Dr. Sam Lam Plastic Surgery Forum

Good morning Dr. Lam,

I had my tear trough with restylane done not to long ago and I only had 1 syringe which covered both my eyes. The guy was conservative. I notice I need more product because it is still hollow because I had my cheeks volumized which resulted in further hollowing of my tear trough region of the eye. Does it hurt to put more restylane in the tear trough after they were done awhile back. Do you ever use a full syringe in each tear trough eye area. I don't want to put too much in the tt area because the skin is fragile and not tolerante of stuff. Thank for the recommendation.

that should not be a problem. i put in a syringe a side, i.e., for each tear trough, in about 90% of people. REMEMBER, I AM VERY GOOD AT THIS. WITH TRADITIONAL TECHNIQUES AN ENTIRE SYRINGE MAY BE TOO MUCH. just be careful.

Thanks Dr. Lam,

i went to a guy who did my tear troughs and then waited about a month. I then went to a dermatologist cosmetic type one, who has a very good eye and good reputation in Berkeley, CA. She did a spectucular job on my cheeks, but my tear troughs are more hollow now and I want to fix them but she didn't because she was too afraid to touch another doc's past work on me. She wanted to dissolve the restylane in my tear trough because she didn't like it from another person in the bay area who did my work. If someone came to you from a previous doc's work and you didn't like it, would you first dissolve the product before putting additional new product in or would you just touch up the area from previous work and add more volume. I think I just need more depth in my tear trough. I just need another opinion. She gave me hers and I was wondering if I can get yours. So, should I have her dissolve the product and start again on my tear trough or just add more product. Her opinion is to dissolve it, but I don't want to waste my money that way. I only had 1 syringe in both of my eyes and I am still hollow under my eyes (partly because I got volumized in my cheeks with another filler) I hope my question is not too repetitive, I am just confused a bit.

Oh one more thing. How many syringes does it take. If I get another syringe, it will be my 8th one in less then 3 months. That seems like a lot but I had major loss of volume in my cheeks and tear troughs. Is it typical to have that many syringes. I find the cheeks take a lot of filler vs, the tear trough and NLF's. Dang.

8 SYRINGES??????????????????????? The most I've done is 7. That was for a woman who was going to a reunion. My true philosophy is that I think when you buy that many syringes in such a short time, you are wasting too much money. That is my opinion. I only do that many for someone who must look perfect before a major event. Otherwise, my philosophy is to do something permanent and a hell of a lot better like fat grafting (if done by someone who knows what he or she is doing.)
best,
sml

I hear ya Dr. Lam. I keep asking myself the same thing. I just don't understand why I needed that many but its like when they first did my NLF, my tear troughs needed work, so I got them done, then my cheeks looked gaunt and there was no depth in my tear troughs to hide the product, so I got my cheeks done which took a lot of syringes. Its like in order to create a balance in my face, they had to keep adding more and more volume.

So, as frustrating as it is to have to keep going back because my face is not balanced, I wonder if fat grafting is a better fix for me. My face was very very thin before I got this done, so you can see the amount of volume it took to get me looking refreshed looking for once.

The face is like a work of art, and needs to be balanced and in harmony, but 8 syringes, youch!!!

Obviously, it's your money and your face. I know how to target for example the cheek so that in almost ALL cases, even extreme ones, I can get away with 2 syringes in the cheek and buccal zones. However, I think people need to know how to place the filler in zones of maximal depression not just to spread it around everywhere. In other words, I can get away with fewer syringes for more effect in many cases. Look at my 4 syringe fills that dominate the injectable filler gallery. There are only a couple 5 syringe fills and one 7 syringe fill.

Even when it comes to fat transfer, I use much more limited fat than my colleagues but still 35 to 45 cc is nothing to sneeze at. Now why is it good that I use less fat? Is it that you are getting ripped off if I don't give you 80 to 150 cc. NO! I know how to use my fat to get maximal results with fewer cc's than my colleagues. Here are the advantages for you EVEN with fat transfer:
1. less recovery.
2. better fat take since there is more fat to surrounding tissue hold
3. more predictable results in the long run since limited fat does not have the risk of becoming too big or small when the blood supply kicks in post 6 months.

If you decide on fat when you have budgeted for it and want it at a certain point, I can dissolve out all of the Restylane, Perlane, and Juvederm. If you have Radiesse or Sculptra I should most likely wait at least a year and I would encourage no more of those non-reversible products in the face until you can do fat transfer. Also, understand one more thing, if you were my patient coming into my office and asking for an 8th syringe of fillers, I would highly discourage it and encourage you to wait until you can convert to a permanent option. Unfortunately, most docs don't do fat transfer or at least they may advertise it but they don't do it well enough to encourage you to do it or they feel as if they are losing their revenue stream with your injectables. to be honest, anyone getting that many syringes will suffer from what i call injection burnout. you will get exhausted continuing to fill that to maintain the results especially at that level. a very simple question: WHEN WILL YOU BURN OUT? HOW MANY TEMPORARY SYRINGES WILL MAKE YOU HAPPY?

Well, here is the thing I am comparing myself to. Old pictures of when I was a teenager. I told the doctors I wanted to look like I used to. I am older now and have lost tremendous volume before I got the fillers. I went to a couple of doctors that did not do the procedures correctly and missplaced the product which resulted in further uneveness. It has been tough for a lot of PS's to help me because I didn't do a lot of research and homework like I should have on who to go to and those with the most experience.

I think I would very much like to come to you in the future for fat tranfer. I agree it is a smarter choice in the long run. When you do 35 to 40 ccs of fat, are your patients asleep and do you use a blunt canula? Also, do you do the entire face where needed that is?

1. yes, you are sedated. i have my own surgery center. i want you to feel NO PAIN just like when i do fillers. to make your experience painless, i use sedation.
2. yes, i do the whole face in order to sculpt the proper areas. most docs cannot see what needs to be done. you have to apply an artistic eye to create the desired effect. it is not just filling the obvious but shaping the subtle areas to create a composite of youth and beauty.
3. blunt cannulas 100% plus all anesthetic is applied with a blunt cannula. in summary: no needles, no knives, no sutures, no bandages. 100% cannula.

Dr. Lam,

I think you definately got me sold on this fat grafting. It sounds like a wonderful solution for a permanate fix. How about when you take the fat from my thigh, am I sedated.

You say this is 9k, right? How long shall I wait because I just got fillers injected, only the HA products though. Can some of the product be present when you inject fat or all completely dissolved.

If I fly out which I plan to do when you recommend I do, how long do I stay in texas after the procudure for recovery.

hi,
1. i truly recommend that everything get dissolved. only because i don't want something to disappear in 8 months when i am putting something permanent on top of it. i usually like to dissolve things at least a few days before to make sure that it is gone. in fact, it is ideal to try to start once a week before then a few days before if at all possible. i know that is oftentimes not feasible. your doc can start the dissolving process a month before then i can finish it before you start.
2. yes, 9k.
3. yes, sedation for harvesting. that is critical.
4. many patients fly out the next day or so. my legal recommendation is a week but almost everyone flies out after a day or so because there is nothing for me or you to do once i have done the job. the only thing is a few people stay into the 5th day because I can laser them if they get a bruise so the bruise can disappear in a day or so thereafter.
5. i am pretty booked out but 20% down will secure a date. just email constanze@lamfacialplastics.com or call 888-866-3388 to schedule.
sml

Dear Dr. Lam,

When you do fat grafting or fillers, were do you generally put the product location wise? If the person wants tear troughs, that is obvious, you just do the inner and center trough right, do you do the outer eye area as well because I know a lot don't do that area although I wish they would. For the cheek, do you do anterior and buccal zones mainly.


Here is a question I have for you. If I wanted a more heart face shaped face (triangle of beauty they say) would you inject the upper cheek and buccal zones mainly, or where do you work to achieve higher cheekbones which most people want.

obviously, these questions are so very difficult because part of what i do is tailor fillers to each individual based on signs of aging, facial shape, desires, budget, etc.

let's divide this answer into fillers first then fat because i do similar but different things.

FILLERS:
as far as tear trough, i fill the entire thing not just the tear trough but the entire inferior orbital rim. i actually miss about the outer 10% with my cannula. if there is a noticeable dip beforehand, i will use a small needle and push it into the outer 10% before starting the cannula fill.

for the cheek area, i mainly do anterior cheek because it is the most bang for your buck. if you are gaunt or have a high outer cheek bone, the buccal region is critical so that you have a balanced look. just filling the anterior cheek in someone with the above criteria can unbalance the face. my goal is to soften the transition to the exposed cheekbone, which despite what many women think they want, it actually is the first sign of aging when the cheekbone becomes exposed in isolation. that is why a cheek implant is in a word, DREADFUL. it exacerbates these transitions and further exposes the bony quality to the outer cheek.

FAT GRAFTING:
Ah, the joy of having unlimited paint. With this treatment, I can truly achieve the desired benefits of youth by designing not just a heart shaped face but one that is blended and balanced entirely. Remember just having cheeks and chin that sticks out (like with fillers) is pretty good but is nothing like the softer quality and blended appearance of a quality fat transfer. With fat grafting, not only am I able to truly improve the above stated zones, but I can blend them with all of the surrounding areas to create a unified composite creation that truly simulates youth, vitality, and in women, breathtaking femininity. the target zones then become: the temple, brow/upper eyelid complex, nasojugal groove/tear trough, inferior orbital rim, anterior cheek, lateral cheek, buccal zone, backfill buccal zone, medial buccal hollow, canine fossa, nasolabial fold (although the fold truly does not disappear with fat but transitions soften), anterior chin, prejowl sulcus, and if needed lateral mandible. That is not to create a fat face but one that has the softened transitions and vitality of youth. That is giving the artist unlimited paint to literally (or really figuratively) airbrush the disparate regions of the face into a more unified whole without creating a fat face or an overfilled one.

Oh, that just sounds too good to be true. I want that so much. Do you expect people to pay the entire 9k at once or do you have a payment plan. I am almost 30, is that too young? I like the testimonies your patients have shared. they are all so happy with their outcomes.

I had my tear troughs filled, but their is a dip on both sides in the outer area of my eyelid. Is that normal balance, I just don't know.

Also, on my right side, I love the tear trough result. the malur septum line is completely filled and blended in; however, on the left side, the malur septum line is still apparent and visible. Why do you think that is, do I need a touch up filler to blend and soften the line a bit.


Finally, is there a procedure that takes away dark circles under the eyes. Even with my TT area filled, the little devils are still there.
Thanks Dr. Lam for everything you do!!! I appreciate you.

hi nancy,
a few things to consider:
1. we have payment plans. we use care credit so that you can pay it out a few hundred a month if you want.
2. 30 is not too young. i have actually recently performed fat transfer on some late 20 year olds. HOWEVER, there are many things that you must consider when I work with someone as young as you. First, if you have not gotten pregnant yet, I need you to understand that during pregnancy when you gain weight your face could actually look distorted. I have never seen that yet but it is possible. With a slow down of metabolism as you get older (hopefully you will work with an anti-aging center to maintain metabolic status as I am doing at 39), you might gain excessive weight and you might therefore look a bit full following fat transfer. that all being said, when you are young, you don't need that much fat but just have it well done. so there is inherent safety with that fact which is good. we can discuss this more in detail if you decide to proceed at some point.
3. the outer dip is due to lack of filling that area. that can be corrected with more fillers or fat. obviously, make sure your physician is comfortable filling out there. some physicians are only comfortable filling in the tear trough. experience is everything.
4. we all have asymmetries and residual lines EVEN after fat transfer. when we begin to micromanage the face, we really will never be happy. i try to make the face look good as a composite. also, as you may have read in some other posts, i do not believe fat transfer is a safe option to try to fix asymmetries. then again, i don't believe anything out there is good to try to fix asymmetry. the first step is to put away your mirror. don't judge yourself by symmetry. it is an elusive goal that has no bearing on beauty.
5. there is no treatment for dark circles if they are due to muscle or veins. if it is due to hollowness, of course, fat transfer, etc. will help (not get rid of it but help). i have heard mixed reviews on the product Teamine with only a success rate of less than 30%. Do NOT have lasers that close to the eye to fix this problem. That is unsafe.
thanks for the kind words!
sml