LAM FACIAL PLASTICS

Two and a half years ago, I had IPL on one side of my face to clear up some thread veins and almost immediately after I started losing fat in that side of my face. Primarily in the cheek and nasal labial area of the left side of my face. I also got a few dents on that side of my face too. Anyway the Nasal fold on the left side is not a fold in the traditional sense as I have never had visible nasal labial folds before as I'm only in my early 30's, it's not like how most people have it where the fat pad decends. Rather, there is a portion of fat missing in the area and it kind of sinks inwards from my nose area only to about the halfway mark of the nose to mouth line between my lip and nose, so basically the top half of my nasal labial fold is hollow whereas the bottom half is full. It looks quite strange not like a normal NL fold and it's only on the one side of my face.

Anyway, I had the cheek area done with restylane and it worked reasonably well, not perfect. I have tried to get the top hollow half of my nasal labial fold filled with restylane many times and it's never worked well infact its makes it look even worse.

1. It doesnt raise the area enough to blend with the tissue around it.

2.I doesnt look natural at all. You can virtually see the divide between the Restylane and the fat that I still have higher up above it. It almost looks like it's pushing the hollowed area to the side without lifting it enough. It does lift it slightly, but it looks as though it widens the hollow area more than anything....like it's pushing it apart and to the side.

Do you think you can do anything with a fat transfer to address this sort of situation? Just looking for some more natural looking improvement.

here are some problems with fat transfer for what you want:
1. fat grafting is way too soft to fix a line or a fold well. it is very very soft. the two things that i don't use fat transfer for are lips and lines. further...
2. fat grafting in my opinion is unsafe to fill in areas asymmetrically. the reason is that the most durable fat in the body is from the belly and thighs and they can grow disproportionately to the surrounding areas since fat is a live graft. it is not like just stuffing a face with a bioinert substance. you must treat it with respect, which i do.

what are then solutions? if it is a tiny pock mark then silicone micro injections can improve the area. but if you are trying to fill the nasolabial fold, i don't like using silicone to do this. it is hard to get a good result with it. i think sometimes the reason that perlane and other fillres do not work as well is due to technique. most often doctors inject too close to the skin and render the area lumpy looking.

finally, i think we need to change perception too. i am not denying that you may have a real problem but most oftentimes we blame ourselves (we do not forgive ourselves for picking the wrong doctor) and it eats us up so when we look into the mirror all we see is the past mistake we made NO MATTER WHAT WE DO TO FIX IT. i see that EVERY DAY. that could be 20% of your problem or 80%. the only way for me to tell you how much is in your perception versus a socially crippling problem is for me to lay eyes on it. i may not have a creative solution but i have an honest, straightforward approach that will tell you exactly what i see and what i think.
best,
sml

Thank you very much for the reply.

I'm definately not disputing your knowledge on the subject (actually the opposite, I know that you're THE guy to ask), but if you could help me understand a few things.

As I said, I don't have a nasal labial fold in the traditional sense where the fat pad decends with age, the fat in the area is quite literally missing, so I'm wondering if it would respond differently having fat placed in the area than a traditional NL fold? Which brings me to my next question:

When you said fat is too soft to sufficiently raise the NL area - How come the fat I lost in the area is enough to make the area appear depressed, yet restoring the area with the same component that was previously lost (fat) would not be able to restore it back to a simlar visual result? I know that 1+1 does not always equal 2 when it comes to medical science and I'm sure that is what we're probably dealing with here.

Also, you mentioned that you don't like to place fat assymetrically - by this I take you mean you can't fill one side if you don't fill the other. I'm wondering why this is safety concern. How does filling one side have any effect on the other? If you were to place a small amount of fat on the unaffected side (I have a tiny smile line on that side) and a larger amount on the other, would that still be considered assymetrical?

Last but certainly not least. With Restylane I find that when look closely, I can see that a substance has been placed under my skin (perhaps due to technique as you stated) - is it also like this with fat? I would think not.

Once again, I'm asking these questions strictly for educational purposes, I'm not here to try to convince you to perform a fat graft when it is not applicable in my case. I thank you for your patience, insight and the service you are doing here for your prospective patients.

As I said, I don't have a nasal labial fold in the traditional sense where the fat pad decends with age, the fat in the area is quite literally missing, so I'm wondering if it would respond differently having fat placed in the area than a traditional NL fold? Which brings me to my next question:
IF YOU DON'T HAVE A DEFINABLE CREASE, THEN FAT MAY HELP A BIT BUT I ALWAYS UNDERSELL THIS AREA. FAT IS TOO SOFT TO LIFT A DEFINABLE FOLD. PLUS, FAT DOES NOT HOLD AS WELL IN AREAS OF TREMENDOUSLY HIGH MOBILITY LIKE THE FOLD. SO YOU NEED THE RIGHT BLOOD SUPPLY TO HOLD IT THERE. MOST OF MY PATIENTS WHO WANT A FOLD FILLED WITH FAT ARE FRANKLY DISAPPOINTED. BUT THEY ARE NOT WITH MY FAT TRANSFER BECAUSE I HAVE TOLD THEM THAT IT DOES NOT WORK THERE PLUS TYPICALLY IT DOES NOT MATTER. WE ARE TOO FOCUSED ON THE FOLD. IT IS EVERYTHING AROUND THE FOLD THAT TRULY MATTERS.

When you said fat is too soft to sufficiently raise the NL area - How come the fat I lost in the area is enough to make the area appear depressed, yet restoring the area with the same component that was previously lost (fat) would not be able to restore it back to a simlar visual result? I know that 1+1 does not always equal 2 when it comes to medical science and I'm sure that is what we're probably dealing with here.
SEE ABOVE.

Also, you mentioned that you don't like to place fat asymmetrically - by this I take you mean you can't fill one side if you don't fill the other. I'm wondering why this is safety concern. How does filling one side have any effect on the other? If you were to place a small amount of fat on the unaffected side (I have a tiny smile line on that side) and a larger amount on the other, would that still be considered assymetrical?
BECAUSE FAT IS NOT A BIOINERT SUBSTANCE. IT CHANGES WITH WEIGHT AND WHEN BLOOD SUPPLY FORMALIZES. YOU CAN'T SAFELY STUFF ONE SIDE OF THE FACE BECAUSE IT MIGHT GROW WHEN THE BLOOD SUPPLY FORMALIZES AND MAKE THAT SIDE LOOK TOO BIG AND THEREBY ACTUALLY CREATE A DEFORMITY.

Last but certainly not least. With Restylane I find that when look closely, I can see that a substance has been placed under my skin (perhaps due to technique as you stated) - is it also like this with fat? I would think not.
NO, NOT AT ALL. THAT IS DUE TO THE TRANSLUCENCY OF RESTYLANE (UNLIKE FAT) PLUS IT WAS PLACED TOO CLOSE UNDER THE SKIN. FAT IS PLACED MORE DEEPLY AND IT IS OPAQUE.
thanks for the questions!
best,
sml

No it is not a clearly defined line or fold at all - rather an area that is slightly sunken in. I don't want to overexagerate it's magnitude either. It is only the top half of the NL area as I previously stated - probably an inch in length and about .5 inches in diameter. It does not appear nearly as deep or defined as your average NL fold, but wider - giving it an appearance of fatloss as opposed to a NL fold. It only makes up a small area of my face, but it's unfortunatley enough to throw off my overall look. At first glance, it looks like it would be relatively simple to fill, but as I have seen with my attempts at Restylane, that is not necessarily the case.

Besides being unsatisfied with my Restylane treatments, I am interested in fat because something tells me that if fat is what was lost, fat should also be it's replacement, and also that fat would give the surface of my skin in the area a smoother look as the Restylane makes it appear uneven. I really think a little improvement in such a small area (which I didn't get from the Restylane) would go a long way, but if it has the potential to cause a greater problem as you are elluding to, I will take your words of wisdom into serious consideration.

Do you think that adding a bit of fat to the unaffected side (where I have a miniscule smile line that looks like it would fill if you sneezed on it) would increase the safety margin of the procedure?

Also, what are your thoughts on Sculptra. I know that it is often used for fatloss, but besides lasting longer does it offer any advantages whatsoever to hydraulic acid fillers?

Sorry for all the questions. I think that pretty much covers it. Thanks.

let me clarify: i do not think fat is unsafe for the area you are talking about (i call this btw the precanine or canine fossa). i just think you might be disappointed in the results. so don't pay all that money and bank on fat effacing that area consistently and reliably although i do put fat in that area almost in every single case.

i almost always add fat the same to both sides even in the area of the canine fossa that may not need like it needs a lot because it is very hard to overfill the canine fossa, seriously.

i hate sculptra, simply put. here are the reasons that i have enumerated over and over again throughout this website:
1. it is fine for cheeks, that is about it. in the area around the mouth it is a "bioactivator" meaning it is relying on collagen to effect the change in shape over time. i have seen nodules in my hands and in other people's hands simply due to this phenomenon.
2. it is unpredictable since every person's collagen response is different. if you are banking on collagen responses it is very hard to predict. sometimes i have seen absolutely no results and sometimes i have seen good results but really safely only in the cheeks.
3. i hate it around the temples and eyes. it is truly risky and unpredictable here.
4. it is painful to inject. it is a pain to massage for 3 days. it takes way too long to see a result. you need multiple rounds. it is based not on sculpting but educated guessing of the collagen response. (that was 5 reasons put into one).
5. it is too expensive for what you are getting and you have to wait too long to see the changes, which are again unpredictable.
6. although it has gotten clearance from FDA for use in immunocompetent people i still do not feel comfortable with it.
ok my thoughts only.
best,
sml

Okay, so based on your responses, I think I'll hold off on pursuing the fat transfer and save that as a last resort option. I think I will go the filler route once more, this time under your hand to see if I can get a more aethetically pleasing result (No pressure, I'm not even sure if any amount of filler with anybody doing it can solve this to my satisfaction anyway. Likely because the problem area simply won't permit it. I only live a few hours away and I'm willing to give it another try though.)

Do you think a more viscious filler like Radiesse or Perlane could give me a little more lift in the area?

Also. Could another possible solution could be some sort of custom impant for the precanine area? I have read about something called a Transmaxillary Implant used in this area. It's funny because if I stick my my toothbrush up into that area or blow air into my mouth and presto, problem solved, the tissue puffs out and looks perfectly normal. Unfortunatley, I cant walk around with a toothbrush in my mouth or blowing air into my mouth and still look sane! lol

Anyway I will book an appointment with your office in advance. It's going to take another few months for my latest round of Restylane to wear off anyway.

Thanks much,

SO

i think i am booked into november so just make sure you make an appt. sooner than later. yes, i will do perlane for you. thank you for being realistic with your expectations.

those implants are TERRIBLE. i have taken almost all of the ones i have put in out because it affects the smile. they feel weird when you move your mouth.

look forward to take care of you.

Hello Dr. Lam, me again hope you had a great holidays and new year.

A few things:

I'm still waiting for the my previous restylane treatment to completely diminish before setting another treatment. It's taken a very long this time for some reason. As I said my restylane treatments have done nothing to help my problem, but it's still there as I can still literally feel it under the skin.

Also, I went to a new dermatologist to have some moles removed, I also showed him the problem on my face and took some notes! Essentially what he said to me was that a nasal labial fold was not my problem, that my problem was instead, a hollowing of fat in my lower medial cheek giving the illusion of a nasal labial fold. He believes there is a possibility that the prior vascular treatment I received may have damaged an artery that provides blood supply to the fat, roughly within that area (all the damage occurred within about 1.5 inches of the treated area).

He also said that restoring this area would require specific knowledge of the different fat compartments in the lower cheek. He thinks the reason why the Restylane is failed is two fold. 1. Restylane is not really all that good for simulating the restoration of lost facial fat and doesn't do much in this layer, better to use something else, and 2. The Restylane was injected in the wrong area and for the wrong purpose as the problem was treated as a NL fold rather than what it actually is, hollowing of the lower medial cheek. The proper fat compartment needs to be filled with the right filler, and if so, it will be immediately apparent and should restore the area well.

Given this new information I have a few questions for you.

1) Do you think a fat transfer could help? My dermatologist was under the belief that it could help a lot, but now he got me thinking; if an artery was in fact closed off or damaged and the blood supply to the area was compromised, wouldn't a fat transfer to this area, which already has a high chance of failing due to the mobility in this area, have an even greater chance of failing due to the lack of blood supply?

2) Any kind of treatment, medication, supplement or anything at all I can do to help repair damaged or cauterized arteries?

3) When you do Perlane, can you inject it into these deep compartments of fat that the dermatologist was referring to that is supposed to result in an immediate improvement?
Or is another filler better suited for this pupose (ie; Radiesse, Artefill, Sculpra, Fat)?

Thank you very much!

1) Do you think a fat transfer could help? My dermatologist was under the belief that it could help a lot, but now he got me thinking; if an artery was in fact closed off or damaged and the blood supply to the area was compromised, wouldn't a fat transfer to this area, which already has a high chance of failing due to the mobility in this area, have an even greater chance of failing due to the lack of blood supply?
That concern that you present has always been on my mind. Although I don't have a lot of cases of people post-IPL fat loss, I do have one lady that did a video testimonial that shows that it is holding very well. So in theory you are right. Just can't promise anything. However, I believe that it will hold well.
2) Any kind of treatment, medication, supplement or anything at all I can do to help repair damaged or cauterized arteries?
Not really in my opinion. I am a firm believer in the power of the mind and have been reading Michael Samuel M.D.'s Healing with the Mind's Eye. You probably think this is bunk but that is fine with me. I think we have a lot of power for healing when conventional medicine may fail us.
3) When you do Perlane, can you inject it into these deep compartments of fat that the dermatologist was referring to that is supposed to result in an immediate improvement?
Or is another filler better suited for this pupose (ie; Radiesse, Artefill, Sculpra, Fat)?
I hate to say this but I have NO idea what your dermatologist is talking about. Of course, there are anatomic compartments throughout the face, but I use Restylane and Perlane principally for treating volume loss and only occasionally (every few days instead of daily) to address the folds and lines. It is an amazing volumizer for the face. That is something that I love to use. I think when people have early fat loss that Perlane is enough. However, for people with little signs everywhere, fat is the most amazing product (minus folds, which we talked about already).

Remember one thing: whenever you have been hurt and have less than an ideal result, you must overcome the psychological barrier of fixing it o/w you will always see the problem. No surgeon can get it good enough. I know that I have already addressed that point in a previous post but I want to reiterate it and elaborate it with these videos (if you find them applicable. if not forgive me.):
http://www.lamfacialplastics.com/galler ... s.flv.html
and
http://www.lamfacialplastics.com/galler ... Video.html
best wishes,
dr. sam lam

"I am a firm believer in the power of the mind and have been reading Michael Samuel M.D.'s Healing with the Mind's Eye. You probably think this is bunk but that is fine with me. I think we have a lot of power for healing when conventional medicine may fail us."

Wow... it's absolutely amazing and almost eerie that you just brought this up. Perhaps you have learned a few mental tricks of your own and don't realize it! Without reading any books on this subject, over the last half decade, I stumbled onto this little mental trick that helps me relax. What I do is go into a deep trance like state of concentration: I imagine and can actually feel a ball of energy I move it through me into my mind, and then I release it, and when I do it sends this wave of relief and energy throughout my mind then body. If I repeat it just a few times I feel much more relaxed and almost elated.

Here's the really eerie part... just last night when doing this to relax, for the first time a light bulb went off in my head and I thought about how I could apply this to helping my problem. So, what I did was conjure up the same ball of energy and instead of focusing it into my mind, I took the ball of energy and mentally focused it directly on the problem area of my face, and released it there instead. It felt both healing and relaxing. I think I will continue to repeat this and see what happens. I'm doubtful it will lead to any kind of miraculous improvement but I am a firm believer in the power of the mind and it certainly couldn't hurt!

I have not read the book you just mentioned (though now I'm definitely going to pick it up!), and I'm sure the author uses different mental techniques... but perhaps to accomplish the same thing. I stumbled onto this little mental trick with my intuition and that's exactly why I trust it. Times in my life when I went against my intuition have been disastrous.

What you said about using Perlane for small areas of fat loss actually makes a lot of sense to me. I'm young, I have tight skin and high cheekbones and an overall fat graft to me seems like dramatic overkill. Just looking at the area that bothers me, which is relatively small, I get the sense that some well placed filler could help. I think one of the problems with my Restylane treatments is that they have been injected too superficially. I can tell because after my injections until the filler wears off completely, the surface of the skin looks a little clumpy and irritated as though it were injected very superficially. So I feel it is being placed improperly. Also that Restylane may be a bit too soft and I might require a harder substance like Perlane to give more lift.

I think the question I was asking before in regards to the dermatologist was, do you inject Perlane into the subcutaneous layer where the fat has been lost?

I recently spoke with a doctor online who lives in another country just for advice and described my problem thoroughly, and he said that I would be best to have the filler deep RIGHT ON TOP of the bone to push everything up like an implant would.

His advice: "You need a doctor who fills the area from bottom-up and not a serial linear type injection. The needle should be penetrated deep, vertically down and the filling should be in the deep sub-cutaneous area in order to push everything up and volumize it."

Do you think given my description, you would use a similar course of action?

Thanks very much for the amazing replies Dr. Lam.

glad to hear that you are open to these ideas and already practicing them!!! actually, yes, that is precisely how i inject it. i go vertically in and depot it up (hard to describe). no threading. if you ever pass through Dallas, I would love to try it for you. I am very good at doing this. You can't feel a needle go in due to my acupressure technique.
best,
sml

Yes of course. I have already made up my mind that I'm coming to you for the injections long before this conversation and I'm very excited to try out your technique! I want to thank you for all you help on the issue.

I have done quite a bit of reading on this subject, and I am concluding that Perlane is the best course of action right now, for the simple fact that it's a relatively hard substance (for lift) but more importantly, it's among the least permanent of the harder substances, and it still leaves me with the option of making a quick transition to fat when it wears off as opposed to having to wait a length of time with the other class of tissue stimulator fillers and facing a higher probability of lumps. So it's Perlane first for me (and hopefully last given my satisfaction), then fat second, and if that doesn't do it for me, I will move into the long term stimulatory style fillers as a last resort (Artefill, Radiesse and Sculptra are my three 'last resort' choices probably picking one of them) or perhaps some kind of implant.

I will leave you with a few final questions regarding my plan.


1. Do you think, given any new information I've given you, that I will be more happy with the Perlane than the fat grafts?

2. Do you use Artefill and Radiesse and how do you think they would do for my problem? I know that Artefill could be dangerous due to it's permanent nature but it is also known as a filler that really delivers great results and lift, especially for thicker skinned people like myself that don't get much a lift from softer fillers. I also know that Radiesse delivers similar results just shorter term. I'm thinking, if I like the Perlane something more permanent injected the same way could be beneficial.

3. You've given me your opinion of Sculptra in the the Nasal Labial fold, but how about in the lower medial cheek where I seem to have more of a problem? (I would estimate its regressed upwards about 1 cm) also into that area more superficial to the canine fossa in order the blend the upper cheek fat into the depressed area, above the crease itself, into the area where the tissue has dissolved?

4. True implants are not used in the NL fold, but are there any used in the lower cheek and Canine Fossa?

Alright, that covers everything and I've definitely surpassed my question limit. You are truly awesome to answer of all them. I wish you a great 2010 and I will see you soon!

1. Do you think, given any new information I've given you, that I will be more happy with the Perlane than the fat grafts?
Yes, given your age and severity, I would most likely say Perlane is better than a FT for you but I would have to see you to give you the right decision 100%. The good thing is that even if FT is better for you Perlane is an easy expedient option and it sounds as if it is the right thing for you.
2. Do you use Artefill and Radiesse and how do you think they would do for my problem? I know that Artefill could be dangerous due to it's permanent nature but it is also known as a filler that really delivers great results and lift, especially for thicker skinned people like myself that don't get much a lift from softer fillers. I also know that Radiesse delivers similar results just shorter term. I'm thinking, if I like the Perlane something more permanent injected the same way could be beneficial.
Yes, Perlane. I have stopped using Radiesse not because it is bad but it creates a very thick scar like cement under the skin after repeated injections which I do not particularly like. That makes further fat or perlane injections more difficult. Artefill is something that at this time I prefer to use only in folds for younger patients and I now use it to touchup fat results or fill in small volume areas in older patients (over 45 years) just because at this time I don't know how it will age. sorry for being so conservative.
3. You've given me your opinion of Sculptra in the the Nasal Labial fold, but how about in the lower medial cheek where I seem to have more of a problem? (I would estimate its regressed upwards about 1 cm) also into that area more superficial to the canine fossa in order the blend the upper cheek fat into the depressed area, above the crease itself, into the area where the tissue has dissolved?
Sculptra is good for volume. I just think it is a bit unpredictable for volume so I generally have stopped using it. Read my other entries for more detailed answers as to why.
4. True implants are not used in the NL fold, but are there any used in the lower cheek and Canine Fossa?
In general no. I don't like solid implants for any of these areas. Here are the reasons. Watch this video:
http://lamfacialplastics.com/gallery2/v ... heeks.html
no problem with the questions. we are probably helping other people with similar concerns.
best,
dr. lam

Greetings again Dr. Lam. Did not expect to be adding more forum posts, but I read some kind of study regarding deep dermal filler injections that freaked me out. It said something to do with deep injections in the canine fossa area, and an artery causing necrosis? It said this is very rare, but what do you do to avoid this? Is it a concern when injecting down to the bone to volumize the area with the technique we discussed?

Thanks!