Dr. Sam Lam Plastic Surgery Forum

Dear Dr. Lam, a while ago you filled my under eye hollows w/restylane and then did cheeks with perlane. It looked great, but with a drawback: suddenly my nasolabials were much worse and stayed that way for about 3 months until some of the perlane went down. Question: Since I wouldn't want that to happen again, can you fill the undereye hollows without doing the cheeks? I know how you feel about the nasolabials, but my friends and I adamantly disagree and to our eyes, bad nasolabials ruin any kind of facial work.

it depends on the nasolabial groove contour. sometimes deepening nasolabial grooves may not look good. sometimes it does not matter. judicious perspective on a patient is really what matters. we are sometimes so programmed to look at the folds that that is all we see, or we react to a person's judgment that the fold is bad and that shakes how we see things and makes us insecure about a decision. standardized before and after images (see attached) tell the real story of improvement versus worsening. remember the cheek is oftentimes the single most important area to fill to create a balanced look. in rare circumstances it can worsen the fold, as i have mentioned in this forum before. i just don't want people to be frightened out of doing the cheek because of your comments.

i have attached 3 photos for you to see how i see the groove: the first lady has nice result from volume balancing without significant change to the groove/fold. the second lady has a worsening of the fold but she still looks a thousand times better. ideally, sure the fold can be filled but would that have been a reasonable area to do instead of the cheek and prejowl/jawline? absolutely not. it would have been a waste of money. however, another syringe in the line would have easily buttressed the line. the final photo is my nurse in whom i did a simultaneous eyelid/cheek/smile line fill because the shape of her smile line (clownish line) is unattractive.

bottom line: i can fill anything you would like me to fill but at least let me take standardized photographs and look at your result. perception is everything but i want to show you a better perception through photos if possible. i want to evaluate your particular situation WITH YOU so that we can come up with a reasonable treatment plan that would be tailored to you. we can even fill the line if it looks too deep for you. look forward to take care of you.

I am not the OP, but I am, too, interested in this topic. Thank you, Dr. Lam, for your detailed answer!


I have noticed that in women who already have n/l folds filling the anterior cheeks definitely makes the folds look worse. Isn't this natural, though, as folds are often the result of sagging cheeks, and if we add more volume to the cheeks, gravity makes the folds even more pronounced? I tend to agree with the OP on this one: Deep folds don't look good to me on anyone. The first girl in the picture is very young, she barely has any folds to speak of, so in her case it doesn't matter.

How do you feel about the combination of mid-face lifts/cheek lifts and fat grafting? Wouldn't it help women with deeper folds more permanently?

I think deep folds if they extend past the bottom of the mouth can look bad. I just think too many people are filling these lines because that is all they see. As far as a midface lift correcting the lines, they only do so temporarily. How do I know that? Because I used to do midface lifts and even did a critical review of 5 years of midface lifting using blinded observers. What I found was no appreciable difference in the nasolabial groove. Here is a link to the abstract with results:

http://www.lamfacialplastics.com/content/view/699/47/lang,en

Further, midface lifts really cause a lot of problems with very little gain. Just because you can lift your cheek up with your hand does not mean that is the result of a midface lift. That is erroneous.

Best,
SML

Hi Dr. Lam,
Thank you for considering my question!
I wish there were more and better treatments for the n/l area than just fillers. I have heard that the combination of a lift and fat grafting might produce a better result; that's why I was asking. I wonder if it depends on the type of the lift (there are so many types of mid-face lifts), but it seems too extreme to me for someone to get a full face lift just because of n/l lines.

I got radiesse only 2 months ago for my beginning n/l lines (to clarify, [i]not [/i]at Dr. Lam's office.) The effect of the radiesse is completely gone. I will be looking for other options.

i have tried everything for those lines. the surgiwire is absolutely dangerous and i stopped doing it. it is used to try to remove the line by releasing the tethering like a cheesewire (not as an implant). solid implants really suck since they look unnatural and feel unnatural. cutting them out is a possibility but in my opinion really not worth the risk. lifting them simply fails in the long-run. i have just finished a full weekend in st. louis and listened to a million midface lift techniques: bottom line is a lot of dangerous surgery for almost no gain in the midface and almost no gain in the smile line. fat transfer to the line is not sufficient to get a good result in many cases. i am not a big fan of silicone in that area depending on the nature of the fold so just don't believe all the marketing hype. just trying to be safe. at some point if you come in for consultation, i can see what your problem is better and tailor a solution that is safe for you.
best,
sml

Dear Dr. Lam, thank you for your thorough reply to my question. Can you fill the undereye hollows and not the cheeks? It seems so often in plastic surgery that if the doctor corrects one thing , another problem can be caused. For example a doctor (not you) put sculptra right under my eye hollpws and made them look even more hollow.

in my opinion sculptra in the area around the eyes is relatively unsafe and not a great solution toward predictable, safe treatments. don't believe me? go to find one of my lectures on fillers and complications of fillers and i say exactly that. as far as doing only the lower eyelids, yes that is absolutely possible. oftentimes though we have a predetermined list of things we want fixed when we come to the plastic surgeon. what my goal is to do is to look at you "objectively", really artistically, and make my suggestions even before you comment what bothers you. i know that is a bit unconventional (okay completely unconventional) but i think you deserve the educated and artistic eye of a "neutral" bystander, which i am. i would not sell you something you don't need but i would educate you in understanding what i could do for you from an artistic standpoint. then if you don't want that, so long as i am not a) wasting your money or b) doing something harmful, then we can proceed.
best,
sml