Dr. Sam Lam Plastic Surgery Forum

Hi Dr. Lam,

Obvioulsy from reading all your posts, it's clear you do fat-grafting for the upper cheeks and orbital rim. I understand you are also excellent with techinquie so it does not have the problem of dissapearing like other surgeons.

Curious, what is your thougtht on sculpting the lower face with fat, for example, the area around the mouth and the lower part of the face that tends to get hollow. I have heard that does not to well with fat. Do you do that, and do you get as good of results as the upper cheek, eye are?

Thank you!

The lower face is a critical area of the face to work on with fat grafting. If most of the questions have centered around the upper and midface with fat grafting, I think that is because it is the area that in most surgeons hands can be the most difficult area to achieve consistent results. Further, it is an area that tends to be the most important area to fix in most cases. In any case, I am glad you brought this point up if it is a point of confusion for the consumer out there.

Nevertheless, I am very focused on the lower face. In fact, I rarely perform partial face fat grafting unless, of course, it is a touch up procedure. I believe the entire face ages, including the area around the mouth, which must be addressed to achieve a balanced and global rejuvenation.

Now, let's explore where fat around the mouth and chin area works consistently well and where it consistently fails. Let's first discuss where it works very poorly. I don't believe that fat grafting is a good option to treat facial lines and for lip augmentation. The very highly mobile region of the mouth and the softer nature of fat make it a very poor choice to fill lines around the mouth. Interestingly, I do put fat in the lines around the mouth almost in every case since fat is free and I can usually at least get a little benefit from it, especially when you consider that when I augment the cheek area the line can actually look deeper from the shadow effect so I put fat in the smile lines just to offset that effect and not to entirely get rid of the lines. I also do not like fat in the lips because there is tremendously long distortion on the order of a several weeks to even over a month or two where the lips look absolutely frightening for a result that in many cases does not last owing to the nature of the highly mobile lip area. To augment the fat loss immediately around the lips will also not work well. Also, you have to be very careful since filling the white lip, i.e., the area just above and below the red lips can make the lips look like a duck if in fact the fat survives. I do put fat in this area in small amounts to help hopefully the stem cell changes that can occur after about a year that can possibly (and I emphasize possibly) help soften the lines over time.

Okay, where does fat work then around the mouth? Just like for the upper and central faces, it is critical to pad the chin and the prejowl area (in front of the jowl) to make the area appear more youthful. If you look at younger chins, there is considerable fat in the chin area that makes it look youthful. Fat in this area really works. I also use it to balance a lower face. If you have a person with very heavy jowls, neck and outer portion of the face, I can strategically put fat into the anterior chin to balance the heaviness of the outer face. It can also thereby soften the presence of the jowl. If it is a very early jowl, the jowl will be almost entirely gone or at least significantly improved. However, if you have a decent jowl, then a combination of microliposuction of the jowl itself and a face lift/neck lift is critical to get an optimal result.

I hope this answer is helpful.
best,
sml

Thanks Dr. Lam, this has been helpful!!! But, there is still one area I am not clear on and since I don't know the name,, I will have to desribe it. Ok, here goes, it is the hollow part of the lower face (or at least mine) and is located below the cheek. The location can be best described as the area on the face where if you drew a horizoneal line starting from the mouth and a vertical line from the pupil meet. Is there a term for this area? And do you put fat there?

Yes, yes, yes. That area is known as the buccal area. It is a very important area to fill especially when the cheek is augmented so that the cheek will not be standing out by itself. It helps me blend the cheek better. In a very heavy face, I typically leave it alone. In a very gaunt face, it is an incredibly important area to fill. I actually am so focused on it that I have subdivided that area into four subcomponents and my staff knows what each means when I call it out so that they can record the numbers of syringes per treatment area as I do it. Not that you would need to understand what they are but they are the medial buccal hollow or I call it MBH, the central buccal hollow which I call just the buccal hollow, the lateral buccal hollow which I refer to as the backfill zone and also the latter three together not including the first which I call the extended buccal zone. The reason I give you this detail is for you to understand the level of sophistication that I take treating the buccal zone.
best,
sml

Dr. Lam,

I cannot tell you how AWESOME you are! As a patient, I love to be educated and enjoy the scientific explanation principles. Personally, I think the more educated a patient is, the more likey they are to fully appriciate your talents---and those that are not, just got lucky to have you!

Anyway, I thought I would mention am coming in from Chicago and have an appointment with you in December. Acutally, I am the sculptra patient that inquired about "transitioning" to fat. (btw, had 3 vivals total of sculptra). Ironically, I just wanted to come to you for the botox for the jaw , but after reading about the fat tranfer, I was intriqued to say the least!!

I appreicate your feedback, but there is one concern I have. This is in regards to fat tranfer and the dissadvantage Radiesse poses when doing it (I think it's because you said you can't dissolve it). I assume this can effect the symmertry and outcome if you add fat and not all radiesse is gons. And if this is true with radiesse, I would think the same would go with sculptra, right? Please correct me if I am wroing on that.

Honestly, the biggest thing that worries me is possible irregularites with fat injection, NOT because of your technique, but due possible scultra remaining. I am no doctor, but I am thinking the way to maximzie my potential for greatest results with fat would be to transition from sculpt to perlane/resty over the next year of so. That way, I can still have volume for my face, but by doing this transition (instead of going straight to fat) I can give it enough time for sculptra to dissolve. What are your thoughts on that. Previously we disscussed going from scupltra to fat, however, my thoughts are this method might allow for a better rsult.

I appreicate your feedback and so look forward to meeting you!!

Kate


p.s. Do you do perlane in the buccal area????

Your questions are absolutely great. However, I don't have a large series of patients who had sculptra then converted to fat immediately thereafter. I have fortunately not had any problems but I can't make any promises so to speak.

I would recommend at least 6 months if not a year or more after sculptra before fat grafting and same for radiesse but i don't have concrete reasons to lay out in front of you. i did have one lady who had sculptra by a colleague in Dallas with lumps and bumps around her eyes whom I told do not do fat grafting for at least another year or until those lumps settle because my fat would make them look more prominent in the meantime.

in an ideal world, we do fat grafting in virgin territories or in areas in which long-term products have greatly diminished.

ultimately, you have to make a decision what you feel best to do. at least, sculptra and radiesse will be diminishing all the time whether you have the fat earlier or later. i don't feel strongly either way.

best,
sml

kashmeister, I have the exact same problem - hollowness in lower cheeks. Was the result after one vial of sculptra noticeable in that area?
Was it injected only in that area or spread over the whole face?

Summertan,

I am fortunate to have an awesome injector and she pretty much made my lower hollow disappear. It was not overnight....took about 4 months to get the results I wanted, but it was cool because as each month passed, I kept improving. She spread a very thin layer over my entire face and has a very good eye for detail so my resutls look pretty good.

However, my injector DID say that many people don't get as good of results as me (I had 4 treatments a month apart). It's not that they get bad resutls, but just not as much improventment.

Be careful whoever you go to as I have heard of people getting lumps.

Anyway, in hindsight, I wouldn't have gotten the sculptra had I known about Dr. Lam. BTW...he also does Perlane in that area so if I were you, I would go see him and get either that or fat.

thanks kashmeister,
as a point of clarification, i don't do perlane under the eyes but only into the cheek and buccal regions. perlane is a bit too thick under the eyes. elsewhere it is great.
best,
sml

Thanks for info. I am definitely not springing $4000 for sculptra to fill my lower cheeks when I can get the same result with HA filler for much less.

Yes, it's a lot of money and in hindsight perlane or fat would have been much better. But, read my post on perlane cause it seems that Dr. Lam has mastered the technique and like sculptra or any filler, you are really going to want somebody with a good eye so you look natural!

thanks Kate. Maybe I should hire you as my publicist! Spread the word!
sml