LAM FACIAL PLASTICS

Hello Dr. Lam,
Thank you for your very informative site and this forum.
What would be in your opinion the best filler combination for my case (photos enclosed)? I realize that each individual case is different and thus might need a different approach. That is why I am enclosing the photos. I am in my early 40-ies, fit.
I believe I will likely need to prop up the volume in my sunken/hollow cheeks and then fill in the tear troughs to help with the circles under my eyes.
Would a combination of Radiesse (cheeks) and Restylene (in what particle size? Restylane, Perlane, SubQ, ..?) be the preferred solution? Or Juvederm Ultra (in what particle size Ultra 2, 3, 4?). Can you please be as specific as possible?
Thank you very much. Namaste.
Peter

hi,
thanks for the question. as far as fillers are concerned, i prefer restylane under the eyes and perlane the for the rest of the face. the reason i do not prefer juvederm is that it tends to spread out a bit and not hold the structure as well as restylane or perlane. restylane is smoother under the eyes and perlane elsewhere tends to hold better. i stopped using radiesse because i have noticed that the tissues become like cement over time. i don't like that. as far as a more permanent option that is more global as well that can target all the micro areas of aging to make the face look more youthful including the deflated brow, upper eyelid, tear trough, canthus, anterior/lateral cheek, buccal zone, anterior chin, and prejowl...of course fat transfer is more ideal but also obviously cost more. hope that is clear.
best,
sml

Hello Dr. Lam,
Thank you for your very informative reply.
I have a few follow up questions.
Do you use the new Restylane with Lidocaine? Any drawbacks to that?
When you say that the Radiesse becomes cement like, do you mean that it ends up being really hard, is this something that is permanent? Would it still potentially provide a longer lasting solution (than Perllane) if used very deep under the muscle to fill in the hollowness of the cheeks? In your experience does the collagen that is built up with Radiesse stay, or does it break down?
Do hyaluronic acids like Restylane also result in beneficial buildup of collagen and can they potentially provide a semi-permanent solution for things like cheek volume if the treatment is repeated few times?
Thank you,
Peter

Do you use the new Restylane with Lidocaine? YES. Any drawbacks to that? ONLY NUMBNESS FOR AN HOUR OR TWO AFTERWARD.
When you say that the Radiesse becomes cement like, do you mean that it ends up being really hard, is this something that is permanent? YES, IN MY EXPERIENCE. Would it still potentially provide a longer lasting solution (than Perllane) if used very deep under the muscle to fill in the hollowness of the cheeks? POSSIBLY BUT NOT ALWAYS. In your experience does the collagen that is built up with Radiesse stay, or does it break down? OFTENTIMES STAYS.
Do hyaluronic acids like Restylane also result in beneficial buildup of collagen and can they potentially provide a semi-permanent solution for things like cheek volume if the treatment is repeated few times? YES, IN MANY CASES YES.
best,
sml

Dr. Lam,
Your experience and insight with Radiesse is very valuable, could you expand any more on it? Most doctors rattle off favor of it that sounds as favored as the makers own words would be. I personally am very weary of it because it wasn't created for soft tissue augmentation, that usage was approved by the FDA later, likely because it is much easier to get approve for a new purpose than for a whole new product. There is evidence that Radiesse can be unpredictable in regards to what the body will do with it.. Many merely say it stimulates your own collagen, which is true, but the question is what type of collagen is it? Perhaps dense type I, rather than type III, perhaps that is why you feel hardness?

I am also asking because a doctor is pushing Radiesse for me to use around the jaw/chin, and dental support area. I understand that it can give more result and last longer, but I will not do it if that may mean distortion of the tissues in to something unnatural in the long term. That could cause a fat graft in the future to not result as well even.

again, i hate to be dogmatic here. i have used radiesse in the past for many years with good results and very little ill results. i think it is a fantastic product. i stopped using it because i have found that over time with repeated injections it starts to create a very firm feel to the area below the skin almost like concrete in terms of how hard the area can be. anyone doing fewer than 5 syringes probably will never see this issue. in most cases it should really not affect fat grafting so long as you give sufficient time that whatever should be clinically resorbed has been. i will say that if you have tons of it in there it can make cannula passage a bit harder to undertake but with a few syringes in the face i have had no problem navigating a cannula in there or getting good long-term fat graft results.