LAM FACIAL PLASTICS

Hi Dr. Lam

Thank you for your telephone consultation earlier today. I learned a lot. In the following post I wish to share some of the insights I gained from our conversation and my from my personal experience as a veteran fat grafting patient. I have also posted some follow-up questions at the bottom.

Fat grafting as a popular means of facial rejuvenation is relatively new compared to the traditional cutting and lifting of skin and often directly contradicts it. As someone who has researched numerous before and after photos and undergone 3 facial procedures myself with a famous fat grafting specialist, I believe this new trend is nothing short a break-throgh. A well performed facial fat grafting session can yield amazing rejuvenation and a totally natural look. Just view some of Dr. Lam's fat grafting before and after photos or recovery videos. And I wouldn't be surprised if these transformations appear even more dramatic in person. Pictures don't always adequately capture the subtle yet profound improvement this treatment can yield.

But be careful. Taking it too far, which I believe I did, can lead to…a fat looking face, or even a puffy and swollen appearance. It can also create a lower but more rounded jaw-line. Men especially should be conservative because they often look better slightly gaunt. Once you’ve gone too far, the reversal options are far from perfect. The only ones I know of are micro-suction, lipo-dissolve, or perhaps extreme weight loss. If used conservatively, perhaps these approaches can accomplish some reversal. But if applied too aggressively, they can create new problems such as contour deformities (correct me if I am wrong here Dr. Lam).

I would highly recommend facial rejuvenation candidates seek out Dr. Lam. As I learned today, he employs a minimalist approach to fat grafting which virtually eliminates the risk of over-correction and significantly reduces recovery time. About 9 months after my first procedure, I realized that just a moderate amount of fat applied well can yield fantastic results. Unfortunately, I opted for too much of a good thing with my second and third procedures. I also found Dr. Lam to have a strong aesthetic sense and openness to differing ideals between individuals. The impression I got is that he listens well and carefully considers a prospective patient’s cosmetic goals before deciding whether or not to operate.

OK, now to my follow-up questions for Dr. Lam. I realize you may not have direct experience in all of the areas I am inquiring about. But any impressions or thoughts you have from your observations and broad knowledge of the field would still be very appreciated.

1. If my doctor has some micro-suction experience (say 100 or more cases) but few before and after photos, do you think it would sill be OK to have him do some conservative micro-suction below and perhaps to the side of the jaw-line?

2. I rarely read about facial micro-suction with one exception, the submentum. Is this area a special case? I’ve read that there is low risk of redundant or hanging skin from this procedure because the skin actually gets stretched moving a larger distance (right triangle hypotenuse length pre-op vs. length of two other sides post op). But does the skin always move up to fill in the cavity left after the fat is evacuated?

3. If submental fat suctioning is low risk, do you believe, based on my front and profile photos, it might yield a cosmetic improvement for me?

4. Besides my rounded jawline, the other area which I would like to improve is the fat deposit on my left cheek right above the nasolabial fold. Would conservative suctioning of this area perhaps reduce the left nasolabial fold (I don’t have this problem on the right side)? I mean, isn’t the nasolabial fold apparent due to the difference in its projection relative to the area right above and to the side of it? Instead of raising its projection, I would be lowering the area it is contrasted to. Does that make sense? Do you think a small amount of suctioning in this area would be any more risky than suctioning of the jawline area?

5. Finally, assuming the doctor has similar experience with both approaches, which one do you believe is lower risk and which one offers better improvement prospects – micro-suction or lipo-dissolve? Is it ok to apply these procedures conservatively for multiple sessions or is a 'best try in one slightly more aggressive approach' preferable?

I know these quetions are detailed but perhaps others might benefit from some of the answers as well as me. Thanks for this forum.

Hi,
Thank you for your kind words regarding my fat grafting. Yes, it is a highly artistic endeavor and we all have different eyes for beauty/attractiveness. Here are my answers:
1. Unfortunately, this is a very difficult question for me to answer. It is best left for your surgeon and you to make that decision. It is unfair and wrong for me to sway your thoughts on that matter.
2. Good question. The face and neck do act quite differently. "Microliposuction" is usually a term used for the face because the face is very unforgiving in terms of contour problems after liposuction with standard 4 mm cannulas. Occasionally, during a face lift some surgeons advocate "open liposuction" where they feel they have more control since they are seeing the entire playing field so to speak. The submental area on the other hand can in fact be safely liposuctioned in most cases with a full 4 mm cannula. Btw, microliposuction is performed with a 1 mm cannula in general. The skin under the neck is highly elastic and can retract all the way up without cutting. However, in most people over 40 years of age if you don't modify the platysma muscle you can actually worsen the neck because as the skin contracts (better) the neck can expose the platysmal bands more prominently (much worse). I generally do not do neck liposuction in an individual over 40 for this very reason. Also, understand that the fat in the neck can oftetimes be "subplatysmal" which means fat that resides inside the platysma and that cannot be suctioned out. It has to be removed by cautery and sharp excision. Not everyone has this but if you do remove it, you should in most cases (but not every case) put the platysma back together so that you don't have a gun shot wound deformity where there is a central divot.
3. First, read #2 for the better answer why that would be a mistake. Second, your face in my opinion is toward the generous side of being filled. If you make your neck very sculpted and tight, there is a good chance your face will look relatively even bigger. That would be my fear. Read my blog on harmony to understand this aesthetic philosophy.
4. I can't speak on risk but facial microliposuction should be performed by experienced hands. Yes, I have microliposuctioned that mound just above the NLF but to be honest without huge improvement in the fold. YOUR FOLDS DON'T MAKE YOU LOOK OLDER SO YOU SHOULD LEAVE THEM ALONE. Plus, you are again on the highly augmented side for your face, if you obliterate the fold with more filling I think it will only make you look rounder. That is not good.
5. I have no experience with lipodissolve in the face so I cannot accurately speak of it. I have heard of 4 cases of blindness in California from putting lipodissolve behind a layer called the orbital septum of the eyelid to dissolve fat deposits inside the eyelid. That is one area I would recommend not putting it. Beyond that, I cannot honestly make a comment.
Best,
SML

Hi Dr. Lam

Thanks for your last reply. I just wanted to follow-up.

1. OK.

2 & 3. I've always wondered why those after shots of liposuctioned necks often appeared older even though the neck line became sharper. From what you said here, I think I get it now. The problem is not loose skin so much as the loss of fat tissue to cover and fill in around the platsysma bands.

And thanks for reminding me about the harmony issue in my own case. I will definitely avoid lipo for the under chin area. But what about the region right under the jaw bone. Should this be suctioned with a blunt cannula like the under chin area or micro sized cannula like the face? And if your answer is to treat it like the face, do you believe this area still might be a little easier since it is somewhat hidden from plain view and therefore more forgiving of small contour irrgularities? Finally, does the skin under the jawbone move up into the space created after suctioning similar to the skin under the suctioned chin/neck area?

4. Thanks for sharing your experience with suctioning the mound above the NLB and your aesthetic judgement. I will avoid further augmenting the NLB or any area of the face.

5. That's really scary! Why were the 2nd - 4th cases performed in the same area after the first disaster? Is there any way a patient can check-out a doctor's record for extreme accidents like this before deciding whether or not to operate.

Thanks again for providing this forum and keeping it so up to date.

Generally, under the jawbone immediately, I would use a micro cannula. A fingerbreadth below that I would go to a full liposuction cannula. That is not to say someone else doing something different is wrong or inappropriate just not what I do. I don't know if that area is safer per se in terms of deformity. I guess you could say that since it is out of direct view. However, the marginal mandibular nerve does run right there and can be temporarily affected causing difficulty with speech but with a blunt cannula the effects are rarely permanent and also really are rare to begin with. Not to frighten you but when you ask me about safety that is something you should know but uncommon. The skin should shrink in that area after suction.


I assume the four cases were done in separate offices. I doubt the same surgeon would have committed this error twice let alone 4 times. I think a reliable way to check out your doctors' credentials in terms of lawsuits, probations, fines, etc. is to go to your state board's website if they have one.
best,
sml[/i]

Hi Dr. Lam

Besides liposuction under the neck and micro liposuction of the jowl area, I've noticed that quite a few surgeons perform buccal fat removal with incisions made from inside the mouth. And I even found what looked like some pretty good before and afters for combinations of all three (I will send you a private message with one of the websites so you can view some of them). Some of the reductions in these appear rather dramatic.

Now I noticed that you recently replied to rick3568 that facial fat grafting is not reversible. By this, do you mean that it is something you do not do or is it something you believe no surgeon can perform effectively at more than a very superficial level? I am assuming that suctioning a naturally full face is the same as suctioning a face made full by fat grafting. Please correct me if I am wrong here. What do you think of the photos from the website I sent you?

By the way, my story is not so sad as may have come across in my first post. People who saw me a few months after my first procedure would often wonder what I did to look so young and healthy. And even after my third procedure in my present fullness, my girlfriend still hasn't left me (yet anyway) and I still have my sight (20/20 in-fact).

Hi,
a couple of things:
1. i looked at the before and afters and the neck lipo looks good the facial lipo either looks like no difference or some mild to moderate changes. that is what i would expect with facial lipo versus neck lipo results.
2. i always hate to state that something is impossible to do. fortunately, i have not had to do it myself so my experience is more limited. however, in general, i would say reversal is not easy at best and very very hard at worst. i would seek advice from a surgeon who has more experience than i do in this matter since i would tell you my opinion does not count for much since my experience is limited in this arena. i sincerely wish that i could help more.
best,
sml