LAM FACIAL PLASTICS

Dr. Lam is it true that nasolabial lines are caused by the malar fat pad sliding downwards due to gravity? Is it proven it really slides downwards or it's just a hypothesis like the going down of the upper eyelids which you say actually don't go down but only deflate due to fat loss.

If the malar pad is really sinking, does it slide with respect to the facial muscles or it is the muscles that get loose and the pad follows them? I am asking because there are claims from facial exercise programs that toning the muscles will raise the pad back to the previous position. If the pad is not attached to the muscles in a rigid way, I don't see how that would happen.

You can ask ten surgeons and you will get ten answers. I truly believe that the fat pad does not slide down but really deflates. Now a very heavy malar fat pad may both hypertrophy (get bigger) and possibly slide down in the setting of hollowing in the upper cheek that would make that lower portion seem much worse. The malar fat pad in my opinion would not be significantly improved with muscle exercises. Why do I think this? Because a full surgical midface lift that releases all of the musculature and suspends the malar fat pad still FAILS IN MOST CASES BECAUSE IT IS A VOLUME ISSUE. So if a full surgery fails how can a few muscle exercises help? How do I know about midface lifts? I wrote the book on it. My first book, Comprehensive Facial Rejuvenation, was all about midface lifts. I have since abandoned this essentially useless procedure that is much more highly invasive than fat grafting. At least that is my opinion.
Best,
SML

Thank you for answering. The facial muscle exercise programs claim they create volume by muscle hypertrophy but the proof they can generate enough hypertrophy to fill in significant volume deficiency is really shaky - mostly based on smiling pics LOL.

If the malar pad doesn't fall down, how do the nasolabial lines actually form? I can't imagine the process. Could it be sinking/deflating of the skin triangle formed by the mouth and the nose with respect to the cheeks? What is your working theory about it?

First of all, oftentimes folds do not deepen. When they do, I think it is a combination of deflating the midface where the line gets deeper as the midface falls inward. I also think there is a gain of weight in the lower cheek that can make it hang so that it looks like a deeper line. Also, I think there can be some sag in the midface leading to the line so yes, some gravity can play a factor. In summary, even though you may have some gravity fall in the midface, the principal mechanism that occurs is hollowing in most individuals. I think when the midface truly begins to sag if at all, the neck does as well. At this point, my face and neck lift does capture the midface to lift it up but I don't think the midface really requires much lifting.

I find this to be an excellent question and something I think is very important and curious in general to how to approach correction . It seems to be that the majority of physicians who talk about it have assumed automatically that the malar pads (does this also mean the whole SMAS?) decent toward the mouth (though some say the 'center of the face') with age.

I personally for my own prospects would prefer this not be the case, or at least something that changes far less than they suggest. It is obvious with observation that we do lose a lot of volume, regardless. However I also cannot deny that the positive volumetric difference between a slim 18 year old and a slim 45 year old seems to be that many, though not all, exhibit a greater amount of volume along the nasal labial folds. This is even accounting for the negative volume changes, because if you fill in the areas that now have less, it appears it has to become fuller than it once had been in order to compensate for the areas that have lots of volume. So the question then is, is it because the pad fell, or did the pad change shape/become distorted, perhaps even folded a bit due to expression? It almost seems that the pad on a young face that is late teenage, early 20s (let's say for this person beyond having lots of baby fat, but still evenly full) is flat almost in appearance. Its coverage seems even and complete, you cannot even really isolate and identify where the pad is unless they smile big.

In young people and children with larger pads or still in the 'baby fat'' period, they appear to have the majority of the pads volume be right near the nasolabial fold all the same, and sometimes doesn't even appear to be covering their suborbital rim, it seems like that is covered by different fat, and/or just good thick skin. Though this really varies between each person. Short of being able to feel between the inside of the mouth and exterior cheek, I cannot say exactly what I am seeing.

There really should be a study that just outlines the pads shape and position in in different age ranges, to get a typical idea of how it compares from 10, 15, 20, 25, 35, etc, to really get a better idea of what is happening. Every face lift I see that involves SMAS or malar pads always claim they need to be brought up high right on the top edge of the suborbital rim, and toward the zygomatic arch. But I am pretty sure that even when I was 19 it didn't cover high up to the zygomatic arch like that.

Again though, it would be nice to really know if the suborbital rim is covered by the malar pad itself, or with neutral expression if it really sits a bit below, and that area is covered by fat independent of the pad, and young skin. It is clear however that in expression the pad slides up to the eyes, giving a youthful smile as it forces a squint that is framed high all around.

I love that you philosophise and re-think what many have accepted as fact, thank you for having this forum and taking the time from what must be an incredibly busy life you have!

thanks for the question. obviously, we will never know with perfect accuracy what happens in the aging face. there will be competing theories and models that will explain things reasonably well but not perfectly. is it volume only? skin changes? ligaments changing over different ligaments? gravity? etc.

one colleague of mine took photos of individuals in their 60s and matched rigorously for position of photos of themselves in their 20s and found that in the midface specifically there was zero evidence of any gravity at all. things were entirely involutional. he even looked at moles relative to the position of the eyelid, eyelid-cheek interface, and nasolabial groove and found no mole ever moved downward after 40 years. interesting thoughts but i hate to be overly dogmatic about any of this.
s.

I understand and agree. Using moles for skin position reference is an interesting one. Though it seems the position of the underlying soft tissue could descend independently of the skin, making the skin no use in indication of fat position change. Thanks.

good point. that could be the case as well. who really knows. but i seriously doubt the skin would not move a millimeter and everything below it would. that just makes no sense.

Thanks for replying again, I agree with that regarding the SMAS, though strictly regarding the malar fat pads, they have an independent dynamic range, right? If one merely lays down on their back, or smiles, the position tends to rise higher. I wonder if this range increases over time, and if heavy pads will tend to sit lower. It would ultimately be great if a collage would do a group study to measure with an MRI the volume changes across multiple age groups. I did find this one medical study that did a small scale of that, if you are interested: https://www.thieme-connect.de/ejournals ... 329545.pdf

Unfortunately it claims ptosis as the issue rather than atrophy.

honestly, i am a practical practitician rather than a theoretical one. there are too many competing theories out there of what happens and there are too many competing practices of how to do it well. bottom line is that i have tried many different methods to rejuvenate the midface and in my hands there is no doubt that volume restoration provides reproducible, safe results. in other words, whatever the theory should say, i would not change my practice because of it in either direction. those are just my thoughts but i always appreciate the intellectual exercise, and that is why i go to a ton of meetings to constantly refine my knowledge in all areas.
best,
s.

It is always a pleasure to hear your thoughts, thank you for your patience. I look forward to visiting you.

thank you as always for your input and thoughtfulness on this forum.
s.