Jim lies in a hospital bed clinging to life as I write this blog. Ten months ago he was diagnosed with severe mitral valve disease and advised to have surgery. Jim declined. As his health deteriorated he could no longer put off surgery. He had a choice of going to a community hospital or to a university hospital. He wanted to stay near home so he chose to stay in the community. The morning after surgery as Jim lay in the cardiac intensive care unit he complained of vague chest pain. He complained several times until his nurse said ” Now, Jim, You have just had open heart surgery. You should have chest pain.” Six hours later his right lung collapsed. Several hours later the left. Then kidney function deteriorated. Now he clings to his life.
Kyle needed surgery for cancer of the esophagus. The cancer was limited but Kyle was obese and not in good shape. I told him that if he went to a community hospital he had a 25% chance of dying from the surgery vs. only 1% risk of mortality at a university setting. Kyle wanted to stay in the community to be near his wife. Kyle declined to be operated on at a university hospital in Chicago. Six hours after surgery Kyle’s kidneys began to fail. Three days later he was dead.
The evil secret that no one wants to say is that community hospitals cannot provide the post operative support for major surgery that a university hospital can provide. An excellent surgeon can do his job to the best of anyone’s ability, but life and death hangs in the balance of the post operative care unit. Another evil secret is that affiliations of community hospitals with university hospitals are economic alliances and do not bring the level of care of the community hospital up to the level of the university center.
The trauma of a life threatening disease is difficult at best and emotionally traumatizing. It makes little sense that the welfare of a patient is left to the economic survival of a local hospital or the medical staff of a community center. Decisions like these should not be at the whim of emotions of a confused and traumatized family. The only solution is to have centers of excellence where such difficult surgeries can be most safely performed. In fact, we have the centers and we have the statistics to prove them. What we also have is a politically dominated system that cares more for the economics and welfare of local politicians and health care systems than for the welfare of a patient.
Every patient needs to read the book “How Doctors Think” by Dr. Jerome Groopman. Do this before you need to make a decision. Do it before someone has to write a blog about a person close to you.

The poor prune. Delicious and rich looking as it may be it is saddled with epithets like “prune-face”, a “wrinkled grape”, and a prune every morning keeps you “regular”. For a fruit whose taste is enjoyed by so many the euphemisms seem dishearteningly displaced and not the least metaphoric. I mean, isn’t the image of the aging face wrinkled and collapsed? Don’t we think of the elderly as sweet and interesting but not to be overindulged? Of course neither you (the reader) nor I know what it is like to be “old” but like a red face in an embarrassing moment we know it when we see it. And none of us want to be there.
That said, what is going on here? How is it that the firm and beautiful grape that makes such lovely wine becomes the wrinkled prune with time? How do our faces age and can we arrest time? Yes we pretty much know and yes we can arrest some of the aging process of the face. The obvious attempts by some actors and actresses with fat lips, pulled faces, and altered mouths hardly qualify as arrested aging. More like promoted grotesque. The reality is the subtle modifications best exemplified by Meryl Streep and Kate Winslet are difficult to discern and so pleasing to the eye.
Cosmetic surgeons agree that the aging process is one of deflation. The most noticeable changes are the loss of facial fat and with its disappearance the face collapses. More subtle changes include loss of muscle and bones. Bones atrophy and whither and this is especially noticeable in the orbital bones around the eyes and in the maxilla and mandible which frame the mouth. Eyes sink in, bags appear beneath the eyes (often accompanied by dark circles) and the mouth recedes into oblivion as lips vanish and withdraw into the recesses of the mouth. (The visuals are almost too much to bear). To this the skin envelope, hanging from attachments to formerly firm muscles and subcutaneous tissue, degenerates with elastotic changes due to damage from the sun and wrinkles in a prune-like fashion into an amorphous cover.
Yet there is some good news. Joel Pessa, MD. a surgeon in the Department of Plastic Surgery at University of Texas Southwestern Medical Center, has done extensive work on the fat compartments of the face. Because of his work we now know that fat is distributed into fat compartments and is not a confluent layer under the skin. This adds mightily to the work done by Roger Amar, MD, of French fame who observed that the form of the face follows the tension and thickness of the muscles of facial expression. Now, knowing where the muscles of facial expression exist and knowing where the compartments of fat exist, we can erase many of the signs of facial aging by enhancing these two structures.
In my opinion fat grafting is the best material with which to reconstruct these tissues. The reality is many of our patients, in fact those most in need, may not have enough fat to harvest and others do not want to share their fat with their face. (Shame, shame! Why look older and more gaunt by not keeping up your weight.) Facial fillers have created remarkable results in the past 10 years toward improving facial outcomes. What is important here is that injecting fillers into facial lines is not only passé, it looks unnatural. The medi-spas and the untrained practitioners of cosmetic enhancement and surgery who not recognize that a youthful face is properly structured are out of touch. They are penny wise and pound foolish. Restructuring the face requires not only proper placement of augmentation, but the time to do it correctly (Picasso did not sculpt in one day, why should facial rejuvenation be done with a single filler intervention?). Aging is a process and so is its remedy.
Next week, popularization of a collagen promoter to naturally recreate lost tissue in the aging face.

Professor Higgins: “Why can’t a woman … be more like a man? Men are so faithful, gracious and nice. Men are so caring, sagacious and polite. So why can’t a woman … be more like a man?”
This is another version of “Men are from Mars, Women are from Venus”. Perhaps more chauvinistic and without acknowledging biases, yet trying to understand the differences between the sexes. And yes, there are differences. Perhaps they are due to hormonal influences, perhaps to genetics. Hell, 2 X’s are not equal to an x and a y whether we are talking about algebra or genomic determinants.
My computer guru calls his computers “He”. He says computers are male because they always do what he tells them. And yet might it be that males and females don’t ask the same questions or even see the same question in the same way? Might it be that the color green to a female is not the same color green to a male, or that 3 objects laid side by side representing a gun, a doll, and a baseball evoke different emotional responses in males and females.
Without question this is true of appearance. When a man looks in a mirror he sees a preconceived notion of how he appears, mythical as it might be. When my son was 5 years old he had a plastic vest that transformed him into The Incredible Hulk. One day I watched him don his muscles outfit, then walk in front of a mirror, flex his barely visible biceps and pecs, and roar as only The Hulk could do. Clearly, in his mirror, he was The Hulk. Not uncommonly that is how men see themselves as they prepare to go out for an evening.
By contrast, women prepare for a party by prepping their hair, putting on their fine clothes, maybe some jewelry and finally add a dash of provocative perfume. They go to the event feeling very beautiful and then a photographer asks if he may take a picture. After seeing the picture the party is over. Why is my nose so big or I can’t believe the pimple on my nose. My hair just isn’t right and I look older. Or worst, I look like I am bulging out of my clothes. The beautiful lady of a few hours ago has become Cinderella.
Women are simply more critical of themselves than are men. Both visualize themselves in the mirror or the photograph as they wish to be seen. But men have other attributes that they use to bolster their ego: wealth, muscles, strength, wit. Women still find themselves in the unenviable position of judging themselves by their sexuality. And this leads me back to Oscar night where the female actresses not only stole the show with panache. They did it with self-confidence. They had full figures, strong bodies, healthy demeanors, and intelligence. In my judgment they did not present themselves as sexual aperitifs but rather as healthy examples of beauty and self-worth in their gender. They can avail themselves of breakthroughs in cosmetic wellness without looking grotesque and emaciated. They can go to a cosmetic surgeon for non-invasive or invasive procedures to enhance their appearance without confusing their wish to be attractive (vanity), with narcissism.
In this regard men have a way to go. We still pretend to hunt the saber-toothed tiger and derive our self worth from our manliness. We are still afraid of our emotions and fear our own sense of narcissism when we want to look attractive and be accepted. And yet even here, the world is changing. 20% of men make up the population of people who have major or minor cosmetic improvements. Magazines that promote sensible dress are popular. For this we can take a page from women: healthy appearance begets a healthy response from others. Enhancing what we are given at birth: a musculoskeletal form; a soft round subcutaneous shell; and flexible, elastic, smooth skin is the opposite of narcissism. It is vanity in its finest sense of self-appreciation. We can do this with our knowledge of skin care, our fillers and Botox, our lasers and sometimes our knife. But always with perspective of what is healthy, natural, and long-lived, of what is a healthy life-style.
Next week: Looking at aging mechanistically and how we can modify its effects.

The Oscar show is always a fun-filled affair, although mostly boring to the television viewer. For me it is an insight into popular social trends in the US especially as regards appearance. Last year I noted that the producers kept the anorexic youth characterized with their not so young leader Angelina Jolie in the audience and instead featured mature women on stage sporting full faces and bodies and appearing most beautiful. I need only refer to Kate Winslet and Meryl Streep.
This year the trend continued with two obvious additions. There were teen-aged actress presenters who looked healthy with few exceptions, although their dresses were less than flattering. And more importantly on stage were mature women with full bodies who now showed off muscular arms, shoulders, and necks – a result no doubt of some serious weight lifting. The emaciated look of half-starved and emotionally unhappy youth has been abandoned in favor of health and vigor and with it a much more mature and gracious appearance (delete that for a rather immature acceptance speech for Monique, an otherwise talented actress).
So with all due praise now rendered, it is time for me to give out awards for the worst appearing actress and her runner-up. In both cases the award is given for poor choices and in spite of the fact that I have very high regard for the social sophistication of both actresses.
The worst-face runner up clearly goes to Sarah Jessica Parker who mangled her skin and had the most peculiar hues I have seen on such a show. I don’t know if she sprayed herself with self-tanning solution or pickled her face in the sun but either way the color, texture, and hue of her face was not complementary. Also, her smile seemed constrained, though her personality was not, and could that have been the result of minor surgery or botox? I simply do not know. I continue to admire her work both in front of and behind the camera, yet she will grow drearily old before her time if she continues to hide behind poorly conceived cosmetic masks.
The winner of the worst face on Oscar night goes to Sandra Bullock who not only lost weight and aged her face but compounded it by framing her face with long hair making her face look even less attractive. She alluded to this in the red-carpet interview in which she said she will hurry to devour a hamburger and fries as soon as the event was over.
For me, this was the healthiest Oscar ever and the maturity, beauty, and grace of the female participants has not been equaled. The lessons for all of us are: a healthy and youthful face cannot be long and narrow; skinny adults look old; and long hair framing the face of an adult adds 10 years to appearance. There are now a panoply of treatments to produce a healthy and youthful face and I will address them next week. However, they all start with a healthy diet and a healthy attitude toward body shape.

My wife won’t let me have lunch with Liv Ullman. At least she won’t facilitate my having lunch with Liv Ullman. My wife is Swedish. Liv Ullman is Norwegian (almost the same). We will be visiting Swedish friends outside of Nice next summer. Liv Ullman lives outside of Nice. I have asked my wife to call her best friend to find someone who knows Liv Ullman and to invite her to have lunch with me. My wife laughs. Maybe she is jealous! I really don’t know. But Liv Ullman is 70 and I am 65 and sometime in the future we will be dead and I won’t be able to have lunch with Liv Ullman so I need to do this now.
Suffice it to say I am infatuated with Liv Ullman. How many dreams, how many memories do each of us put away, put off, hoping that by serendipity one or more of them will come true. What we do pursue may happen. What we do not pursue almost for sure will not happen. At the very least we can each put ourselves in a position that something good can happen, or that something we want to experience will be there to allow us to interact.
Being a doctor is like that. I meet people from so many walks of life: rich and poor, famous and infamous; artists and trades-people. I have a woman patient who is attractive and svelt and operates heavy machinery at construction sites. I have met professional athletes from many countries, some highly educated, others not. All of my patients have a different experience, a different perspective on life than I do. In fact, I can say that every person I have met who may or may not read this blog has been a fascinating person for me to meet.
I watched Liv Ulman being interviewed. She said that for the drama of life to unfold each of us has to allow ourselves of us to keep our fantasy, our view of ourselves, our view of the world, our view of each other. She calls this acceptance. She paraphrased Tennessee Williams in saying that if the characters in a play recognized each other the play would never have occurred. She made a plea not to crush someone else’s fantasy.
Yet often that is what I do professionally. I crush people’s fantasies. I tell them their hair styles are not becoming, their make-up is too gauche, their waistline is greater than they think and they keep wearing their pants lower and lower. I tell women they look like men as they age and I tell men that when they are naked they don’t appear as powerful as when they are wearing a suit. I might feel bad about all of this except that I also promote other fantasies. I tell my patients that they can be anyone they want to be if they are willing to work for it. I tell them if they will leave the comfort zone of Kabuki make-up they might feel as attractive as they would otherwise look. I tell them that by walking 4 miles outdoors daily they will wash away many of the troubles of their day and they may self- actualize. Also they will lose weight. I tell teenagers and college students that they won’t have to search for a job if they will learn another language. I tell them that a degree in communication is a euphemism for learning how to talk, and I expect it is a given that someone with a college degree can speak. I tell them that a degree in marketing is a job description for Barnum and Bailey Circus and if they want to make a difference they need to create something or help someone instead of selling a nameless item in return for an ill-begot salary. I tell them there is a fabulous world out there waiting to embrace them but they must travel and think of goals to achieve. Most of all, I say that each day is a blessing to be lived with awareness.

The dichotomy in the hype of filler products for facial rejuvenation has confused physicians and made intelligent comparisons on the part of the public virtually impossible. In order to understand the confusion in marketing fillers I will divide the protagonists into 2 camps: the manufacturers and salons (medispas) vs. cosmetic surgeons which include sophisticated dermatologists, facial plastic surgeons, plastic surgeons, oral maxillofacial surgeons, and oculoplastic surgeons.
The hype looks like the following:
Manufacturers must sell as much product as possible to maximize profits. In order to increase consumer consumption, marketing revolves around simplistic notions of instant repair such as erasing nasolabial folds- the fold between the sides of the nose and the corners of the mouth and advising frequent re-treatments.
Medispas likewise promote simplistic makeovers which are quickly performed and provide instantaneous results.
These promoters can get away with such obfuscation by exploiting the difference between the forest and the trees. As the saying goes we tend to focus on the trees and not appreciate the forest much as we might not recognizing the elephant in the room.(Kindergarten: How can you tell if there is an elephant in the room. Answer: By the faint odor of peanuts on his breath). A typical patient complains about a line around her mouth and misses the point that her cheeks and eyes are sunken-in which not only causes the line but is the real reason she is looking older. By contrast a child with a scar on her cheek looks youthful and has a scar. (Don’t fall for the “I will just inject filler under your eyes and your circles will go away” either.)
Manufacturers and medi-spas also promote differences in products in order to justify more and less fee schedules for products. They do this primarily by claiming that different products have different longevities which is a concept that is easy for the public to understand. Longer duration of correction should provide lower cost over time and less need to retreat. They conveniently do not explain that in areas of the face with more muscle contraction fillers have shorter duration of action and visa versa. Therefore hyaluronic acid infiltrated into a cheek may last 2 or more years and sculptra may last up to 6 years whereas the same products placed around the mouth may last up to 70% less.
As I have been teaching at MetropolitanMD for the past 10 years rejuvenating eyes, cheeks, and temples not only lasts a relatively long time, the results do make one appear more youthful and healthy. The first step in facial rejuvenation is knowing why one looks older before it is possible to resolve the problem. It is kind of like putting a bigger burger in your sandwich vs. covering it with a larger bun. It’s all in what you want