On the Training of Horses, Linebackers, Pilots and Plastic Surgeons by Dr. Paul Howard

The critical reader may come to the opinion quickly that I am only a Plastic Surgeon and probably know little about training horses or football players.  While this is essentially true, I don’t believe it disqualifies me to comment on other fields of endeavor that require many of the same complex skills that are inherit to the plastic surgeon.

The training of surgeons is unlike any other field of endeavor.  One can read massive amounts of material, study diligently for four years of medical school, memorize the indications for an operation, actually study the pertinent anatomy and how to perform an operation and yet know virtually nothing without taking the final exam by incising the patient’s skin and performing an actual procedure where the stakes are as high as they can be.  This discipline is entirely different than any other medical specialty as the requisite study of disease is not the endpoint of training, it is the ante that allows one in the real game which is the application of knowledge to perform a mechanical skill (surgery) which is basically unnatural and requires skills that are not genetic but entirely learned.  Since surgery is learned behavior, there is no way to be graded except by the subjective appraisal of a competent surgeon.  As time evolves and the surgeon becomes independently proficient, the grading of results requires continuous, honest self-assessment of one’s results.  The built-in weakness of the surgical training paradigm is the quality of the “on-the-job” training.  This is the primary reason why surgical, and more specifically, Plastic Surgical training, can lead to widely diffuse results in the quality of the surgeon.  These facts became self-evident to me and led me to seek the most talented and well known surgeons of my era of medicine.  Since we learn surgery by watching and imitating others, it makes perfect sense to seek the best to emulate.  This quest is how I came to know John Kirklin, M.D, Ralph Millard, M.D, and Paul Tessier, M.D.  For those who are unfamiliar with the names, these are the best of the best in surgery.

Let me begin by admitting that I am a hero worshiper.  It happens that I have a small but unique set of personal heroes that I have accumulated over a lifetime.  These men have excelled in their respective fields which happen to include the thoroughbred racing business, the aircraft industry, the National Football League, and the field of plastic surgery.

Those who only know horse racing by watching the Kentucky Derby the first Saturday in May every year are not privy to the complexities of thoroughbred breeding, training, and racing.  You may notice the atmosphere in Louisville, KY at Churchill Downs includes beautiful hats and the unfettered consumption of Kentucky bourbon in the form of the ever present Mint Julep.  This pageantry belies the complexity of horse genetics and gene pools as well as the training of these extremely fragile animals.  Additionally, they are trained to race beginning as a two year old animal.  The three year olds that race the Derby are still adolescent animals and behave in many ways the same as our teenaged children.  Yet, the results of their early races can lead to a multi-million dollar horse, both as a racer and later as an addition to the thoroughbred gene pool.

Dr. Ruel Cowles is a veterinary physician/surgeon whose practice and life is dedicated to the healthcare of these majestic animals.  One of my mentors, John Kirklin, MD, was an established horseman and was convinced that race horses were essentially untrained whereas gaited, dressage, and jumpers were the only horses truly trained.  Dr. Kirklin also opined that a good jumper must be at least 10 years of age.  Racing 3 year-olds in packs of 10-20 over a mile long course against the best 3 year-olds in the world would probably be a daunting task for a 10 year-old thoroughbred.   It’s like training a 15 year-old to pitch in the major leagues – you can never be sure exactly what you will get.

Dr. Cowles embodies the best of clinical veterinary medicine as well as the intellect to excel as a horse breeder.  Dr. Ruel Cowles is one of my heroes.

I have more than a passing interest in the sport of American Football.  I was, as many of my colleagues were, a high school football player.  I managed to keep my NFL dreams alive through my first year of college where the physical and mental rigors of the game caused me to turn in my shoulder pads to pursue academics full-time.  As such I developed an almost unhealthy respect for those players who made it to the NFL.  I particularly liked linebackers as that was my chosen position.  The day I met Kevin Greene, at the time playing for the LA Rams, I realized who I would have become if I had the fortitude to continue playing.  Kevin was a walk-on at Auburn University in the early 1980’s under Coach Pat Dye.  He showed early on his pass rushing prowess, but only a few NFL scouts agreed and was chosen by LA in the sixth round of the draft. From his first training camp, Kevin’s coaches and teammates understood that going easy on the veterans was not part of his game.  All Pro offensive tackle Jackie Slater found out Kevin was a “maniac” on every play, pre-season or not.  Kevin was soon inserted in the line-up for the Rams and there he stayed.  After leaving the Rams for Pittsburgh, he truly found his identity, grew his hair to his shoulders, married a beautiful Alabama girl, and became a favorite in Pittsburgh because of his aggressive and relentless style of play.  He was known for sacking the quarterback but in fact was a complete linebacker in the 3-4 scheme.  I cannot remember a single time that a running-back or receiver managed to even fall forward after he got his hands on them.  I was privileged to be Kevin’s friend through the entirety of his 16 year NFL career including multiple Pro Bowls and defensive linebacker awards.  His intensity and dedication to his craft were unparalleled.   Ten years after his retirement from the NFL, he still holds the career sack total among linebackers.  Today, Kevin is imparting his knowledge to younger players as the outside linebacker coach for the Green Bay Packers.  Kevin is also one of my heroes.

I’ve known but a few fighter pilots and one submariner personally.  There are a few common traits these people have that separate them from the rest of us.  First, they all have very acute and agile minds that can assimilate knowledge quickly and apply it so that they are constantly evaluating their performance and improving by self-evaluating and reflection.  These traits are similar to those needed for plastic surgeons with the added immediacy of going Mach II or being thousands of feet under water.

As a first-year resident under Dr. Ralph Millard, I became acquainted with Dr. Gregory Lovaas senior resident under Millard.  Greg was like a xenon light in a room full of candles.  He shown brightly and was a wonderful teacher to me.  Knowing Greg as I did it was not easy to imagine the government putting him in a single seat F-104 fighter with nuclear weapons.  As I learned more about Greg, I realized he was the perfect personality for such a dangerous, in-your-face profession.  Greg, as most intelligent people do, had a wondrous sense of humor that may or may not have served him well over the years. My most vivid memory of Greg is the fighter pilot/Plastic Surgeon maniac.  He taught me the fighter pilot credo – “sometimes wrong, never in doubt.”  Greg Lovaas is one of my heroes.

A young boy and his twin brother grew up fatherless during the Great Depression in rural Griffin, Georgia.  Times were tough for everyone and the twins did the best they could for themselves and their family.  As they became teenagers, sports helped fill their days.  It was an accident playing baseball that knocked out the two front teeth on one of the boys causing a speech impediment and a lasting impression as he did not have enough money to receive the necessary dental care.  The twins with no prospects on the horizon lied about their age and enlisted in the Army and the Navy.  The story goes that the twins couldn’t understand why the new recruits were homesick and even cried at night while the twins were elevated from their Hell to three square meals a day and they weren’t worked very hard.  The addition of free dental care made WWII a life altering experience, all for the good.

New pair of shoes, one suit, two new teeth and training in electronics were enough to start a new life several years after the war with a new wife and further training in repair of the new-fangled American commodity – the television set.  The younger of the twins was desperately trying to live the American Dream.  Fixing the notoriously unreliable TVs and their vacuum tubes was a decent job.  Utilizing his military training and hands-on electronics experience, twin got a job with Lockheed Aircraft in Marietta, Georgia where he taught electronics to the new hires needed to build the C-130 “Hercules” and the new super airliner – the L-1011.  The younger twin learned he had a knack for teaching and especially training people to do a job.  He eventually parlayed this experience into industrial training programs for four Southern states eventually having a training facility posthumously named after him in Montgomery, Alabama.  Twin number two, and one of my heroes, was George L. Howard, my father.

The training of plastic surgeon is a long grueling process due to massive amounts of material to learn, but more importantly the aptitude, mental acuity, and complex decision making necessary.  Most students of plastic surgery realize that the training is so long (± 6 years) because the depth of knowledge necessary is vast and by necessity practicing plastic surgery requires a malleable mind to attack each challenge with freshness, intensity, and thoughtfulness. These attributes are not something one can read about, but can only be obtained by acquiring the knowledge from others who already have it.  This is why it is so important to ask the credentials of a plastic surgeon so one can surmise the quality of his/her education in plastic surgery.  In plastic surgery, it makes perfect sense that truly the best plastic surgeons are the best teachers.  My final heroes are two of my plastic surgery mentors that encompass the best that our field has ever created.  D. Ralph Millard, Jr., M.D., and Paul Tessier, M.D. are also my heroes.

Recent history has taught us the penalty to be paid by the consumer of plastic surgery who is swayed by the exquisite marketing of doctors who believe for financial reasons that the least amount of education in the intricacies of plastic surgery is somehow better than the full training program that has been in place for 30 years.  There is no other example of attenuated training in any of the surgical specialties.  Neurosurgeons are required to train in all aspects of neurosurgery and even take a year of basic neurology training even though few neurosurgeons practice all of the aspects of the specialty.  This is mainly because for the last 100 years it is clearly shown that almost all specialists benefit from a wide and diverse basis of knowledge leading to calmness under pressure and the ability to elicit a laser-focus required of the expert.  This is true for training many kinds of endeavors and one will never find a short-cut to the training of the best race horses, NFL linebackers nor in the making of aircraft or the training of plastic surgeons.  Hippocrates said it best in his aphorism “Life is short, and the art is long; opportunity fleeting; experience perilous, and decision difficult.”  The first time I heard this warning was from the great cardiac surgeon John Kirklin, M.D. in his famous surgical “blue-book” to help train young cardiovascular surgeons.

To learn more about Dr. Paul Howard, please visit his web sites:

PaulHowardMDcom

TheHowardLift.com

Joggers and Runners: Beware

In our current healthy and image conscious environment many people choose to maintain fitness by running, jogging, or high impact aerobics.  While these exercises are great for cardiovascular fitness they are extremely bad for facial aging.  First and foremost facial aging is primarily a result of loss of skin elastic tissue due to sun damage, environmental factors and smoking.  Pounding the pavement has an adverse effect on facial aging in the face of poor skin elasticity.  Compression garments can be worn to hold firm abdominal, thigh, and buttock tissues as protection against the effects of running on these tissues.  No such garment can protect the face from the deleterious effects of extreme exercise.  Runners are usually thinner than others of the same age.  It is a well-known fact that while healthy, thin faces age quicker than faces with some fat content.  The opposite is true for necks – little fat in the neck is good whereas a fat neck is difficult to contour.  Many people who exercise heavily do not maintain adequate hydration.  Drinking large amounts of water help keeps skin hydrated and less likely to manifest dryness, fine wrinkles, and laxity of aging.  There are plenty of aerobic exercises and machines that provide a serious workout without the up and down pounding that can exacerbate the facial aging process.

Rhinoplasty – Minimal Surgery with Major Results

There is a certain subset of patients who, by genetics or trauma, will require a true septo-rhinoplasty to correct breathing problems and to straighten an injured nasal pyramid.  There is a much larger group of patients who have relatively minor cosmetic nasal problems, usually confined to the tip or the bridge of the nose.  It is a well-known that the tip of the nose tends to lose its support as we age causing the nose to tilt over the upper lip and gives the impression of a longer nose.  Minor nasal tip cartilage problems can create the impression of a “boxy” tip or even a “pointy” nose.  Minor bridge problems can be addressed with small operations.

The use of filler in the nose has only recently become popular.  There are a few situations where fillers may improve the nose without surgery.  Small discrepancies of the nasal bones usually due to trauma and certain small tip and bridge asymmetries may be improved with the judicious use of fillers.  To this point in time the “perfect filler” is still your own fat.  Harvested and processed fat is long-lasting and usually does not require secondary procedures.

The nasal refining procedures do not require general anesthesia and are not covered by insurance.  These procedures are for refining the nose and as such do not change to overall ethnicity of your nose.  Think of your same nose yet more refined, elegant, and at a greatly reduced price.  For some people a major nasal reconstruction may be necessary due to trauma, for those who want a completely new nose, or those with significant nasal breathing problems.

Dr. Paul Howard

View rhinoplasty before and after photos on Dr. Paul Howard‘s web site.

Luscious Lips

Beautiful, full, pouty lips are considered youthful. One of the natural consequences of facial aging is the loss of normal lip volume causing a deflated appearance with wrinkling.  There are many misconceptions regarding attractive lips that seem to have found their way into the social consciousness due to plastic surgery results that seem to have gone awry.  Merely increasing the size or the amount of vermillion show (red portion of the lips) does not make lips youthful or attractive.  In fact, exaggerated lips seem to invoke the opposite response much like the overdone rhinoplasty, facelift, or breast augmentation.  It should be clear that exaggerated plastic surgery is a choice, not a necessity.  Plastic surgery has progressed do the point where overdone is not mandatory and we Plastic Surgeons should question not what we can do but what we should do.   Because a patient asks for bad plastic surgery doesn’t mean we are obliged to do it.   Our role should be to educate those who ask for things we know are unattractive and if no common ground can be negotiated, no surgery should be performed.

There are details commonly associated with youthful lips that are easy to achieve as long as you know what you are trying to achieve.  Full lips are youthful, grossly inflated lips are not attractive and reek of bad Plastic Surgery.  Full lips require replacing the lost lip fullness with natural material such as fat.  There are numerous off-the-shelf graft materials that seem easy to use, but as foreign materials they present a multitude of problems that make the result less than perfect.  Autologous fat taken from the abdomen or hips, when properly processed, provides the best graft material for lip augmentation.  Increasing lip volume causes some increased vermillion show (red portion of lips) seen from the front as well as increased “pout” as seen from the side.  The increased volume must be apportioned so that they appear fuller and pouty.  Other aspects of the beautiful lip include definition of the white roll, fully visible philtral columns, and important for a natural look, a lower lip that is slightly fuller than the upper lip.  These nuances are not obtained by luck, but rather because of detailed surgical planning using the correct filler material.  The results should be apparent immediately and should last a lifetime.  Continued aging may lead to the need for touch-up grafting after several years even though the transferred fat, once healed, is permanent even though the lips are a highly mobile area of the face.  Any perceived problems with graft “take” are generally due to poor harvesting of the fat and inadequate processing of the harvested fat.  One should expect to have the fullness lost since the teenage years. It can be helpful for your Plastic Surgeon to see high school photos for reference.

Dr. Howard has been a world leader in fat grafting for over 25 years.  Patients travel from all over the world for his fat grafting mastery to rejuvenate their appearance, or fat grafting for reconstructive procedures due to injury or birth defects.  To learn more about fat grafting for  lip enhancement, facial rejuvenation, or cosmetic hand rejuvenation please visit:

Read more about Dr. Paul Howard’s lip augmentation.

Lip Augmentation Before Picture Lip augmentation before photo
Lip Augmentation After Picture Lip Augmentation after picture

The Modern Browlift by Paul Howard, MD

There are a number of techniques to smooth the forehead and elevate the brow.  Practitioners always tout the technique they use as being the “best” but more likely the procedure some view as “the best” is primarily the operation they are more comfortable with.  Surgeon’s comfort should not triumph patient results for browlift or any procedure where the results of the two procedures are different.

The antiquated browlift requires an incision in the forehead skin – the so-called “direct browlift.”  In an attempt to hide the scar and elevate the brow without the hairline, surgeons flocked to the pre-hairline incision and many claim the very long incision is easy to camouflage and causes no problems.  Common sense belies these claims and most surgeons have abandoned this procedure due to the scarring involved.

The last 10 years has seen the development of endoscopic techniques which minimize the scars by placing the two short incisions behind the hairline while allowing access to the three glabella muscles and the forehead muscles from beneath the skin.  Elevating the brow must be accompanied by some sort of fixation to hold the forehead skin and brow in the raised position for at least 2 weeks. The brow elevation may relapse to its pre-operative position without fixation while the muscle surgery used to decrease glabellar rhytids (wrinkles) and sometimes forehead wrinkles is not fixation dependent.  These rhytids are improved by effectively weakening the forehead and glabellar muscles that cause wrinkles.

Over the last 8 years or so we have developed a unique and quite elegant way to fix the brow and forehead in the raised position with bio-absorbable screws that dissolve after the golden 2 week period of required fixation.  The polymer chosen must be strong enough to withstand screw placement in bone, must maintain its bio-mechanical properties for at least 2 weeks and must eventually be cleared from the body.  The material chosen is a co-polymer of polylactic acid.

The “Modern Browlift” is a well researched procedure with at least 8 years of documented results, short incisions, no hair loss, no prolonged numbness in the scalp and minimal to no elevation of the hairline.

Read more about brow lift and view brow lift before and after photos.

Call today to schedule your consultation 205-877-PAUL

The Perfect Facial Filler by Dr. Paul Howard

Botox and Restylane have become the mantra for those seeking facial rejuvenation without the inconvenience of having a “surgical procedure.”  While these off-the-shelf products are enticing, they are expensive, temporary, and can be painful to inject, especially in the lips.  For more Plastic Surgeons, these artificial fillers (Restylane, Juvederm, Strattice) are appropriate only for temporary improvements where there are time constraints and the need to be in public within a couple of days.  Searching for the perfect facial filler had been elusive until recently.  The emergence of fat from your own body (autogenous) has paralleled the refinements in fat harvesting and injection techniques that have elevated the “take” of fat injections to the 80-90% range.  Coupled with improvements in local anesthesia and anesthetic agents make the overall experience with the new fat injection techniques less painful and more likely to give a permanent, elegant improvement in facial contours and rhytids (wrinkles).  Many non-surgical practitioners complain of the donor site for obtaining the fat.  While we must respect the donor site, offering the patient an improvement in body contour by harvesting fat for injection offers the patient the benefits of a liposuction (method of harvesting fat) procedure and cosmetic improvement of the donor site as well as the areas of the face injected with fat.

What does the future hold for facial fillers?  Ongoing research using stem cell and growth factor technology may lead to even further improvements in fat injection techniques while artificial filler research tries to make their artificial substances last longer and the cost with longer lasting substances is naturally higher and will continue to increase over time.

Fat injection techniques have proven to be a vast improvement over foreign-body injections for facial rejuvenation.  Fat is permanent, soft, cannot be rejected by the body, natural, and requires only small (3-4mm) stab wounds for injection.  The patient can request which body area is preferred as a liposuction donor site obtaining body contour improvement at no additional charge.  The well informed patient will usually choose the elegance of fat injection over the expediency of foreign material injected in the face.

As an extension of fat technology, we have begun fat injections in the back of hands for hand rejuvenation.  The injected fat decreases the appearance of prominent veins, knuckles, and tendons that become more pronounced as we age.  No one should let their hand reveal their age when we have the procedures to reduce the signs of the aging hand.

Read more about top fat grafting surgeon Dr. Paul Howard and view fat injection before and after photos.