Dr. Sam Lam Plastic Surgery Forum

Hello Dr. Lam,

I have always had a very thin face and very little volume in my cheeks, especially on the left side. The right side has slightly more volume interesting enough. I have had my tear trough hollows filled and although it looks better, my left side looks very gaunt, flat looking. i have a little restylane left over from the doctor's office. Where would you recommend that be put to give me a little more volume from tear trough to cheek? I heard you say anterior cheek area, what part of the cheek is the anterior cheek?

yes, anterior cheek is the most effective site. just look at your cheek where there is maximal depression of soft tissue. that is where your anterior cheek is. it is toward the nose and down from the cheek bone.

Just another question I want to address. I had restylane put in my tear trough. I have a few lumpy areas and I can see the product through my skin. I have very thin skin, so was it inevidable that it would show through my skin because of the thinness of it. He did inject along the rim at a sordive sideways angle. I am just wondering do most plastic surgeons know how deep they need to inject the product so it wont reveal lumps and become visible through skin? What technique with your canulas do you do to prevent that from happening. I ask this because I am going back on Wednesday for a follow up and I am going to ask him what technique he uses and see if your way compares to his way of injecting besides the obvious difference that you use a canula. If you didn't use a canula and only used a needle, I am just curious to know what technique you would use to prevent lumpiness and from the product showing under the skin.

if you can see the product, it is too close to the skin. most doctors talk about injecting the product intradermal. i truly believe this is too close to the skin in 99% of the time (except in dealing with fine lines around the mouth). i know most docs are still doing a very outdated treatment of restylane into too superficial a plane. a cannula, per force, must be injected below the dermis since it is impossible to go intradermal with it. he will probably say that i don't get longevity with a deeper injection. that is rubbish. i personally hate that artificial beady appearance that a lot of "experienced" injectors get in the smile lines for instance. that is due to the textbook answer of injecting deep dermis.

i use perlane to ensure greater longevity, typically my patients hold about 10 months to 14 months in the cheek. however, perlane will be significantly lumpier since it is much thicker than restylane if injected badly. i don't see this problem. you should dissolve out the lumps first and try again fresh. also i inject across the malar septum (see if he knows what that is). if you go parallel you can actually worsen the depression in the anterior cheek in about 10% of people. i know this is all very complicated sounding but most docs simply do not understand volume and how to shape a face accordingly.

also, with cannulas you get little to no bruising in most patients. if you get a bruise, i can laser the bruise out in 5 to 7 days. ask if your PS knows about that. most do not.

to truly get the results that at least partially simulate a fat transfer, you need 4 to 5 syringes in most cases. that is probably laughable to most docs who are used to filling one syringe in the smile lines. however, sculpting a face back into a youthful shape requires more than one syringe in almost every case and filling the face in such a way that even most savvy patients do not understand until i actually do the procedure.

sorry, i hope i didn't sound too harsh. however, i have found that what i do is almost inconceivable to most PSs out there who are not focused on volume contouring. It is hard to even ask your PS what he does compared with my work, even for something as seemingly simple as restylane.

Hi Dr. Lam,

I totally get where you are coming from. It is true, MOST board certified PS's do not know what the heck they are doing. I went to a nurse practitioner and I used a lot of technical terms like malur spectum (I think that is how to spell it) and orbital rim, and she got intimidated and backed out of doing my tear troughs and sent me on my way to see a board certified PS, who did my tear troughs and now I have visible lumps. I have been watching your videos and I feel so much more empowered and knowledgable compared to before.

I just want to clarify something. Do you think it is more important to inject in the anterior cheek then in the tear trough. I used my hands to mold what would look like more volume in my cheek and my eyes looked so much better. I just think in the future I will never get injected again in the tear trough region because 1. the skin is too thin there and I just think it is too lose and doesn't mold well on me. 2. The skin in my anterior cheek region is way more thicker and I think would give a better result. Watching your videos, it sounds like you think it is more important to put restylane in the anterior cheek area and NOT the tear trough rim area, but if I am wrong, maybe you can clarify me on that. Again, I have learned so much and I do agree with you so much on everything. Before I didn't really agree with your philosophy on the laugh lines, but now I do. I think that the number one place of volume should be in the anterior cheek. If it is put there, laugh lines and hollows are enhanced by that volume in the cheek. It is exciting to know that there is one place on our face that can add such a youthful appearance to our face that so many people don't do injections in.

I think in most people the gaunt anterior cheek is number 1. (however, i have not seen you!) just remember that if you don't do the tear trough with the cheek, the tear trough can look deeper. in an ideal world, you do both. however, i understand about your past experience. simply put, cannulas can avoid this problem no matter how thin your skin is. when you get tired of doing injectables, you really should consider a permanent fix like fat grafting that can address all areas of concern and areas you might not have even thought about.
best,
sml

Hi Dr. Lam,

I had my tear troughs done already but all that did was make my face extremely flat on the left side. I have essentially no volume in my cheeks, so that is why it looks so flat. The ride side like I said before has slightly more volume. As an older woman, I am noticing a more gaunt look and so I think I will go and get more filler in my anterior cheek areas to help give me a more restful look. For years, people have told me I look tired and so this is more motivation to get this done for myself. I think that the bad experience I have had in my tear trough area makes me more motivated to come and see you in the future. I like the canula technique you use. I think you are right about the balance that needs to be in store. As I was watching your vlog on the good, bad and ugly cheeks, I realized that having balance in our face and harmonizing both sides is essential. I may have had my tear troughs done with one syringe of restylane, however, I don't think my face looks balanced with out more volume in my anterior cheek. Like I said, it looks flat and guant and the volume in my cheek is what will give me more of a rested appearence.

I did not know that fat grafting was permanent. I thought that aging diminished the fat in our bodies. So if you put fat in the cheek area or any other area on the face, wouldn't age eventually break down the fat tissue. I am very curiuos about that. I don't agree with silicon implants, those would be awful I think, but fat grafting seems interesting.

fat grafting is permanent but does not stop the aging process. the fat that i harvest from difficult to lose areas like your hips and thighs should not be lost over time. however, you will continue to lose your own natural fat in your face. the nice thing is if you don't age much, i can add a little more fat each decade.
best,
sml

Thanks Dr. Lam,

On Wednesday I am going back in to have him look at my tear trough area including the lumps. The bruise on the right side is starting to heal. Looking in the mirror, something about my appearance just doesn't seem right. I don't know if it is just the shock of not having steep tear troughs for the first time in my life (I have had them since I was a kid, but more prominent when I was about 20 from looking at past pictures) or that something just doesn't seem balanced. Like I said before, the tear trough area is very flat as well as my cheek and it looks like someone took a rolling pin and rolled my face flat just to give you an idea of what my structure looks like. In most of your cases in the past, those that you have seen that have fairly guant faces or little cheek volume who request tear troughs filled, do you usually see a need to fill the cheek area as well. As an older lady, I feel I want to look more restful as I think I deserve it and I want to look as good on the outside as I feel in the inside. I will update you after my visit on Wednesday. It is nice to be able to vent my concerns to someone who understands even though they have never met or seen me before. thank you!

no problem. and yes, the cheek is critical. actually, to be honest with you for someone gaunt, filling the anterior cheek is oftentimes also very unbalancing because the buccal area (the area that dips when you suck your cheeks in when your mouth is closed) is just as important. sometimes in a gaunt individual, this area is even more important, actually far more important. that area requires at least a full syringe to fill. a partial one in a gaunt individual won't work. i truly think the problem to get a good fill to simulate a real fat transfer requires in your case 4 but really 5 syringes (again without seeing your photos i am making some assumptions). however, if you are not happy with the first syringe, are you willing to trust your PS with 4 more, especially the cost that that would entail? just to let you know, in my situation when someone needs 5 syringes., i charge for only 4 and give the 5th free. plus, all syringes then get discounted at a price to 500. that is not a bad deal.
best,
sml

When I had my tear troughs done, I had no numbing cream or anything for the pain. The PS said he only uses ice. Is that a good thing just to use, dr. lam?

My face is also fairly guant. my tear troughs look awful because like above posts, my face looks flat and doesn't have a lot of volume either. It had more volume before he did my tear trough because at least I had that crease which made it look more natural. I look so superficial its like you can tell something wierd was done on me (also by a board PS) I feel hopeless like nothing can be done to fix it. It looks like a flat tear trough with bags under my eyes that are really lumps that never went away. What can be done to help. The PS doesn't have any enzyme to dissolve the product so I essentially have to live with it. I am attending a wedding and I am going to look like this. Would adding more product to my cheek help, what is your advice Dr. Lam. None of the doc's in town have enzymes to dissolve this so that is out of the option. help!!

i truly cannot believe that they have no enzymes. this boggles me beyond even comprehension. they need to get it. it is called vitrase. you can get it online, at least a doctor can. obviously, if you were in my area or came to my area, i can dissolve it and wait 24 hours and place the product in properly in all areas. i do not charge for vitrase if you do the restylane. i can't think of how else to help you when the solution is so easy: DISSOLVE IT! i wish i could give you an alternative. even though i am booked out 2.5 months now, i would be willing to see you (if my staff does not kill me) to fix your problem. i can't promise you.

I would fly out to see you immediately if you weren't booked.

I only trust you and nobody else. I hate going in to see PS in my area because most of them have not taken interest in my condition and I have seen 3 of them already wanting feedback.

I am going to keep you in mind in the future.

I watched one of your vlogs and you spoke about cheeks and how the cheeks can make eyes look younger if you push your cheek upwards a little bit. I did that and yes, it looks so much better. I am wondering if the result of a filler put in my cheek would give me a similiar result because when I push a little volume in my cheek with my hands, wow, that would be the result I would want, but if only that were really realistic it terms of restylane or juvederm doing that for me . Thanks for your feedback.

yes, filling the cheek that way is realistic (if done right). i don't want you to compound your problems even more. however, the cheek is technically easier to fill than the tear trough. however, as you see on this blog, docs are still creating real problems in the cheek. this is why i stopped teaching injectables. i can't handle any more responsibility of other docs trying to perform advanced injections.