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.

I have been asked this question more often than I can count. Patients are afraid that after liposuction, if they gain weight, that they will develop a particular deformity due to all the newly formed fat settling in one particular area. This simply isn’t true.

After adolescence, the number of fat cells in our bodies becomes fixed. The fat cells can increase or decrease in size due to the amount of fat to be stored, however, they will not change in number. (The fat stores in our bodies are the way the majority of our energy reserves are stored.) However, after liposuction, the number of fat cells decreases due to the removal and destruction of fat cells from the procedure. If your diet is in good control, and you are not consuming excess calories, then there should be no change in your fat stores. If, however, you consume more calories than you require, there will be deposition of fat. The question is “where?”

The answer is that the fat will be stored where it otherwise would have been had you not had liposuction. If you are female, the most likely place would be your abdomen (outside of the abdominal cavity), flanks, inner and outer thighs and buttocks. If you are male, then the answer is within your abdominal cavity, flanks and chest. If you underwent liposuction of one of these areas (except within the abdominal cavity which is not accessible by liposuction) then the remaining fat cells in those areas will enlarge as well due to the deposition of fat to the other areas listed here.

The end result if you gain weight after liposuction is that you will look heavier, but more like you would have had you not had liposuction, rather than developing a specific deposit of dreaded fat in one area of the body.

To your health & beauty,
Mark Epstein, MD

Do you take vitamins and herbal supplements on a regular basis? Although there are both anecdotal and scientific reasons to do so, many herbal supplements can interfere with surgical recovery, from increased bleeding to unwanted anesthesia interactions. By telling your plastic surgeon what you take, he or she can tell you what to avoid prior to cosmetic surgery, and ultimately decrease the risks for potentially dangerous side effects!

Many of today’s miracle drugs (penicillin, digoxin, codeine and many others) were derived from plants. Conversely, many plants that are not used as a source for medicines do have potent biologic activity and can produce problems if taken shortly before or after surgery. Here is just a short list, not all-inclusive, of potential problems that can occur from taking some herbal preparations around the time of surgery:

• Ephedra - Possible complications: heart attack and stroke
• Garlic - Possible complications: bleeding during and immediately following surgery
• Ginkgo - Possible complications: bleeding during and immediately following surgery
• Ginseng - Possible complications: bleeding during and immediately following surgery
• Kava - Possible complications: may increase the sedative effect of anesthesia
• Saint John’s Wort - Possible complications: may cause acute rejection of a transplanted organ by interfering with anti-rejection medications; rejection may begin within 24 hours of taking Saint John’s Wort
• Valerian - Possible complications: may increase the sedative effect of anesthesia
• Vitamin E - Possible complications: bleeding during and immediately following surgery

It is imperative that you discuss with your surgeon any herbals or over the counter drugs that you are planning to take around the time of your surgery. Furthermore, it is best to stop all herbal medications, supplements and megadoses of vitamins within a few weeks of your surgery. Write a list of any herbal preparations you take along with the medications you regularly take on a piece of paper and keep this list in your wallet.

To your health and beauty,
Dr. Mark Epstein

Women in their 30’s need the real skinny on whether they should start receiving Botox and fillers, microdermabrasion and laser treatments at a younger age to prevent future wrinkling. Logically, many young women wonder if this might be a bit too early and, hence, a waste of money.

Unfortunately, the clock on the aging process begins upon exit from our mother’s womb. If you look at a baby, they have chubby cheeks with plenty of “baby fat”. There is nothing different about baby fat, it is just fat. That baby fat begins to disappear in the first few years of life. Look at a 5-year-old child; already their face is less full of “baby fat.”

The aging process consists of several components:

• Loss of volume (as just discussed),
• Gravitational descent of facial structures (both skin and fat as well as the deeper contents of the face),
• Skin surface wear and tear and
• Biochemical changes to the skin, such as thinning of the dermis and loss of elasticity.

These changes don’t begin when we hit the milestones of 20, 30, 40 or even 50 years of age. Rather, these changes begin immediately as we begin our lives. So then, the question is, at what age to do what?

There are two approaches: Preventative and Reparative.
Preventative is easy, but you really need your parents to have been proactive. When we are children, the last thing we think about as we go outside and play is to put on our sunscreen. Much of the sun damage that occurs to our skin happens when we are children; too young to know to prevent it. And to those of you who are reading this and have small children, take note. You can protect their skin now.

Ok, so what can you do now? Now it’s time for the reparative activities to repair the damage. Just about everyone has some element of damage to their skin due to sun exposure. It is never too late, nor too early to learn how to protect your skin and use topical agents to repair some of the damage to your skin. A knowledgeable aesthetician can evaluate your skin and make appropriate recommendations. I think that anyone concerned about his of her facial appearance should pursue this. It is easy, painless, not very expensive, and can preserve as much of your appearance in the future as possible. Maybe even undo some of the damage you already have.

Where do Botox and fillers fit in? Botox is a purified protein derivative that relaxes muscle. Although Botox has over 100 medical indications for use, in the face it relaxes the muscles that cause facial lines, hence the lines fade. This happens only for as long as the Botox is working, then the lines come back. Botox lasts about three to four months, so it is advisable to repeat treatments at those intervals to maintain your new look. Fillers, on the other hand, replace lost volume to the face and fill lines that are not due to muscle activity, such as the nasolabial folds, or “smile lines” on your face. Most fillers are temporary, lasting from 4 to 24 months, depending on the particular filler. I personally do not believe in permanent fillers such as silicone as there have been some problems with them, and facial aging continues, so what looks good now, may not look good at all in several years. I think that anyone over 18 years who has concerns about facial lines that would be improved with Botox and/or fillers, or wishes to enhance the fullness of their lips should give consideration to using Botox/fillers.

There are many other non-surgical treatments for facial aging of varying efficacies. It is beyond the purpose of this blog to evaluate each one, but this group includes chemical peels (of which there are several types), microdermabrasion, and radiofrequency treatments. I do not believe that there are any age minimums here either, so if you are over 18, I think that these can be considered. The main thing is to find a knowledgeable plastic surgeon or dermatologist to consult.

There are many different types of laser treatments. Laser treatments and chemical peels are essentially facial resurfacing treatments. By removing the outer layer of the skin, the skin will re-heal by generating a new outer layer. Different peels and laser treatments ablate (remove) the skin to different depths. The deeper you remove the outer layer of skin, the more rejuvenation you get, but there is more downtime and potential for scarring. Young women (and men!) with minimal sun damage can benefit from light peels even while still in their early twenties. As you age, and as there is more damage to the skin from the sun (and there is also a strong genetic and environmental component) deeper peels and lasers may be required. Again, this is best discussed with your dermatologist or plastic surgeon.

The next issue is surgery. The purpose of surgery is to remove excess skin, elevate and re-position structures that have fallen due to gravity and to improve on issues that may have existed even before noticeable aging. Surgical procedures include facelift (rhytidectomy), eyelift (blepharoplasty), browlift, nasal surgery (rhinoplasty) and liposuction (usually the neck and jowls). Most all surgical procedures can be repeated as the aging process continues.

When deciding if it is too early to think about surgery, I would suggest putting aside your age and just look at the deformity. If your plastic surgeon feels that a substantial improvement can be had with the procedure, then it might be worth proceeding, even if your chronological age may be earlier than you would think would be appropriate for the given procedure. For instance, I have several patients who have consulted me for facelift and eyelid surgery even though they had the surgery 10 or 15 years earlier. The previous surgery is in no way a hindrance to the performance of a quality surgery once again.

The bottom line is to use the technologies at our disposal to maintain your youthful look as long as possible. Each of us ages in our own way. For some, Botox and fillers at 24 is a normal and correct choice. For others with a different set of genes and different habits with the sun, alcohol and tobacco, they may not need this until they are 40. The mirror will give you clues and your board-certified plastic surgeon can help you make the right decisions.

To your health & beauty,
Dr. Mark Epstein