Dr. Sam Lam Plastic Surgery Forum

Hi Dr,
I watched your youtube video and was very impressed. I liked your ideas of viewing patient pictures in younger years as well as adding volume can help over traditional surgical procedures. My question is you hint in the video that the placement areas of fat for men are different. Can you talk about that a little, do you place fat in different areas for men generally? I have had restylane done and was not really impressed with the results because most of the material was placed in the Apple of my cheek, rather then the outer edges of my cheek. Again, did not look like me younger. Also, I am not local to Dallas, (upstate NY) but am considering seeking a treatment from you. How do you treat out of town patients in terms of consults, or can you either recommend a Doctor in upstate NY.

Thank you!

I hope you are not offended but I have already answered this question in detail in other parts of my forum. Just do an archive search or just go down the list and find the topic on fat grafting for men. In summary however, I keep the anterior cheek relatively more suppressed and overall fat volumes lower depending on the photos you show me and my aesthetic judgment with you. I also need to look at your facial shape to make that determination. I apply a lot of artistic judgment to help you bring out your best features. Remember that yes I want to preserve your identity but if there are a few areas that I can make look even better than in youth, a consultation with me will help make that determination with you.

Actually, about 20 to 30% of my patients come from out of state and out of country. I do a lot of men for fat grafting from out of state. Because there are no incisions and really no after care, it is easy to fly in and fly out. You can just stay a few days and fly back out. I have an entire section called "flying in" under the contact segment of my website that will help you with hotels, transportation, flight info etc. it is very easy to do.

As far as recommending someone else, I really can't. My fat grafting results are completely different than most peoples' out there. This is my specialty and focus of my practice. As fat grafting is as much artistry and technical skill, you have to select a surgeon who matches those criteria. If you look for an entry by "Rock" in this forum who had his fat grafting done in New York by a very experienced surgeon, you will see a very sad tale. I have seen his photos but cannot share them with you. Fat grafting is irreversible so you must choose your surgeon carefully.

If you would like a consultation with me, you can call my office 888-866-3388. I always prefer an in-person consultation but we can do a phone consultation if you cannot fly here for the consultation. You will have to sign a waiver that I did not see you in person and there are limits that a phone consultation will inherently have in my judgment. I hope all of this helps.
Best,
SML

Hi Dr Lam
Yes, right after I sent my message, I saw that huge post on fat transfer for men. I searched, just missed it the first time around. No offense at all!
As far as out of state consult, that sounds great. I will give a call later next week after the holiday to set something up. I would probably have to do the phone consult, but I will gather together some pictures and notes.

Your dedication and focus on the patient is tremendous and refreshing!
Happy New Year.

Rick

thanks rick. this may sound like a line, but i am literally obsessed and passionate about this to the point that this is what gets me up in the morning excited and drives me through the day. i am so lucky to do a job that i love beyond my dreams. looking forward to speak with you and take care of you in the future.
sml

Hi Dr Lam,
This is Rick, nice speaking with you this evening. I look forward to meeting you in person. I did think of a few more questions.

1. You mentioned about adding volume to the jawline. I was curious about what that will do. For instance, one local doctor suggested a Micro Pulsed UAL treatment on my jowls/jawline, so I had thought that you may suggest the same while also adding volume higher up? I do see my jawline/jowls as “too heavyâ€￾, certainly much heavier than I was in my early 30’s and thought that perhaps it would get fat removed with Lipo and not added? Just trying to understand.

2. Speaking of Lipo, tough to see in my pictures, but would you suggest this on my neck and under my chin? A couple of the photos do show how that has filled out more and I wondered if it was just loose skin or fat under there. Do you do a lot of those kinds of treatments and are they effective?

3. Any suggestions for the oily skin/sebaceous hyperplasia? I had hoped to try low dose accutane again in the future since it was the only thing that worked, but the dermatologist retired. Obviously even if I had found it, I would want to wait on this before doing my fat treatment, but I wondered if there were any other medications or treatments that help. Currently I use Tazorac for the skin and prescription Sulpher cream 3 times a week for the redness/irritation. They don’t help much. I have read about different treatments - everything from Red Light to Progesterone(which kind of scared me!), but have tried nothing else, and know of nothing that helped liked low dose accutane.

4. Would you be able to do any treatment to the acne scars as part of the procedure at the same time as the fat treatment? Again, I know tough to see in the pictures I sent, but assuming you agree that I could benefit is there a scar treatment that can be done at the same time as fat? They are the flat wide shallow type for the most part.

Thanks again. I love your “differentâ€￾ approach to surgery. More more personalized and not so cookie cutter. I am calling your staff tomorrow to discuss details for an appointment.

Rick

Hi Rick,
It was nice speaking with you tonight too. Here are my responses in all caps:
1. You mentioned about adding volume to the jawline. I was curious about what that will do. For instance, one local doctor suggested a Micro Pulsed UAL treatment on my jowls/jawline, so I had thought that you may suggest the same while also adding volume higher up? I do see my jawline/jowls as “too heavyâ€￾, certainly much heavier than I was in my early 30’s and thought that perhaps it would get fat removed with Lipo and not added? Just trying to understand.
OKAY, LET ME CLARIFY. I FILL THE AREA IN THE SO-CALLED "PREJOWL". THAT IS THE DEPRESSION THAT LIES JUST IN FRONT OF THE JOWL. WHAT THAT DOES IS MAKE THE HANGING JOWL APPEAR MUCH SMALLER. AS WELL AS PUTTING FAT IN THE ANTERIOR CHIN. LOOK AT THE PHOTO OF SHARON STONE'S CHIN IN YOUTH AND IN HER FORTIES IN THE BLOG SECTION OF MY WEBSITE. THAT WILL HELP YOU UNDERSTAND HOW THE CHIN GETS BONY WHEREAS THE JOWLS GET HEAVY.

2. Speaking of Lipo, tough to see in my pictures, but would you suggest this on my neck and under my chin? A couple of the photos do show how that has filled out more and I wondered if it was just loose skin or fat under there. Do you do a lot of those kinds of treatments and are they effective?

LIPO IS AN EFFECTIVE TREATMENT, AND LOOSE SKIN SHOULD TIGHTEN AFTERWARDS. HOWEVER, YOU ARE 39, WHICH MEANS THAT IF THE PLATYSMAL BANDS (MUSCLE BANDS) CAN START TO SHOW AFTER SURGERY UP SO I WOULD NEED TO SEE YOU TO MAKE THAT DECISION. I WANT THE LIPO TO HELP NOT TO HURT. I CAN DO SOME ACCENT XL RADIOFREQUENCY TREATMENTS IF NEED BE.

3. Any suggestions for the oily skin/sebaceous hyperplasia? I had hoped to try low dose accutane again in the future since it was the only thing that worked, but the dermatologist retired. Obviously even if I had found it, I would want to wait on this before doing my fat treatment, but I wondered if there were any other medications or treatments that help. Currently I use Tazorac for the skin and prescription Sulpher cream 3 times a week for the redness/irritation. They don’t help much. I have read about different treatments - everything from Red Light to Progesterone(which kind of scared me!), but have tried nothing else, and know of nothing that helped liked low dose accutane.

I REALLY AM NOT A DERMATOLOGIST BUT A SURGEON SO IT WOULD BE BAD IF I GAVE A BAD ANSWER HERE. HOWEVER, RETIN-A DOES HELP BUT OBVIOUSLY NOT AS MUCH AS ACCUTANE.

4. Would you be able to do any treatment to the acne scars as part of the procedure at the same time as the fat treatment? Again, I know tough to see in the pictures I sent, but assuming you agree that I could benefit is there a scar treatment that can be done at the same time as fat? They are the flat wide shallow type for the most part.

I CAN DO SILICONE IN THE FUTURE BUT UNFORTUNATELY NOT AT THE SAME TIME AS FAT GRAFTING. REMEMBER THAT FAT GRAFTING MAY HELP YOUR TEXTURE AND TONE OVER TIME. PLASMA SKIN RESURFACING CAN HELP TOO BUT THAT ADDS MORE COST AND REQUIRES MORE WORK THE WEEK FOLLOWING. ALSO, IT IS NOT A HOME RUN ON SCARRING MORE FOR ROUGHER TEXTURE. YOU HAVE SOME OF THAT BUT PERHAPS NOT ENOUGH FOR ME TO MAKE IT WORTH YOUR WHILE TO SPEND AN EXTRA $3500 ON THAT.

Look forward to take care of you,
SML

Hi Doctor,

I had a few more questions on fat transfer. I am reconsidering going for the fat transfer treatment first rather than the restylane, but I wanted to clarify a couple issues. My apologies if I get a bit wordy, Im just trying to clarify if its worth doing restylane/perlane first vs a fat transfer. My original reason for restylane first vs fat was financial, but also I thought that restylane would give me an approximate idea of what degree of improvement I can expect from a fat treatment, it was just more temporary. Im beginning to question, however, that a restylane/perlane treatment can approximate a fat transfer in terms of improvement and wanted to ask questions on that issue.

In my phone consult, you mentioned that you would inject 25-30 cc's of fat. Afterwards, via email, you mentioned that if I get restylane/perlane treatment, I would get about 4 cc's to roughly equal the improvement from the fat transfer. I believe I can benefit greatly from 20-30 cc's of volume, but that amount of material surprised me a bit when compared to a treatment of 4 cc's of restylane/perlane treatment. It is just so much more volume than the restylane.

First question, when you do a fat transfer, do you “overfillâ€￾ with fat, and thus end up with much less volume than the 30cc’s. In other words, do you end up with much less material, and thus a restylance/perlane treatment can actually approximate the fat treatment, or is it just that it is impractical to use 25-30 cc’s of restylane/perlane because it is a temporary filler.

As a related point/example, you have mentioned that with men you often inject much less material than with women. That seems to hold true with the photos on your website. The men in the photos seem to have much less volume added than the women. This was another reason why I was considering doing restylane/perlane first. However, after our discussions, Ive started to realize how much of an effect adding volume to the jawline (outer and prejowel) and outer/posterior cheek can have on appearance. When I looked further at pictures when I was younger, I didnt realize how much volume I lost in the lower outer jaw as well as the entire outer cheek. Im guessing that contributes a lot to looking younger. Based on our discussion, if I did have a perlane in these areas, only about .5 cc would go to each jawline and .5 cc to each of the outer cheeks. That does not sound like very much volume, again, when compared to fat. Will that small amount of restylane improve the jawline/cheeks, similar improvement to fat, or is it again just impractical to add that much restylane and in fact a fat treatment will show much greater improvement because of total volume.

Ive read how over time the fat transfer looks better after 6 months, a year and beyond? What is the reason for this? Why do you look better at 6 months post vs say 2 months, I would think some of the effect would diminish?

Finally, the swelling for fat transfers last about 2 weeks or so, is that correct? After about 2 weeks, you are "presentable" in public.

Thank you again for answering my questions!

Rick

Hi Rick,
No problem at all with the questions. That is why I'm here:
1. Yes, I know it sounds like a stretch to go from 4 cc of restylane/perlane to 25 to 50 cc of fat. However, there are two reasons why 4 cc still looks very good: 1) I target the most aesthetically deficient areas and not just spread it everywhere as i do with fat grafting. By targeting select regions I can maximize gain and minimize expense, 2) Restylane and Perlane are very hard materials compared to fat so a: less material is required to achieve a "fat grafting" result (that is my opinion) but b: it would be unsafe (and way too expensive) to push it beyond 4 to 5 cc. The most I have done in a face is 7 cc. The reason I did this was the individual was going for a reunion and did not mind spending more on the treatment. I typically will push past 4 cc to 5 to 7 cc in a person who has a very important social/professional event in which money is not an object like a daughter's wedding or something like that. Otherwise, just to look better for a temporary amount of time, it is crazy to buy that many syringes. Also, I can't predict with certainty your longevity with the product so spending more than $2000 is a bit ridiculous in my opinion. Further, as mentioned, under the eyes, I can't really fill it all in with Restylane, as I believe past about a cc (at most 1.5 cc) would lead to bulginess that could be problematic. Of course, you can manage this with Vitrase but that becomes harder if you are from out of town. Not trying to scare you just explain why I can't totally fill in the lower eyelid but just make it look a lot better with Restylane.
2. I don't overfill with fat grafting. I fill what I see because you cannot reverse the fat so I fill what is necessary. Don't worry I have done this for many years now and have never overfilled someone. Overfilling is a dangerous thing to do. However, that being said, when I do hands I do overfill by about 20% for two reasons: a: sometimes you lose more in the hand area over time, b: if the hand is a little fuller no one really notices.
3. I can be much more creative with fat grafting like the outer jawline and anterior chin, etc. Since "fat is free", I can do what I need to do to get the job done.
4. It is not entirely clear why fat looks better after 6 months to a year. My speculation is that the blood supply begins to thoroughly kick in and you start to have some growth of the fat into a more blended and seamless look. I liken it to hair restoration in which the hair graft starts to grow around that time (a bit earlier but starts to look good by that point). The second point that I would like to make is that there may be a stem cell change in which the skin starts to look better after that point. That has not been precisely confirmed but I see it all the time.
5. Conservatively, I always say two things regarding recovery: "The only thing that I can predict is that human nature is unpredictable, i.e., I don't know how someone will react to you." In general at 2 weeks, you are still full but much less noticeable than at 1 week. Most people say something like "Man, I had some bad shellfish" and get away with it because people really don't know about fat grafting and without any incisions it is hard for people to guess what the heck you did. That is by the way why I film my video journeys so that people can be comfortable with the recovery visually. The second point that I mention is that conservatively I say at one week you might not like it and other people might not like it. At two weeks, other people will probably like it but you may still not like it and at 3 weeks you will probably like it and other people will probably like it. Again, that is conservative. For people in town, I usually take a photo at a week to show them how much better they look and how a third party sees them. that usually helps. Most people cannot take 2 weeks off from work so I usually say that a lot of distortion goes down between days 7 to 10 so if you are pressed for time, if you can do it on a friday and have 2 flanking weekends that is usually pretty good.
hope that helps and look forward to take care of you,
sml

Thank you for answering all my questions. It seems that the fat grafting makes the most sense in the long run, both financially and ecstatically, especially since you can use so much and that most likely will last beyond 2 years. The only concerns I have is my prior filler treatments, specifically 1 Radiesse treatment about 2 years ago(march 06), 2 Sculptra treatments the last one in june 06, and a couple of Artecoll treatments about 3 years ago, one in an acne large scar and the other along the tear troths near my nose about an inch long. I read some of your other previous posts about other fillers, but was not clear on how you handle this. Im guessing some of the product is still there, especially the Radiesse which I believe I can feel in one small hard spot where it is.

The problem is, most of these areas still need some filling, in my opinion. How will this affect the fat transfer treatment, if at all in this and other areas? In reading your previous posts, it seems that you often inject around it to blend it and you cannot place fat in that area. Is this always the case, or can you still inject fat below these areas if they still require correcting/lifting? Fortunately, it has been a long time since these were placed, and I did not have it placed in all areas (eg none in jawline, chin, brow or outer cheek) so I know fat can help, just curious about worst case scenario in these other areas.

Thanks and see you soon!

Hi Rick,
I plan on filling into and around the areas with fillers. Of course, if some of your fillers dissipate, I may need to add more fat but that is unlikely since you are a little while out from having anything done. I don't anticipate any problems at all.
Best,
SML

Hi Dr Lam,
Sounds great about the fat placement! Im glad to hear that the previous fillers Ive had should not affect much in terms of placement of fat. It will be nice to get a treatment from someone who has a good eye, and not just follow the standard procedure on everyone.
Im all set for my fat transfer procedure in a little over two weeks. I wondered, if upon seeing me it is decided that a ACCENT XL radiofrequency treatment is an appropriate for the jowls and under the chin, can this procedure be done at th same time as the fat transfer? As a reminder, another local surgeon suggest a pulsed ultrasonic lipo treatment in these areas, and you thought at my age, 39, there are risks of that in the face and thus you suggested perhaps an Accent XL treatment may be helpful. Part of the issue I would like to address is that my lower face got much heavier over the past couple years, despite the fact that I did not put on any weight. As a result, I would prefer to do as makes sense in 1 visit.

Looking forward to meeting you and your staff!
Rick

I can only do the Accent in areas where I did not perform fat grafting like the neck. Going over the jowls is not a great idea. Look forward to take care of you.
SML