LAM FACIAL PLASTICS

Hi Dr. Lam,

I am a 33 year old male with hollow cheeks due to fat loss, though I believe my cheekbones were relatively flat to begin with. I'm also hollow under the eyes. I had a lower blepharoplasty at age 25. It looked pretty good for about 5 years (maybe a tiny bit overdone under one eye), but then got worse over the past few years at the same time that my cheeks hollowed.

I've visited three plastic surgeons and received three different opinions about what to do:

PS #1: fat grafting into lower eyelids and cheeks. Theoretically a good candidate for cheek implants, but won't place them because there's a risk of looking unnatural.

PS #2: prefers fat grafting to lower eyelids, but also mentioned the possibility of tear trough implants or restylene. For the cheeks, prefers medium sized silicone implants or 2 vials of Radiesse into each cheek. Cheek implants should look very natural, and should look better than the Radiesse.

PS #3: 1 vial of Radiesse into each cheek. Theoretically a good candidate for cheek implants, but won't place them because there's a risk of looking unnatural. No recommendation for lower eyelids.

How do I figure out what to do? I am definitely gaunt/hollow in the midface and lower eyelids, and ideally would like to achieve some form of permanent augmentation. However, I don't want to look strange or feminized.

Questions:

- Are cheek implants a good long term solution for men? What about tear trough implants? While I know you report good results using fat grafting, I'm hesitant to spend several thousand dollars on a procedure whose results might vanish or mostly disappear within a few years.

I can send you some photos if that would help.

Thank you for taking the time to help me.

- Dave

Hi Dave,
Thanks for the inquiry. You know that all plastic surgeons have biases based on their experience and skills so, of course, you are going to have different answers, including from me. Here are my thoughts on the matter.

1. RADIESSE: Most people that offer you Radiesse do so for one of two reasons: a) they are uncomfortable with fat grafting (most likely) b) you don't have enough fat to harvest for a good result. I love Radiesse for the latter option since I think it offers the best long-term solution with the lowest expense (relatively speaking). However, it usually only lasts about a year or so. Therefore, this is definitely not a long-term solution of any kind.
2. CHEEK IMPLANTS: As you probably know, I am not a big fan of cheek implants for facial volumization in anyone over 30 for several reasons. First, it will hollow out the eyes further since they will augment the cheek but not the eye area. That is a real problem. I think most people that need cheek implants really need fat grafting. That is not my opinion regarding chin implants. If someone has a weak chin, they really need an implant unless it is only mildly weak or they are a female with a just slightly weak chin. The other problem with a cheek implant in someone very gaunt is that the implant either a) may be visible since there is almost no soft-tissue envelope to hide it or b) will just look like a bony prominence in a gaunt face which is not a healthy, youthful look. Most cheek implants (almost all that I know of) are placed over the zygomatic arch (the cheek bone) because it is a stable platform. The problem with putting an implant over the zygomatic arch is that it really does not help with all the other areas around it that are gaunt, e.g., the lower eyelid, tear trough (yes, you could have another implant for that but how about the rest of the lower eyelid), anterior cheek, and buccal (lower cheek hollow) regions.
3. FAT GRAFTING: Of course, I have a bias toward fat grafting because I really believe it works. Yes, occasionally, the fat will not hold to the 100% level and that is always a concern so I appreciate your concerns. Obviously, I can't make that promise to you, but I do stand behind what I do so if you lose more than I would like I will eat the cost of the facility and do a touchup without a charge. At a year or so, I charge $1000 for a touchup which is just to cover my costs. Will fat last forever after that? yes and no. Remember that with aging, you will continue to lose your natural fat but not the fat that I transplant. A similar analogy, since I do a lot of hair transplants, is that after one year the hair that I transplant for you is a live, viable graft so how does it disappear? It won't obviously. What you lose instead is your surrounding fat, i.e., the non-transplanted fat and the non-transplanted hair, that may necessitate another hair transplant or fat graft as you get older and lose more fat and hair. I hope that makes sense. Also, remember I think men look good a bit gaunt (not too gaunt) but just a little suppressed that is a masculine feature. As you know, I sculpt male faces differently. Therefore, even a little volume for you can go a very long way. In summary, fat can address all of the critical zones that you have lost: lower eyelid, upper eyelid/brow (most people don't understand this until i help them review their old photos), tear trough, anterior and lateral cheeks, buccal, and even areas around the chin. I hope all of this makes sense to you. Please feel free to ask a follow up question if I have failed to make my answer sufficiently clear or detailed.
best,
sml

Hi Dr. Lam,

Thank you for your response. Below are some assorted follow-up questions.

- Cheek Implants vs. Fat Grafting to Promote Favorable Aging: You wrote that you generally don't like to place cheek implants in people over age 30. However, I've read that, all other things being equal, a person with "built out," prominent cheekbones will age more gracefully than a person with a flat face, because prominent cheekbones support the soft tissues, while deficient cheekbones permit the facial tissues to descend sooner. If this is true, wouldn't having cheek implants help to slow the aging process by better supporting the tissues of the midface? And wouldn't having fat injected into a flat face just weigh more heavily on the already poorly supported tissues?

- Fat Grafting Longevity: I read your comments about longevity. Is it safe to say that most people will look better 5 years from now than if they never had fat grafting? How much time passes before your typical male patient could benefit from a second fat grafting procedure?

- Fat Grafting to the Brow: You mentioned injecting fat into the brow. How does that improve one's appearance? Does it help to elevate the brow and remove some of the hooding over the outer eyelid (which is what I have)? Or does it do something else? I've read that hooding in younger people is caused by brow descent which is treated with either a brow lift (which I can't have due to baldness) or botox (temporary).

- Fat Grafting Cost: How much does fat grafting cost? Do you charge by the number of cc's injected or by the area of the face treated? Can you give me an idea of what certain treatments would cost including all fees? For example, approximately how much would it cost to treat the cheeks, lower eyelids, and brow?

- Fat Grafting Healing and Recovery: In a recent thread you mentioned that people look "distorted" for the first week or two. You also said that people travel from out of town for fat grafting, but leave the next day. So do people get on the plane looking bruised and swollen, or is there time before this appears?

Thank you for taking the time to answer my questions. Your comments have been very helpful.

thanks for the question. it was very thoughtful. as far as good bone structure leading to diminished aging, i would highly highly agree with you. when i see a good looking person without much sun damage the reason that i think that person looks better most likely is due to the presence of good bone structure, especially in the cheek region followed by the chin.

CHEEK IMPLANTS VERSUS FAT GRAFTING: now, your question as to why fat is still better lies in understanding that we have choices to make the midface/cheek area better. if you look at a lady with good bone structure in her 40s for example, she looks good but she still looks older. why? that is due to the exposure of her bone. you can see the bone through the skin which you can't in a youthful face unless that face is extremely haggard and gaunt. second, when you look at where a cheek implant goes, it goes over the zygomatic arch generally speaking where it can be better anchored to bone and not directly over the anterior cheek which does not have much bone support. remember that the anterior cheek is oftentimes what ages a person the most so you create more hollowness in the anterior cheek and lower eyelid relative to the built up zygomatic arch.

now, won't a cheek built up with fat look fat or have too much weight over time? not the way that i do it for several reasons. first, a lot of people that build cheeks up with fat put way too much. i typically put 1 to 3 cc over the entire anterior and lateral cheek. that is not very much but i get excellent results because i know how to target my fat placement over maximal zones of deficiency like the malar septum/depression. second, i don't place a ball of fat in the cheek, i put microdroplets distributed over multiple layers so that the fat is well suspended in the soft tissue. in summary, you don't need a huge cheek implant or a lot of fat in most cases to get a tremendous difference. i think the big mistake no matter if you go with fat or with an implant is doing too much: too big an implant and too much fat. that is why having a good aesthetic eye and substantial experience with technique are critical so you know that a little well placed fat can get a tremendous improvement and cover just enough bone that the face looks young. it would be a lot easier to sit down with you and show you photos of beautiful people in their 40s and 50s who have great bone structure but could look a lot better with fat grafting.

FAT GRAFTING LONGEVITY: yes, fat does hold well especially in the younger patient. it is always hard to predict how much further aging you will have. a good idea is to look at your previous 5 years in terms of aging. if you continue without significant sun exposure then you should maintain your current pace of aging. remember that UVA (ultraviolet A) exposure leads to lifetime and chronic skin and fat loss, especially proportionate to the degree of sun exposure prior to the age of 20. just stay out of the sun as much as possible you will most likely continue to age roughly at the same pace as you have based on your genetic predisposition. generally speaking, every 5 to 10 years will be necessary in most people but people that are aging rapdily and significantly you may need another round in 2 to 3 years. most likely after the second round, you will be able to have a little time off from another treatment. all of this is variable and i can't give you a strict answer. these are just general guidelines that i have observed.

FAT GRAFTING TO THE BROW: The fat does not actually lift the brow. That is what one person who did a research study found that the actual brow did not go physically upward after fat injection even though the brow looked amazing. second, i also thought that the brow descended. that is why i did a lot of browlifts. i haven't done one in 3 years now because i have reconsidered what i thought. there is a guy in California that measured brow and cheek positions over 20 years comparing relative distances to the eye using old photographs matched for position. What he found is that the brow actually does not descend but deflates. All you have to do is look at your old photos. You will see that your brow was NOT higher but it was fuller. Even if it were higher, a browlift on a guy looks terrible. (I think equally so on a female). Plus, as you mentioned, it is much harder if you have hair loss.

FAT GRAFTING COST: The total current cost for fat grafting including all facility and anesthesia costs is $8674. Everything is done in my surgical facility, which is on-site. I don't charge per cc or per zone. Most people need fat over multiple areas, and oftentimes they don't realize it or can't see it until I am done. Therefore, it is important to let me do what you need done, obviously with proper consultation and agreement between both parties.

FAT GRAFTING HEALING AND RECOVERY: Yes, even though people go back the next day, they are still distorted on the airplane. Two things: first, sunglasses do a tremendous degree in hiding distortion. Most of your distortion is around the eyes. Second, you will typically look much worse 2 to 3 days after the procedure then the swelling comes down rather quickly thereafter but still really distorted for the first 7 to 10 days.

hope this clarified your queries.
best,
sml

Hi Dr. Lam,

CHEEK IMPLANTS VERSUS FAT GRAFTING: When you place cheek implants in younger patients what happens when they age past 30 and begin to hollow? Do the edges of the implants become visible? Do you remove them if they're no longer attractive? How often does this happen?

FAT GRAFTING TO THE BROW: In your experience, does fat grafting to the brow negate the need for a brow lift in all patients? Do you ever use botox to temporarily lift the brow? If not, why not?

YOUR ARTWORK:
On an unrelated note, I really like your painting "Le Reve." It reminds me of the Reid Miles-designed cover of one of my favorite jazz LPs:

True Blue: http://www.amazon.com/True-Blue-Tina-Br ... B0007DBJ6O

Le Reve: http://www.lamfacialplastics.com/painti ... id-43.html

hi,
CHEEK IMPLANTS: I do not use large implants or a lot of fat so typically the implant does not become more exposed to a large extent. The best way to think about it is how you presented the information regarding a more attractive mature face, i.e. one in which good bone structure is present. The person with an implant (that is not too big) will look like a mature person with good bone structure but still not entirely youthful because bone is exposed and transitions are marked. Of course, if the implant is unaesthetic, for example, is simply too large, then it should be removed. Most likely, that would already be obvious early on even when you are young and you do not need to wait until you are older for it to be obvious in that fashion.

BROW FAT: Fat grafting to the brow obviates the necessity for a browlift in 95 plus percent of women and 99.9999999999999999999999999999999% of men. I simply do not like a browlift look in a man. Yes, I use Botox as a "browlift" until the person is ready to have fat grafting. Now why would I use Botox as a browlift if in general I do not believe in browlifts? Two reasons, the browlifts with Botox are subtle and a temporizing effort. Second, remember that I look at the brow problem being a deflation rather than descent of tissue. Even if the brow is deflated and droopy, it can be made to look better by pulling up even though deflation is the problem. Therefore, browlift with Botox is a great temporary effort until you are ready for the real procedure.

ARTWORK: Thanks for the complimeent on the artwork and the link. I really enjoy art and will be about to do a slew of art very soon for my new spa and anti-aging center inspired by the artist Morris Louis.
best,
sml

Ok...last round of questions about cheek implants and then I'll stop beating the dead horse.

It's apparent from your comments as well those of other surgeons that proper size and placement are crtically important to achieving a good result.

- What are the actual millimeter differences in forward projection between small, medium, and large cheek implants? I'm assuming the sizes differ by just a couple millimeters, so there must be a way for you to try out the implant in the patient before fixing it in place.

- When placing a malar implant do you select the implant from among many different styles or do you just select the appropriate size from within one style that you're partial to?

- Why do you use a bolster dressing instead of a screw (which is what my PS does) to hold the implant in place?

Thanks for taking the time to answer my questions.

I don't have the sizes of the implants in front of me but there is only a couple of mm difference between them.

I typically use the Implantech Conform implants since they tend to bend and fit onto the bone much better, but there are many styles to choose from and many ways to perform malar augmentation.

I used to screw in implants but I don't anymore as I have found that a well-designed pocket is sufficient to keep the implant into position. The bolster is really designed for 3 reasons: 1) stabilize the implant during healing, 2) minimize hematoma formation which can lead to destabilization 3) used as a guide to minimize the tail of the implant from bending during insertion.