, we learn how to plan our incisions, close wounds, perform surgery and handle tissues so as to minimize scarring, but we cannot eliminate it. Some patients will form scars more visible than other patients. As surgeons, we have no control over patients biologic wound healing properties. I inform all of my patients of this fact many times over before surgery is performed.

4. Surgery is stressful. Altering your physical appearance, even for the better is stressful. Combining the two can produce stress as well as emotional ups and downs in the immediate period after surgery. This is all normal, and again, I advise all of my patients about this. I even have a cute little diagram that we give them before surgery to explain this. Some patients undergo two or three procedures in a single sitting. With advances in surgical and anesthetic technique, this is rarely an issue. However, where do you draw the line? I am not sure just what the limit should be, but I do believe that ten procedures at once is probably a bit much.

5. With the exception of Heidi Montag’s breast augmentation, I think that most of her results look good. Maybe not perfect, but plastic surgery is rarely perfect. Let’s face it, our tissues are rarely perfect and the surgeon can only work with what he is given, but that doesn’t mean he can’t still deliver exceptional results. My suspicion is that Heidi was not adequately counseled before her surgery about what to expect in terms of results and scars after the surgery. As far as her breast augmentation, I think that that alone can be the subject of another blog, but suffice it to say that it is ill advised to go from an A or B cup to a G cup. The destruction to the breast tissues is irreversible and uncorrectable. A properly performed augmentation based on the natural characteristics of the breasts yields excellent, natural results with minimal risk of problems, both in the short term as well as the long term.

My advice for those interested in plastic surgery is to not be put off by Heidi’s unusual story. Her story is one of a woman with perhaps unrealistic expectations, a long list of features about her body that she wishes to correct, a surgeon who more than pushed the envelope on what in my humble opinion is reasonable and a lack of appropriate preoperative counseling and preparation.

I recommend those interested in cosmetic surgery to do your research. Spend time on the Internet looking at lots of plastic surgery websites. Learn as much about the procedure that you are interested in. Visit several surgeons. Ask lots of questions. Speak to patients who have had the surgery that you are interested in. IF you personally know people who have undergone the surgery that you wish, visit their doctor as well. An informed patient, as with any other consumer, will in the end be the happiest patient.

To your health & beauty,
Dr. Mark Epstein

In my practice, I find that most consultations for facial aging are driven by a patient’s concern about a particular feature of their face that bothers them. Rarely do they ask me for my opinion as to what is making them look older, nor do they have concerns about large areas. And the fact is, many times what the patient is concerned about is a minor factor in making them look aged or tired, and they are overlooking more significant factors. All the components of the face age simultaneously. Around the eyes, sometimes the uppers or the lowers may look more severely aged than the other. Rarely, however, does the patient appreciate the role played by the brow in the appearance of age in their face.

In order to evaluate the upper eyelids, first you need to assess the brow. If the brow is low, there may be hooding of the brow over the upper eyelid; the patient may think they have an upper eyelid problem. The thing is, you do not want to remove excess brow skin to “tighten the upper eyelid” when the problem is, in fact, the eyebrow. If you do this, then you will just tether the brow down, when if fact it needs to be elevated. I manually elevate the brow to where I think it belongs and then I assess the upper eyelid for excess skin. If there is still excess skin after elevating the brow or fat protruding through the skin, then an upper blepharoplasty is indicated. If the brow doesn’t require elevation, then no browlift is required.

In a consultation for a blepharoplasty in my Stony Point plastic surgery office, the lower eyelid is evaluated independently of the upper eyelid. If there is excess skin, then an external incision just under the lashes is required to remove the excess skin. If there is no excess skin, but there is excess fat protruding through the lower eyelid, then I make an incision just inside the eyelid to approach the fat only. When there are a combination of problems, sometimes I use an approach from both sides. This allows me to preserve the middle muscular layer of the lower eyelid to prevent the development of deformities due to scar contracture later.

Before and After

Patients often ask me if they can avoid a face lift and just focus on the neck. The question is also asked the other way around: is it possible to have a facelift without a neck lift? This is my response:

With the advent of techniques that permit greater facial rejuvenation with less operating time and less risk of nerve injury (such as with the MACS lift), I believe that the neck should be treated with the face for a variety of reasons.

Aesthetic reason: The neck ages with the face. For example, they are both exposed to the sun in equal amounts (this assumes you don’t wear a turtleneck every day of the year!). It is a very rare case indeed (I’ve actually never had one) where the neck couldn’t benefit from surgical rejuvenation at the same time as the face. As I am already there, why leave it out of the equation when there is benefit to be gained?

Technical reason: If you are having the face lifted, then you need the neck skin to come up and re-drape over the jawline. It takes only a few minutes to undermine (elevate) the neck skin (I like using power-assisted liposuction with or without suction as needed). When elevating the cheek skin (I prefer the MACS lift) it is a simple extension of the surgical plane to enter the neck. After lipo undermining, this is very easy and quick. As the MACS lift is a pure vertical lift, it is a natural extension to bring the neck skin up to the jawline and at the same time elevate and tighten the platysma (the thin, flat muscle in the neck). I see little to gain by treating the neck without the face and vice-versa. Doing them together gives a much more natural look, which is what you want, right?

Give a jingle to our Stony Brook plastic surgery office if you’re thinking it might be the right time for some neck and/or facial rejuvenation. I promise we’ll guide you to the right decision for you.

To your health and wellness,

Dr. Mark Epstein