Dr. Sam Lam Plastic Surgery Forum

Hi Dr. Lam,

My midface area is somewhat recessive or retrusive making my face look elongated. I'd like to know where exactly you would place soft tissue fillers in the midface to correct this and achieve better facial balance in my case, which product and how many syringes would be required. Is it generally tricky to place soft tissue fillers on men to restore fullness and retain a natural, masculine look. Do you tend to opt for a more conservative approach compared to women? How do soft tissue fillers compare to implants on men in terms of the visual differences?

Thanks

interestingly, i saw your photos in my PM then now i went back to check on them at home and i don't see the images anymore just your PMs. can you please resend?
best,
sml

Okay, I got your photos. I tend to like to keep the anterior cheek more suppressed in most younger men because I think it looks good. When you get much older and you start to hollow in your anterior cheek, then filling the anterior cheek somewhat will create a more youthful look. You don't need that. To create a more masculine and less elongated look, I would recommend considering strengthening the outer cheek. That being said, you have one of 3 options: temporary fillers into the outer cheek, fat transfer, or a solid implant. Most of the cases I perform with fat transfer for someone with aging face but you clearly do not need that. Fat transfer also is a live graft so it could change a bit with aging so I don't think it is the safest or best option for you if I am just treating the outer cheek in isolation. Fillers are a great way to start if you are interested to try on what a permanent option would look like. Ultimately, you would probably benefit from a small solid cheek implant. In women, I think cheek implants further masculinize the face because the anterior cheek is what feminizes the face. In older men, I work on the outer cheek with fat transfer but those who have absolutely no signs of aging and benefit more from a structured face should have a solid implant. The only caveat is that in the future you might need fat grafting to blend the implant in better because as mentioned a strong outer profile will accentuate hollowness around it. However, I wouldn't be too concerned about that now for 3 reasons: 1) you are young, 2) you will need fat grafting down the road anyway to rejuvenate the face so we'll cross that bridge when we come to it, 3) I use a more natural smaller implant so that the edges should not be exposed in most cases even with ongoing aging. Hopefully, this response was clear.
best,
slm

Great explanation Dr. Lam, thanks. As for the temporary filler to outer cheeks, does the filler reabsorb at equal rates? In other words, as the product wears off, does the area where it's injected tend to look somewhat lumpy or visibly apparent that a filler was used in the area?

Can you tell me more about the small implant that you use? Is it silicone or porex? Do you have a personal preference on either? I've heard that infection rates are somewhat higher for cheek implants, why is that the case? Are they harder to position and secure in place in that area of the face?

Thanks

Hi,
Glad my explanation was clear for you. In answer to your new questions:
1. Fillers can provide a result close but not exactly equal to an implant. It is hard to articulate how a filler, a fat transfer, or an implant differ given that this is a limited area for facial augmentation compared to a wider area of the face. In short, the 3 are relatively similar for a smaller defined area.
2. There is always a risk that a filler will reabsorb unevenly but that risk is very small. I have seen a handful of times a filler near the eye have a small lump that I dissolve with Vitrase but this is usually very small and like 1 in several hundred people. The good thing of using something like Perlane is that I have noticed pretty good longevity like a year to 2 years in static areas like the cheek but obviously could not promise that to you. I am more of a conservative person when it comes to fillers, fat transfers, and implants. I don't like a very large cheek. That being said, I tend to use only 1 syringe to do the job but possibly might need a 2nd when I see you in person. It would be unlikely if I needed a 3rd.
3. As far as implants go, I prefer Implantech's "conform" type of implants for several reasons. First, they are very soft so that they conform to different cheek surfaces very easily. Second, they are low profile so that they would not look like a foreign object sitting on the cheek. Third, they are less palpable (you can feel it less) because they are lower profile. Silicone stays very firmly in place due to encapsulation but they are still very easy to remove. Infection is always possible but pretty rare. Porex implants in my opinion have a higher incidence of infection and are really hard to remove without surrounding tissue damage. I go through a technique of placing the silicone implants through the mouth using dissolvable sutures in the mouth to close the incision. The implant is held in place with a bolster through the skin for 3 to 4 days, which I then remove in the office. The bolster is a cotton tied (a dental cotton roll) to the outer cheek skin to minimize a chance of fluid collection (that would displace the implant and increase recovery time) and to secure the implant in place during healing. In short, you should not have any permanent sutures. I like to have no permanent sutures that can risk infection or difficulty in removing the implant if need be. Again, hope that is clear.
best,
sml

Hi Dr. Lam,

Sent you a quick message regarding scheduling an appointment for the temporary filler option. Can you check your schedule to see if the following dates would work to see me: Feb 18, 19 or Feb 24, 25? I have an important function to attend, which is why I'm narrowing down to those dates. Please let me know.

Thanks

i know i'm booked until april but you can send an email to constanze@lamfacialplastics.com to see what i have. sorry.
best
sml