LAM FACIAL PLASTICS

Dr. Lam,

The first time I had restylane for my N/L folds it was done by a PS and it looked fabulous except my face was very puffy. Was i overfilled? It still made me look much younger. Also i was so bruised for about 2 weeks.

The 2nd time i went to a nurse who didn't bruise me at all. I had radiesse done but it seemed to dissipate in a matter of a few months!! By the 4th month I had to redo it and went back to the restylane. This time it was not as puffy but i seemed to develop pouch-like areas on the sides of my mouth. When i went back to top-off a bit, i told her to stay away from that area, but even so it looked more pronounced afterward.

I don't know what has happened, is it her technique? Was i not filled enough? I have somewhat of a flat face, not much cheek, but now it looks somewhat gaunt between my cheek area and between the 'pouches'.

My question is, can a filler such as restylane or radiesse cause 'pouches' to form on sides of mouth, possibly formed by water retention?

Apart from that, i have developed fine wrinkles around the lower eyes, right below my lashes, above the tear trough. If i push my skin up forward to puff up that area, it looks much smoother and plumper... can a filler be placed so close to the eyes? If not how close can it be placed?

Thank you very much.

the pouches are most likely caused by having filler placed just outside of the marionette line. the marionette can easily be overfilled or technique could lead to placement of the product outside of the line. in addition, the product can go inside the mouth and make a bulge that way. therefore, when i inject the marionette, I don't inject the line, i inject just inside the line to raise the line and decrease the depression. filling directly into the line can cause the product to fall on the wrong side of the line. the other problem that can occur is if you overfill the line, the line keeps going up and up and up leading to a bulge from the displaced line.

whatever the reason for your dislike, you can go back to your injector and have them reverse the product with Vitrase (hyaluronidase). that will safely reduce the product without eliminating it (if the dosing is right). within 24 to 48 hours, you will see the correction.

as far as near the eye is concerned, DO NOT USE RADIESSE THERE. very unsafe and terrible. i guess you won't be anyway since it did not last for you. however, my opinion is that it is much safer to use a cannula injection rather than a needle and i go just to the rim not higher. unfortunately, almost no one else does what i do. the cannula really cuts down bruising and in my opinion is so much safer and smoother around the eyes. check out my before and afters on this website under "fillers".

i laser all my bruising down at a week so that you don't have bruising for more than 7 to 8 days. most physicians don't offer this service because they don't know how to do that or don't have a laser to do that for you. i see all my injections back at a week in order to make sure that the result is smooth and you don't have any bruising that i need to take care of.

besides all of that, my dental blocks are so good that you don't feel a single needle go in. i mean not one. that means you don't feel the dental block. you don't feel the cannula. you don't feel the needle. and the block is off in less than one hour.

best,
sml

dr lam,

i'm starting to believe that it really is the injector, not the product that makes all the difference. my second experience with an RN is SO different from the 1st one with a PS. My whole lower face seems so much more fuller than my upper area. I don't like this look at all. i am afraid to inject more to my mid face where it seems a bit 'deflated'. do you think i should wait for all the substance to dissolve before redoing my folds? i will probably go back to my old PS.

also, do you think that injecting into the cheek area might be better for me, than to inject into the folds? Would that give my face more of a lift? My face is flat though, i've never had much cheeks... would injecting into cheeks reduce the need to inject into the folds?

finally, my jawline to become more puffy as well, and i used to have somewhat sharper jaws... could this be from the water retention? it doesn't seem avoidable because that happened to me with both injectors. is this normal?

thank you very much for all your time.

In answer to your quesstions/comments:

Yes, the injector makes all the difference. There are two things (besides honesty and integrity) that are important for an injector: good technique (a given) and a good eye (not a given). Artistry of knowing where to put it can be more important than in fat grafting (not entirely) because filler products are so expensive you need to know where to maximize your dollar spent.

You need to watch my video in my vlog section on smile lines. It will give you an accurate perspective that I have on the subject. In short, filling smile lines is totally a waste of your money in about 85% of people even if you don't think so. I can show you in about 10 to 15% of people I fill their smile lines because it detracts from the way that they look. That is where artistry comes in. Unfortunately, filling smile lines out there is like a knee jerk reaction by 99% of injectors and it is terrible (only if you care what you are doing).

I think the cheek is critical if your cheek is flat and can take precedence over your smile lines. However, two things: One, I have never met you and don't know what your face looks like so I can't respond to that question with certainty. Second, filling the cheeks can oftentimes make the lines EVEN DEEPER. Usually, no one notices it but I know how women see the world and you may be upset afterward. Generally, the cheek augmentation creates more of a shadow effect (very slight in most cases) over the smile line that can make it look deeper.

I really cannot answer the question regarding your puffy jawline. I have no idea about your anatomy or your injection. If you are saying it is puffy in the area that they injected then it would either be due to swelling which is more common with hyaluronic acid products for 2 to 3 days or it is due to too much product in that area.
best,
sml