Guy M. Stofman, MD, FACS

Guy Stofman, MD, FACS, Certified Plastic Surgeon with UPMC discusses how the pandemic helped to spark an increased demand for cosmetic treatments and what you should consider before any procedure.

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–  This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider. From fillers and lasers, to chemical peels, and more, there are lots of cosmetic treatments that can make you look younger. But can you start some of these too soon? Hi, I’m Tonia Caruso. Welcome to this UPMC HealthBeat Podcast. And joining us right now is Dr. Guy Stofman. He is a certified plastic surgeon with UPMC. Thank you so much for joining us.

– Thank you, Tonia.

– So, you have been in this for a very long time. You have treated thousands of patients, and I would imagine the industry has evolved.

– Right.

– And you were telling me, certainly, the pandemic has affected your field, for sure.

– Tonia, there’s no question about it. It’s this Zoom rush phenomenon. Prior to all of this, you’re in a meeting room, you’re not staring at yourself while you’re talking. You don’t see yourself in a certain way. And then, all of a sudden, you’ve been restricted to congregate with all your colleagues looking through a Zoom lens on a computer. At the end of the day, there is a degree of distortion. You’re not seeing yourself exactly how you look. I can’t tell you how many times in a given week, when I have my weekly office hours, that somebody says, “I just hate the way I look on this computer.” That’s not just one person. It’s been a phenom across the country, and it has driven cosmetic procedures up considerably because of what we call that Zoom phenomenon.

– We’re hearing a lot these days about these fillers, these neurotoxins. You see ads for Botox. We’re also hearing that really young people are getting them. Does that make sense?

– Tonia, these are not new things. They’ve been around for a long, long time. Botox, or the neurotoxins that you referred to, really started in the ’80s for facial asymmetries from nerve injuries or for people that had eye twitches that were uncontrollable. And, they were given these drugs, and somebody with an aesthetic sense started to notice not only did the nerve function or the muscle function become affected, but wrinkles disappeared. So, Botox started as a medicinal component for facial nerve injuries in the central twitching of your eye that was uncontrollable and moved into a Botox arena that catapulted that into a billion-dollar industry. These are neurotoxins. They come from bacteria that they are specially created and developed in a laboratory, if you will. And they make this toxin. It’s a neurotoxin, and it affects the ability of the nerves to control the muscles. It blocks that. So, that’s why when you get Botox in certain places, we’ll say between the the eyes, where they have the the “H lines” or the double lines. When you get that, those muscles have to relax now, because there’s no more nerve innervation. So, essentially, they’ve been partially or completely paralyzed by an injection.

– Are there concerns? What are the benefits? And, then, what are some of the side effects or things that folks need to keep in mind?

– Side effects are rare. It would be unusual to give somebody so much Botox that they’re going to stop breathing. But, certainly, when you over-indulge in anything, that could be a bad side effect. I think the most common side effect, physiologically, would be headaches. There are people that get them across the forehead, especially with the first time. And, the muscle interaction between muscle that’s paralyzed and muscle that isn’t can sometimes cause a tension headache across the forehead. Some of the other side effects could be just when it’s given poorly. You can look like you’re deformed, if the brows are dropped, or if a lip is not being able to move for whatever reason, it’s because most likely, the injector just gave it to them in a wrong place.

– Right. So, that’s why it is so important, when you decide that you want to get one of these treatments, that you go to someone who is experienced.

– Absolutely.

– And, maybe, would you say even ask a friend, if you see that someone has had something done, and you like the way it looks, and it looks natural?

– Absolutely. You know, it’s more than just giving a shot. Because when you’re looking at the face, at that moment, that syringe is your paintbrush as you’re addressing the face. And where you are strategically putting these injections are changing facial expression. And, so, if you do the same thing on everybody, without looking at them and making a diagnosis, almost in a robotic way, I don’t think your results are going to be as good as if you actually look at a person, make a diagnosis, and then decide where these needles are going to go.

– How long does it last?

– Everybody’s different. Your first injection typically will not last. If you’ve never had it before, it’s not going to get that three months that you hear people say. It very well could, but it’s unusual. The reason for follow-up injections over time, every time you inject an area of the face, or wherever else you’re putting it, you’re going to get atrophy of that muscle, right? Because it’s not going to be working for a serious amount of time. Over time, it’s going to come back. But if you do it constantly, you’re going to spread out the time distance, or the interval, between the times you need that injection. The eyes, because they’re thin muscles, they’re large, and they’re constantly moving, don’t tend to get the longevity, as let’s say, between the eyes or the forehead. But for the general population, I tell patients anywhere between two and a half to three months, and they should expect to come back for another round.

– So, this whole idea, and it sort of makes sense, started to read about younger and younger people, getting these preventive treatments. And, it would make sense, if I have it up here, and I’m not squinting, those wrinkles aren’t going to form. Why do you say that’s not necessarily the case?

– Certainly, when we started out doing this, we were not advocating 20-year-olds coming to our office. There’s no data that suggests that if you start early, that you’re going to prolong your aging process, or your wrinkles aren’t going to come around. You’re going to get old no matter what. And it beats the alternative, I tell everyone. But, young people that are doing this in their 20s, I can honestly say I can’t tell them that it’s going to affect their facial aging and delay that.

– So, let’s move from these neurotoxins to dermal fillers. And, in general, that’s a pretty wide class?

– Yes.

– And what is a dermal filler in general?

– A dermal filler is an off-the-shelf product made up of many different things. It could be anywhere from the hyaluronic acids, to certain gels. It could be hydroxyapatite crystals, that come from coral, to collagen. We’ve gone full circle. Collagen was around in the early ’90s, and now we’re going to these very sophisticated constructed products that are designed for different areas of the body, even. So, if you’re going to use, let’s say an eyelid filler, it’s got to be made of a certain consistency. It’s got to be a lighter molecular weight product. Whereas if you’re going to go into the midface, and you’re going to inject that, that’ll be another different type of product with a different consistency. Then, you’ve got products that are made for the lips, that you know, can be put there. So, really, there’s quite a bit of different options that people have out there. As we teach our residents, you have to familiarize yourself with a small amount of products for different use and get good with them. And, then, at that point, once you’re satisfied by the technique of the injection and you’re using it appropriately, like thin, small fillers for thin skin, lips, midface, etc., then you can move on to experiment with others. But the principles stay the same. So, once you know the chemistry and the biology of these fillers, then people shop them for price. People shop them for how it’s stored. Some have to be refrigerated, some don’t. So, there’s a whole different array of reasons why you would use one or the other. For the consumer, they just have to make sure that who’s injecting them just knows what they’re doing.

– So, there are commercials all day long on television promoting these. And, I often wonder, can you overdo it? If you do it for a certain amount of time and a long stretch of time, eventually, are they ineffective, and does your skin sag? What’s sort of the thinking?

– The volumizers and the fillers work. If you put something under a space, it’s going to get bigger. But, all of us have seen patients, or people, that look funny, or look like maybe they shouldn’t do this. And, I say that certainly, beauty is in the eye of the beholder. I think that someone who does a lot of this has to help patients. Sometimes, you can direct them to what is a, what you might think looks good, versus what looks funny. And there’s a fine line in between it. If you have lips that look like there’s bananas in your upper and lower lip, and that’s something you want to look like, well, that’s certainly up to you. But, you as the injector, may not want somebody walking around, telling people, “Who did that to you?” So, at the end of the day, I think you need to be judicious and have an aesthetic sense of normalcy. This is designed to replace what has, over time, been taken away from us. As we age, our subcutaneous tissues, we lose water volume, we lose content, the face becomes flatter, we might jowl. And these fillers have that opportunity to prolong a surgical intervention, if they’re done well. If they are done too much, as we’ve all seen, you’ll know it right away, ’cause they don’t look normal.

– And is that the thing? do most people come to you and say, “I want to look natural”?

– They do. And, so, everybody’s interpretation of natural is different, right? So, if somebody comes, and they have a reasonable expectation, and you can look at them, and you can say: “Listen, I can offer this. This is what you’re going to get out of it. You might have some mid-facial fullness. I might be able to bring your upper lip a little bit. I can establish a cheekbone that you don’t have.” You can reproduce that, time and time again. But if somebody says, “Listen, I’ve got a really deep wrinkle here, and I hate it, and I don’t want to have an operation, so can you just fill this up?” and you put thousands of dollars worth of material into their face, and it looks like they just ate a golf ball, then, you have to say to yourself, “Is it worth it?” And I think there’s a degree of ethics as well. In other words, you don’t want to send somebody out looking so unnatural that it’s noticeable just because you want to capture a fee.

– And, so, I wonder, too, how long, does it vary just by individual? How long do these typically last? So, your body then just ingests it over time? How does that work?

– So, that’s a very good question, and the answer is yes. Over time, it’s metabolized, right? So, like any foreign body that goes into you, the body recognizes it, and it does work to try to get rid of it. And that starts from day one. Each product has a different consistency, has a different ingredient that it’s bringing to the table, if you will. And, so, for that reason, the longevity is variable as well. I’ve put fillers in patients’ lips, and it’s lasted 18 months. I’ve done the same exact thing, and I’ve put it in another patient, and it’s lasted eight months. So, I generally tell people that they have to expect at least a seven-to-12-month period where the fullness is going to be noticeable. And then, at that point, they may have to consider doing it again. But I don’t think there’s any guarantee because everybody has a different metabolic clock.

– Right. Chemical peels, we hear a lot about those. What are they most good for and used for?

– So, chemical peeling is like looking at a menu, all right? You have very good options. Each peel brings to the table an action based on its level of efficacy. What does that mean? You have light-depth peels, medium-depth peels, and deep peels. And, they’ve been around for a long time. It’s not like this is just invented, you know? The European “rejuvenation health spas” in the ’40s and ’50s were using deep acid peels and putting them on people’s faces, and they were coming out with skin that looked 20 years more youthful. But, you paid a price for it: not a monetary price, but a recovery price. So, a light peel, like a glycolic peel, would be considered almost like a lunchtime peel. You can get this done at your salon. It’s typically like exfoliating. Guys are in the shower, we shave. So, every time we shave, we exfoliate our skin to some degree. Women don’t tend to do that. And, so, what happens is they can do it in various ways. So, by taking a light peel, that might over time, as you do it weekly, or you do it monthly, it’ll be a cumulative effect. Fine, fine wrinkles may lay out, Variegated pigment, a little freckle, or an age spot, that you see that’s not so deep or accentuated, that can go away. Then, you go to a medium-depth peel, which will essentially have an effect on a deeper layer of skin, usually a superficial dermis. That’s good for deeper skin spots, or age spots, some melasma, if you will, that can come with birth control or being pregnant. And, that will effectively work, but it’s not necessarily in for lunch and out. You might be red for a number of days. It might even cause some scaling, or some peeling, of the skin, as you call it, a chemical peel. And then, you have the clinical situation where the lines are deep, or the pigment is significant. Older-age skin, people that live in the South, they’ve been in the West, and now they’ve got deep age spots, they’ve got the smokers’ lines they’ve got deep forehead lines. And then you can go to deep peels, that go to deep dermis, but then you’re creating a controlled burn. So, these people need lotions, and recovery time, and they have to be out of the sun for weeks at a time. And, so, people that engage, that want to do that, have to be prepared, because they’ll be out of circulation for two to three weeks.

– Wow. And so. we were talking earlier, you are a professor. You teach up-and-coming doctors the entire time.

– Yes.

– When someone comes to see you, what is the approach? Obviously, you’ve also talked about, you know, sort of being an artist with a paintbrush. So, what do you tell them, and what are things that you want everybody to keep in mind when they come to you?

– So, I think the first thing to be successful at what we do, you have to, like anything else, we’re doctors, right? So, you make a diagnosis. So, the diagnosis between patient and doctor is established. Every consultation starts with a mirror, and it’s, how can I help you? And then, with that, there’s an expectation. You have to have a realistic expectation. If you are 70 years old and you show me a picture of your prom in high school, and you want to look like this, then I don’t think I can help you. But, if you want to age gracefully and allow us to set back your clock, there’s a host of things that we can do. So, again, it starts out the patient has a complaint, or an inquiry, and then you make that diagnosis. Is it poor skin? Is it excess skin? Is it a deep wrinkle? And then, you have to say to yourself, how am I going to address that? Does it need a surgical operation? Does it need, perhaps, a filler, or a fat graft, taking fat from someplace or other, and putting it in a place where it’s needed, or a combination of those? And, then, I think your experience will dictate the right operation, right procedure, for the patient that’s in want.

– Well, when folks do come to you and want surgery, I hear about facelifts, mini facelifts, what is a mini facelift?

– So, we have been, Tonia, doing fairly sophisticated cosmetic operations on younger people that are less invasive. It wasn’t that long ago where you brought up facelift, and that was really something that your grandmother had when she was in her late 60s. But people today, I think a lot of it has to do with the smartphone, and social media, and they’re out there all the time. And so, not every 40-year-old, or 50-year-old, needs the operation that your grandmother had. So, these are essentially, they’re not mini operations, per se, but they’re less invasive. So you’re not dissecting as much as you have to do. You’re not, let’s say, adding liposuction to somebody who doesn’t need it, or you’re not cutting out a ton of skin because they actually don’t need that as well. And there’s certain suture techniques, or less invasive operations, that you can achieve the same thing. And, so, they’re basically the same operations, they’re just less involved.

– I can imagine something’s bothering someone enough that they come and see you. It also, though, has to look a little weird, or self-deprecating. What do you want people to know? Like, I think I would go, and I would be like, “Oh, he’s judging me.” What do you want people to know about how you approach this?

– That’s a great question. But you have have to remember, we’re all professionals. So, it’s no different than, you know, you go to the dentist, you’re worried about your breath being bad. You know? I mean, at the end of the day, we’re here to help you. And I think that the most important thing is, for patients out there, is their word of mouth and the reputation of the people they’re going to. It’s always good to have a friend, or it’s always good to be able to read about somebody. You want to check the credentials, you want to see how well they’ve been trained. So, going back to your question, if you’re going to go to a mechanic, and you’ve got a warning light on your car, and it could be as simple as, “Lady, your gas cap was open.” You don’t want to be embarrassed by going to ask him. No different than you coming to us. There’s no silly question. If you’re good at what you do, and you’ve got ethics, and you feel that you’re doing the right thing, you’ll tell somebody, “Listen, this is something you don’t necessarily need to do right now, but this is my suggestion.” And, again, it begins with a mirror. And you look, and you show what some of the options are, and if it makes sense to the patient, and the relationship has been good from the start, it’s kind of speed dating, right? Think about this: You’re walking in, you’re telling something to somebody very personal, something that maybe bothers them, and you’re spending 15 to 45 minutes with them, and then you’re giving them your body, and you’re saying, “Hey, listen, create this.” And if there’s not a trust factor and there’s not a confidence factor between patient and physician, then you can go to somebody else. So, I think it’s important. You have to have a feel about your consultation.

– And, so, what made you get into this field?

– My goodness, I had an interesting past. I started out an ENT actually, and I was a head and neck oncology surgeon, and I loved doing that. It was very challenging. But I found I liked putting them back together better than I liked taking them apart. So, it started from a intense course on reconstructive surgery, and taking the body apart, to then, becoming less aggressive but having some very powerful changes at the same time. And it slowly gravitated toward elective operations. And, it’s a great feeling, making somebody feel better.

– And you also do medical cases, not simply cosmetic issues.

– Right.

– And talk a little bit about the joy that that brings you.

– And, so, when you say medical, I’m going to call it reconstructive surgery. And, again, that’s the foundation of plastic surgery. And that’s what we take great pride in. If I can take a gunshot wound to the face, that is unrecognizable, and with dozens of operations and little techniques that we’ve been trained to do, and I make them look human again, so that they can get back out there – not that I’m belittling a facelift, but it’s a much less endeavor. But, it gives me the background. Great reconstructive surgeons go on to become great aesthetic surgeons. All of the training that goes into a plastic surgery residency gives them the full breadth of what plastic and reconstructive surgery does. And then, you can take it from there. You know, you can be a skin cancer doctor, you can be a cosmetic surgeon, or aesthetic surgeon as we call it. You could become a breast specialist. So, there’s a total gamut, but it all starts with great learning and great foundations, great principles. And that’s what we’re taught.

– Well, great principles, and great conversations everyone should have with a doctor that they go to see before considering anything.

– Absolutely.

– Is there one tip you tell people to do at home? Like, “You should drink eight glasses of water every day,” or, “You should start moisturizing when you’re 12 years old”?

– Don’t smoke. Don’t overindulge in alcohol. Stay out of the sun to any degree. When I say that, when we were kids, we had reflectors, and oil, trying to burn ourselves. And now, you know, sunblock, go out there, but do skin care health. Moisturize it. Avoid being dehydrated. That gives you the wrinkles that you’re talking about. And, so, if you start early and take care of your body, you’ll find that your skin will follow.

– We thank you so much for coming in and spending time with us today. We appreciate it.

– Thank you, Tonia.

– You’re welcome. I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.

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About Plastic Surgery

Plastic surgery is an option for both cosmetic and reconstructive needs, and the UPMC Department of Plastic Surgery can help with both. Whatever improvement you seek, we can create an individualized treatment plan to help you achieve your desired results. Through our research and clinical trials, we have used cutting-edge techniques in our treatments for more than 70 years. We also have one of the largest academic plastic surgery departments in the United States and operate one of the region’s top centers for restorative medicine.

Plastic surgery is an option for both cosmetic and reconstructive needs. The UPMC Department of Plastic Surgery can help with both. We will work with you to create an individualized treatment plan to help you achieve your desired results. Through our research and clinical trials, we have used cutting-edge techniques in our treatments for more than 70 years. We also have one of the largest academic plastic surgery departments in the United States and operate one of the region’s top centers for restorative medicine. Our goal is to improve your quality of life. Find a provider near you.