Dr. Epstein featured in Forbes
Dr. Epstein featured in Forbes magazine article on increasing trends of using tax refunds for plastic surgery.
Dr. Epstein featured in Forbes magazine article on increasing trends of using tax refunds for plastic surgery.
The goal of otoplasty in the treatment of prominauris is symmetrical restoration of the ears to an aesthetic position with respect to the side of the head. Most commonly, this is accomplished by the creation or enhancement of the antihelical fold. In addition, reduction in the projection of the conchal bowl may be required with manipulation of the antihelical fold. While myriad techniques exist to correct the poorly formed antihelical fold, most involve cartilage weakening and suture placement. Herein we describe a simple and effective technique for cartilage weakening using electrocautery. Using this technique, otoplasty can be performed in a reproducible fashion with a low incidence of complications. In the more than 60 patients treated with this technique, there were no complications related to the use of electrocautery, and excellent results were consistently obtained. (Arch Facial Plat Surg. 1999;1: 204-207)In the early part of this century, most otoplasty techniques relied on full-thickness incisions or excisions of cartilage to create the antihelical fold. One substantial disadvantage of these techniques is the unnatural-appearing sharp contour imparted to the antihelical fold. Most contemporary otoplasty techniques use cartilage sculpting to weaken the spring of the cartilage, thus reducing the tension on subsequently placed mattress sutures that serve to secure the position of the antihelical fold. This suture fixation is necessary until fibrosis of the perichondrium provides permanent fixation. The original sculpting techniques relied on the characteristic of auricular cartilage to curl away from its scored anterior surface. Subsequently developed posterior surface cartilage sculpting techniques are the approach of choice for most contemporary otoplastic surgeons. Many methods of posterior surface weakening have been described. These maneuvers include longitudinal wedge excision, scoring, abrading, and partial-thickness incision. The shortcomings of these different maneuvers are their varying degrees of complexity, the need for special instrumentation, and unreliability in producing consistent results. Herein we describe a method of cartilage weakening unique in its simplicity, convenience, and reproducibility.
Preoperative evaluation of prominauris determines the amount of conchal setback and antihelical fold restoration necessary. The desired outcome is ears that appear symmetrical and natural, with helices located 15 to 20 mm from the mastoid skin. For convenience in the operating room, the mastoid-to-helix distance can be approximated by the width of the index finger. Slight (1- to 2-mm) overcorrection is attempted to compensate for the loss of correction that occurs postoperatively. Otoplasty is typically performed under local anesthesia in adults and general anesthesia is children. Hair control is obtained using a fishnet, and the most protruding ear is operated on first. The desired antihelical fold is simulated by applying gentle pressure along the antihelical rim. The cartilage and skin along the desired fold are marked by inserting four 22-gauge needles through the ear at 4 reference points: the superior crus, the inferior crus, the point of convergence of the crura, and the inferior antihelical fold. The ends of the inserted needles are painted with methylene blue, then withdrawn.The skin incision is designed completely on the posterior surface of the ear, avoiding extension onto the mastoid skin in anticipation of the posterior drift of the scar onto the visible mastoid skin that occurs with healing.
An hourglass-shaped elliptical incision is designed to avoid overcorrection of the middle third of the ear (telephone ear deformity). The ends of the elliptical incision should be no closer than 1 cm to the superior and inferior extents of the posterior attachment of the pinna. The skin is incised and the ellipse is excised in the supraperichondrial layer. Supraperichondrial dissection is performed laterally to the helical rim and medially over the mastoid to permit placement, if indicated, of conchal-mastoid setback sutures. Any excess conchal cartilage along the free edge of the external auditory meatus is excised, avoiding protrusion into the external auditory canal.Next, the cartilage must be weakened in preparation for the placement of scaphal-conchal mattress sutures. The previously marked methylene blue dots along the desired antihelical fold and crura mark the lines of cartilage weakening. The electrocautery is adjusted to a setting sufficient to create, sufficient to create, in cutting mode, a partial-thickness trough through the cartilage. The rounded tip of the spatula blade is used to connect the dots, resulting in a Y-shaped trough (Figure 1).
Several passes are made, between which char is wiped away. The goal is to weaken the fold while maintaining sufficient resilience to prevent a sharp angle at the fold. Typically, this occurs when the trough extends approximately halfway to two thirds through the cartilage.
Following cartilage weakening, any necessary conchal-mastoid sutures are placed, test tied with a single throw of a simple knot to assure achievement of the desired effect, then loosened and tagged. Three to 4 Mustarde-type scaphal-conchal horizontal mattress sutures of 4-0 clear nylon or Mersilene (Ethicon, Sommerville, NJ) are then placed, tested, and tagged in the same fashion. Once all the sutures have been tagged, the conchal-mastoid sutures are secured. The Mustarde-type scalphal-conchal sutures are then sequentially secured, adjusting tension so that the desired antihelical fold is created (Figure 2).
The incision is then closed in 1 layer with 4-0 plain gut sutures. If indicated, the contralateral otoplasty is then performed. A conforming dressing of mineral oil-soaked cotton covered with fluffs and head wrap is applied. Antibiotics are prescribed for 5 days. On the first postoperative day, the dressing is removed and proper ear position is confirmed. The dressing is replaced and kept in place for 1 to 2 more days in adults and 7 to 10 days in children. An elastic headband is worn nightly for 4 to 6 weeks following dressing removal to prevent accidental disruption of the healing cartilage.
This technique has been used in more than 60 patients. Results have been consistent and reproducible, with a very low incidence of complications. There have been no cases of chondritis or cartilage necrosis, of theoretic concern given the method of cartilage scoring. In 6 cases a revision procedure was performed to repair partial loss of correction in 1 ear. The created antihelical folds are uniformly smooth (Figure 3 and Figure 4), avoiding the sharp edges that can often result from cartilage-splitting techniques.
The goal of otoplasty is to create natural-appearing ears with symmetrical size and shape and a harmonious relationship with the side of the head. For the facial plastic surgeon performing otoplasty, a reproducible technique is vital to assure consistent results.
The technique described uses a simple method of cartilage weakening combined with Mustarde-type retention sutures to achieve the desired configuration of the antihelical fold. Subsequent healing reinforces the mattress sutures, although some loss of correction typically occurs over time.
Cartilage weakening may not be necessary in all patients. Scrimshaw reserves thinning maneuvers for thicker cartilage to avoid the kinking that can sometimes occur in thin, excessively weakened cartilage. Ohlsen and Verdung justify not weakening the cartilage in patients younger than 10 years because the cartilage in these younger patients is thinner and more pliable. Adamson et al describe cartilage strength increasing proportionately with age. The success of Millay et al in recontouring neonatal auricular deformities by the application of several weeks of pressure dressing attests to the pliability of auricular cartilage at a young age.
The advantages of our technique include its reliability, simplicity, and the convenience of using a surgical instrument already present in the surgical field. Using this technique, otoplasty can be performed in reproducible fashion with a low incidence of complications. There were no cases of chondritis or any other evidence of thermal damage to the auricular cartilage or skin.
Accepted for publication May 28, 1999
Reprints: Jeffrey S. Epstein, MD, 6280 Sunset Drive, Suite 509, Miami, FL 33143 (e-mail: [email protected])
1. Gibson T, Davis WB. The distortion of autogenous cartilage grafts: its cause and prevention. Br J Plast Surg. 1958;10:257-260.
2. Ju DM, Li C, Crikelair GF. Surgical correction of protruding ears. Plast Reconst Surg. 1963;32:283-293.
3. Stenstrom SJ. A natural technique for correction of congenitally prominent ears. Plast Reconst Surg. 1963;32:509-518.
4. Farrior RT. A method of otoplasty. Arch Otolaryngol 1959;69:400-408.
5. Scrimshaw GC. Otoplasty by abrasion, sculpture, and fixation. Arch Otolaryngol 1977;103:579-581.
6. Psillakis JN. Prominent ears: correction with buried mattress sutures. Acta Chir Plas. 1968;10:315-320.
7. Wright WK. Otoplasty goals and principles. Arch Otolaryngol 1970;92:568-572.
8. Johnson PE. Otoplasty: shaping the antihelix. Aesthetic Plas Surg 1994;18:71-74.
9. Ohlsen L, Verdung S. Reconstructing the antihelix of protruding ears by perichondroplasty: a modified technique. Plast Reconst Surg. 1980;65:753-762.
10. Stambaugh KI. Outstanding ears. In: Gates GA, ed. Current Therapy in Otolaryngology/Head and Neck Surgery St. Louis, Mo: Mosby-Year Book Inc.; 1994:206-210.
11. Pilz S. Hintringer T. Bauer M. Otoplasty using a spherical metal head dermabrader to form a retroauricular furrow: five year results. Aesthetic Plas Surg 1995;19:83-91.
12. Nachlas NE, Smith HW, Keen MS. Otoplasty. In: Papel ID, Nachlas NE, eds. Facial Plastic and Reconstructive Surgery. St. Louis, Mo: Mosby-Year Book Inc; 1992:256-269.
13. ADamson PA, McGraw PL, Tropper GJ. Otoplasty: critical review of clinical results. Laryngoscope. 1991;101:883-888.
14. Mustarde JC. The correction of prominent ears using simple mattress sutures. Br J Plas Surg. 1963; 16:170-177.
15. Millay DJ, Larrabee WF, Dion FR. Non-surgical correction of auricular deformities. Laryngoscope. 1990;100:910-913.
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Despite the frequency with which it occurs, little has been written in the scientific literature on the treatment of infraorbital dark circles. I have developed a technique that simultaneously treats the 2 contributing causes of these circles: hyperpigmentation of skin and pseudoherniation of orbital fat. The technique involves simultaneous transconjunctival blepharoplasty an deep-depth phenol chemical peel. Successful outcomes have been obtained in patients with Fitzpatrick classification skin types 1 to 5, with a low incidence of complications. Adequate preoperative counseling regarding prolonged erythema and careful postoperative monitoring with, if necessary, medical intervention are essential if both surgeon and patient are to be satisfied with the outcomes.
Despite the lack of attention received in the plastic surgery literature, infraorbital dark circles can be a significant cosmetic problem. While there are no statistics giving the frequency of its occurrence, judging from the amount of advertising of cosmetics marketed to treat it, dark circles under the eyelid are a cosmetic concern for a large number of individuals. In my practice, while patients in consultation may not mention infraorbital discoloration, many are interested in having it treated once they are informed that it is a treatable condition.
CAUSE OF INFRAORBITAL DARK CIRCLES
There are several causes for the appearance of dark circles under the eyelids. The most common primary cause is excessive pigmentation, which is seen in such conditions as dermal melanocytosis and postinflammatory hyperpigmentation. Dermal melanocytosis is due to both congenital as well as environmental causes, including excessive sun exposure and occasionally the taking of exogenous estrogens. Postinflammatory hyperpigmentation usually has allergic or atopic components.
Infraorbital dark circles due to hyperpigmentation usually appear as a slightly curved band of brownish skin approximating the shape of the underlying inferior orbital rim. These circles appear even darker when present below the bulging of the lower eyelids that is due to pseudoherniation of orbital fat. In effect, the bulging lower eyelids are casting a shadow on the skin below. When the lower-eyelid skin is manually stretched, the area of pigmentation is spread out, without any blanching or significant lightening.
Blanching of this area with skin stretching would be consistent with the second common primary of infraorbital discoloration, the visible prominence of the subcutaneous blood vessel plexus. This hypervascular appearance is due to some combination of exceptional transparency of the overlying skin and excessive subcutaneous vascularity. In these cases, the entire lower eyelid has a purplish appearance that on closer examination is revealed to consist of prominent blood vessels, covered by a thin layer of skin. While involving the entire lower lid, the vascularity of usually concentrated along the lower aspect of the eyelid, occurring (similar as with primary hyperpigmentation) usually just beneath any pseudoherniation orbital fat.
It can be deduced that lower-eyelid ballooning due to pseudoherniation orbital fat is commonly associated with, and usually exacerbates, the appearance of infraorbital dark circles. Further, it has been proposed that excessive infraorbital fat can increase lower-lid subcutaneous vascularity. In addition, chronic allergies cannot only exacerbate but perhaps even cause postinflammatory hyperpigmentation as well as edema of lower-eyelid fat. Excessive pseudoherniation of orbital fat, thus, is usually intimately related to the presence of infraorbital dark circles.
TREATING INFRAORBITAL DARK CIRCLES
As described above, the cause of dark infraorbital circles is most commonly due to a combination of hyperpigmentation and some degree of lower-lid bulging due to fat pseudoherniation. For a treatment to be effective, both of these problems need to be addressed, ideally synchronously. I have developed a safe and effective surgical treatment, including an important preprocedure- and postprocedure-care protocol.
The treatment basically consists of simultaneous lower-lid transconjunctival blepharoplasty (TCB) and Litton formula phenol peeling (phenol, 44 ml; distilled water, 44 ml; and croton oil, 1 ml; creating a phenol concentration of 48%). The TCB is an effective surgical procedure for reducing excess lower-lid fat, first described in 1924 by Bourquet.5 Contemporary proponents of TCB have popularized this approach, so that in 1999, it has widespread acceptance. When performed properly, TCB has a low incidence of complications and is effective for treating almost all cases of lower-lid fat pseudoherniation. In most cases, skin does not need to be excised, and, when performed through a retroseptal approach (which is my approach) simultaneous lower-lid skin peeling can be performed, permitting the reversal of dermatochalasis and rhytidosis, and, as in my approach, the reversal of skin hyperpigmentation.
There are several types of phenol peel formulations, all with effective phenol concentrations between 40% and 48%. At these concentrations, the phenol penetrates down to the reticular dermis, thus repairing damaged elastotic skin. Similarly, at this concentration the usual adverse effect of phenol peeling is hypopigmentation. Phenol decreases skin pigmentation by reducing the ability of melanocytes to produce melanin. While the Baker and Gordon phenol peel is the most common of the phenol chemical peel formulas, I prefer to use the Litton phenol peel.
The goal of pretreatment care is to prepare the skin for the peeling procedure, and to minimize its ability to produce pigmentation. In addition to the strict avoidance of sun for the preceding 7 days, patients are begun on Kligman formula (hydrocortizone, retinoic acid, and hydroquinone) as early as 3 months before the procedure. Patients are advised to first observe the results obtained with this topical agent, in the hopes that significant improvement is obtained, so the phenol peel process then is not necessary. In the majority of cases, however, while there is some improvement in the dark circles and rhytidosis, in most cases it is insufficient for the patient.
The procedure is usually performed under light intravenous sedation. Before the surgery, with the patient in a sitting position, the areas of lower-lid orbital fat pseudoherniation are marked. In those cases where upper-lid blepharoplasty is being performed, these incisions are also marked. After the administration of the sedation, the conjunctiva and cornea are anesthetized with 0.5% topical tetracaine, followed by the local infiltration of he conjunctiva, fat pockets, and eyelid skin with 2 to 3 ml. of 2% lidocaine with 1:100 000 epinephrine. Under sterile conditions, a transconjunctival incision is made just below the tarsal plate directly over the balloting fat created by gentle pressure to the globe by a Jaeger lid plate (FIgure 1). Through a retroseptal approach that has been well described in the literature, the excess fat is excised using a hand-held high temperature cautery unit. Once the surgeon is satisfied that the appropriate amount of fat has been removed, such that the minimal pressure on the globe there is no fat balloting above the level of the orbital rim, the conjunctival edges are laid back together without sutures.
Once the lower (and, if being performed, upper) blepharoplasty is completed, the skin of the lower eyelids and lateral orbital region is adequately degreased with acetone. This is an important step to ensure even penetration of the phenol. The Litton formula is applied to the degreased skin using 2 cotton-tipped applicators (Figure 2). LItton Formula does not need to be mixed fresh, but can be prepared and stored for several months. A gentle wiping, applying motion is used, extending laterally approximately 10 mm beyond the natural borderlines of the lateral and inferior orbital rims, and within 2 mm of the lower eyelashes. Caution must be taken to avoid contact with the globe or with any tears that may develop that can draw the more dilute (and therefore more potent) phenol into the globe. A deep white frost should develop within 45 seconds, after which ice water gauzes can be applied. Once the white frost fades and ruddy erythema appears, antibiotic or other type of ointment, such as Aquaphor (Beiersdorf Inc., Norwalk, Conn), can be applied. If indicated, other areas of the face can be treated with phenol, or a medium-depth peel, such as Jessner solution followed by 35% trichloroacetic acid.
The major intraoperative risk of phenol is cardiotoxicity. This is a dose-dependent event, the dose of which is not reached when peeling just the eyelids. However, for proper precaution, it is recommended that there be proper cardiac monitoring, and that the patient be adequately hydrated. Phenol must be used cautiously on patients with kidney abnormalities in whom there can be impaired phenol excretion. When peeling more than just the eyelids, the phenol should be applied incrementally, with sufficient intervals between anatomical areas.
Postprocedure Care and Expected Course
For the first 48 hours, patients are to keep the head elevated and the eyelids iced to reduce swelling. Antibiotic drops are applied for the first 3 days, and oral antibiotics are taken for the first week. Care of the peeled skin consists of continual reapplication of Aquaphor for the first 7 to 10 days, with rinsing of the skin 3 times a day before reapplication of the ointment, using a slightly acetic acid containing a mixture of water and white vinegar. At 7 days, there is usually full reepithelialization, after which light makeups can be applied. To accelerate the resolution of erythema, a low-strength steroid ointment can be applied judiciously.
In addition to strict avoidance of sun for 2 months, patients are instructed to avoid taking exogenous estrogens or other hormones that increase the risk of pigment deposition. The postoperative monitoring for and management of recurrent hyperpigmentation is as important a step as the procedure itself. Prophylactically, patients are usually given a 4% to 10% formulation of hydroquinone, mixed with hydrocortisone to help resolve residual erythema. At times, salicea gel is also used. Patients can expect erythema to last for up to 6 months, but usually by 2 months this erythema can be classified as "mild," and patients can resume their regular activities.
Results of Simultaneous TCB With Phenol Peel
for Infraorbital Dark Circles
I have used this approach on 8 patients, 5 women and 3 men, ranging from 28 to 66 years of age. All patients were white, 4 of Hispanic origin, 2 or Mediterranean origin, and 2 of European origin. This corresponds to the breakdown of Fitzgerald skin types: type 2, 2 patients; type 3, 3 patients; type 4, 2 patients; and type 5, 1 patient. In all cases, significant improvement in appearance was obtained (Figures 3, 4 and 5).
The time for maximum improvement was on average 5 months postoperatively, corresponding to the time for the resolution of erythema. Long-term results at up to 30 months have been consistent and satisfactory, with no recurrence of dark orbital circles. While the procedure produced significant lightening of the lower-eyelid skin, in no cases did this result in obvious demarcation between the lighter eyelid skin and the darker surrounding skin. This good result can be attributed to the fat that those patients with darker skin had such significant lower-eyelid darkness that the lightening merely resulted in making the lower-eyelid skin look either the same or only slightly lighter than the surrounding cheek and temporal skin. Demarcation of the lower eyelids and the surrounding skin as a result of alterations in skin texture, luster and rhytidosis was prevented by peeling the remainder of the face with Jessner-35% trichloroacetic acid in 3 patients.
Complications have been few, with 1 case of postoperative granuloma along the (unsutured) conjunctival incision and treated with simple excision, and 2 cases of prolonged erythema lasting beyond 6 months. In 1 of these cases, the erythema was significantly contributed to by an allergic reaction from an over-the-counter hydrocortisone formulation; patients are now treated with prescription steroid formulations. The most common reason for failure in TCB, incomplete removal of fat, was not present in any patients. In addition, there were no cases of lid retraction, dry eye syndrome, lateral rounding, increased skin wrinkling, hematomas, or inferior oblique palsy.
Simultaneous TCB and phenol peeling is an effective treatment for infraorbital dark circles that are due to a combination of hyperpigmentation and some degree of lower-eyelid orbital fat pseudoherniation. Proper diagnosis of the cause(s) of the dark circles is critical for patient selection.
A number of therapies are available for reducing pigmentation. Several topical bleaching agents use different mechanisms to reduce melanin. These agents, which include hydroquinone, kojic acid, and salicea gel are effective, to some degree, on certain mild cases of hyperpigmentation. Lasers can be effective on certain conditions of dark skin due to both hyperpigmentation and increased vascularity. These lasers, which include the copper vapor, the pulsed dye, the Q-switched, and the argon, have their individual indications and parameters; however, this subject is beyond the scope of this article.
Dermabrasion, cryosurgery, and chemical peeling smooth facial skin by peeling to some depth, usually within the dermis. The usual adverse effect of dermabrasion and cryosurgery, and some forms of chemical peeling, notably phenol, is hypopigmentation of the skin. Phenol decreases skin pigmentation by reducing the ability of melanocytes to produce melanin.
Convention dictates that phenol peeling be limited to individuals with Fitzpatrick skin types 1 to 3. Use of phenol on skin types 4 to 6 can produce significant pigment irregularities. However, when phenol is used for reducing infraorbital dark circles, the precise goal is to "harness" these pigment irregularities (i.e., hypopigmentation) to create the desired result. The approach described in this article has been used effectively most commonly on individuals with Fitzpatrick skin types 3 and 4, and occasionally types 2 and 5.
Dark circles that are a result of lower-lid hypervascularity must not be treated with chemical peeling agents. Peeling risks exacerbating the appearance of the hypervascularity, due to the potential reduction of pigmentation in and the thinning of the skin that only makes the underlying vessels more prominent. Furthermore, hypervascularity can increase from the inflammatory response to the chemical peeling. The approach to these patients is not clearly defined; fortunately, they constitute a small percentage of those patients with infraorbital dark circles.
While patients often do not express concern with lower lid dark circles, once it is pointed out as something that can be treated, there is high patient acceptance to undergo the described procedure. Advantages of this procedure are that it is reliable, safe, able to be performed in an ambulatory setting, and not only lightens dark circles but also reverses the sequelae of photoaging and intrinsic aging, resulting in more youthful-appearing skin.
Any treatment designed to reduce hyperpigmentation will be most effective within used in conjunction with steps taken to reduce exposure to factors that contribute to hyperpigmentation. Limiting sun exposure and avoiding the combination of certain levels of hormones, notably estrogen, can reduce the amount of irregular melanin deposition. Altered levels of estrogen and progesterone can occur with exogenous administration (e.g., hormone replacement therapy and oral contraception) and with endogenous production that occurs with pregnancy and breastfeeding.
The major downside of the TCB-phenol peel procedure is prolonged erythema that can last for up to 6 months. Patients need to be counseled that this erythema will eventually resolve and that the erythema is an improvement in appearance over dark circles. As far as the concern about the potential appearance of a line of demarcation between the area peeled with phenol and the surrounding skin, this has been unrealized. The surgeon must be prepared to treat demarcation that is a result of differences in pigmentation with a remaining full-face phenol peel. Demarcation that is a result of differences in skin texture, luster, and rhytidosis must likewise often be treated with a remaining full-face medium-depth chemical peel, such as Jessner solution followed by 35% trichloroacetic acid. Long-term success has been dependent on judicious postoperative monitoring and treatment to prevent the recurrence of hyperpigmentation.
Accepted for publication June 30, 1999
Presented at the Foundation for Facial Plastic Surgery Eleventh Annual Symposium on Cosmetic Surgery of the Face, Newport Beach, Calif, August 6, 1997.
Reprints: Jeffrey S. Epstein, MD, 6280 Sunset Drive, Suite 509, Miami, FL 33143 (e-mail: [email protected])
1. Lowe NJ, Wieder JM, Shorr N, et al. Infraorbital pigmented skin; preliminary observations of laser therapy. Dermatol Surg. 1995; 21:767-770
2. Zarem HA, Resnick JI. Expanded applications for transconjunctival lower lid blepharoplasty. Plast Reconst Surg. 1991; 88:215-220.
3. Garcia A, Fulton JE. The combination of glycolic acid and hydroquinone or kojic acid for the treatment of melasma and related conditions. Dermatol Surg. 1996; 22:443-447
4. Newcomer VD, Lindbert MC, Stenbert TH. A melanosis of the face (chloasma). Arch Dermatol.1961; 83:284-297.
5. Bourquet J. Les hernies graisseuses de l'orbite: notre traitement chirugical. Bull Acad Natl Med. 1924, 3:1270-1272.
6. Palmer FR, Rice DH, Churukian MM. Transconjunctival blepharoplasty: complications and their avoidance: a retrospective analysis and review of the literature. Arch Otolaryngol Head Neck Surg. 1993; 119:993-999.
7. Baylis HI, Long JA, Groth MJ. Transconjunctival lower eyelid blepharoplasty: technique and complications. Ophthalmology. 1989; 96:1027-1032.
8. Zarem HA, Resnick JI. Operative technique for transconjunctival blepharoplasty. Clin Plast Surg. 1992; 19:351-356.
9. Perkins SW, Dyer WK, Simo F. Transconjunctival approach to lower eyelid blepharoplasty: experience, indications, and technique in 300 patients. Arch Otolaryngol Head Neck Surg. 1994; 120:172-177.
10. Dodenhoff TG. Transconjunctival blepharoplasty: further applications and adjuncts. Aesthetic Plast Surg. 1995; 19: 511-527.
11. Baker TJ. The ablation of rhytids by chemical means: a preliminary report. J Fla Med Assoc. 1961: 45:451.
12. Baker TJ, Gordon HL. Chemical face peeling, an adjunct to surgical face lifting. South Med J. 1963; 56: 412-413.
13. Ersek RA. Comparative study of dermabrasion, phenol peel, and acetic acid peel. Aesthetic Plast Surg. 1995; 241-243.
14. Stuzin JM, Baker TJ, Gordon HL. Treatment of photoaging; facial chemical peeling (phenol and trichloroacetic acid) and dermabrasion. Clin Plast Surg. 1993; 20:9-25.
15. Brody HJ. Update on chemical peeling. J Dermatol Surg Oncol. 1992; 7:275-288.
16. Brody HJ. Complications of chemical peeling. J Dermatol Surg Oncol. 1989; 15:1010-1019.
17. Beeson WH, McCullough EG. Chemical face peeling without taping. J Dermatol Surg Oncol. 1985; 11:985-990.
18. Cortez EA. Chemical face peeling. Otolaryngol Clin North Am 1990; 23:947-961.
19. Pathak MA., Fitzpatrick TB, Parish JA. Treatment of melasma with hydroquinone. J Invest Dermatol. 1961: 83:284-297.
20. Ries WMR. Current concepts in cutaneous laser surgery. Facial Plast Surg. 1993; 9:58-67.
21. Goldberg D. Benign pigmented lesions of the skin: treatment with the Q-switched ruby laser. J Dermatol Surg Oncol. 1993; 19:376-379.
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Dr. Epstein served on the faculty of the 20th Annual Facial Aesthetic Symposium, held in Atlanta. He spoke on a variety of variety of topics.
Dr. Epstein has been invited to become part of the RealSelf Medi-Beauty Media Panel - a hand-selected group of respected physicians to speak with the media about plastic surgery. RealSelf is the internet's most respected source of education for the public about plastic surgery and plastic surgeons.
In addition to his being recognized by the lay press as an expert in his field, Dr. Epstein is also highly regarded by his peers. He is a Clinical Professor at the University of Miami, his alma matter, and teaches regularly at scientific meetings nationally and internationally. Also, Dr. Epstein has been published in numerous scientific journals and textbooks including:
Recent television appearances include:
Dr. Epstein was featured in two of the most popular Spanish language television shows. Both Despierto America, broadcast worldwide on Univision, and the Padre Alberto Show, broadcast worldwide on Telemundo, featured Dr. Epstein and several of his patients for stories on plastic surgery.
Channel 6 featured Dr. Epstein on a story about Myobloc©, a product similar Botox©. This treatment for wrinkles may be more effective.
Channel 7 interviewed Dr. Epstein on today's trends for a story on plastic surgery for men.
Channel 4 News featured Dr. Epstein's new techniques.
Channel 10 News interviewed Dr. Epstein and two of his patients on the benefits in the workplace of undergoing facial rejuvenation surgery in "Looking Good to Get Ahead."
Channel 6 News’ Ileana Bravo, Health Reporter, illustrated the surge in interest of men having plastic surgery by following the surgical course of Bob, who a blepharoplasty. Three weeks after the surgery performed by Dr. Epstein, Bob was back at work, giving public presentations.
Good Morning America en Espanol Broadcast worldwide, Dr. Epstein appeared on the Spanish Univision network top rated show Despierto America. He and a patient were interviewed.
Channel 23 News interviewed Dr. Epstein to learn about his work.
Latin Trade Magazine ran an article about Dr. Epstein’s work.
Palm Beach Illustrated featured Dr. Epstein in a story about fashion and style.
Selecta Magazine profiled Dr. Epstein’s work. Selecta is a Spanish language magazine with one of the largest readerships in the Americas.
Miami Herald Cover Story features Dr. Epstein "Plastic Surgery- More boomer men try nips, tucks" (April, 2011). Herald Columnist Ana Veciana-Suarez turned to Dr. Epstein for a front page story on the growth in plastic surgery for men. According to Epstein, for whom 70% of his patients are men, "For the baby boomer generation, looking good and young has always been very important." Click here to read the full story.
The Miami Herald reviewed the different medical and surgical options for looking one’s best. Dr. Epstein was the featured expert.