I routinely read the New York Times every morning and several weeks ago I came across this very interesting article concerning an art exhibition “One Life: The Mask of Lincoln” featuring two plaster casts of Abraham Lincoln as part of the celebration of his bicentennial year in 2009. The first plaster cast was made in 1860 when he was campaigning for the presidency and the second one made 5 years later in February 1865, just two months before he was assassinated — which reveal the nature of the aging process in stark relief.

Although there is a more corrugated appearance to the latter plaster cast, the volume loss of the face is unmistakable. Looking at both faces, the viewer can see that the face looks older despite the relative absence of wrinkles and gravity. Volume loss is the significant player here for aging in an unequivocal way.

Interestingly, what strikes me the most is the buccal zone, the area below the cheek bone. The scooping out of this area truly makes Lincoln look significantly older and already gives the middle-aged appearance of the earlier cast a wizened appearance. The buccal area is a zone that is so little appreciated and in my opinion is a critical area to focus on for rejuvenating the face. Obviously, this is not the case in every individual. Some individuals who are slightly heavier do not need buccal fat or Asians who have a rounder face certainly in many cases do not need buccal fat. However, I truly believe the buccal hollowing can be one of the most dramatic areas of aging that exists.

In my new book, Aging Face: The New Paradigm, coming out next year I have come up with a unique way of looking at the buccal area, subdividing it into 3 zones, which I have previewed in a lecture that I gave earlier this year in St. Louis. The central buccal zone is the area that we are all familiar with, the area that sits below the cheek bone and that we suck in when we suck our cheeks in. However, a refinement into thinking of the buccal area is that there is an area that is near the mouth that I call the medial buccal hollow that represents bone loss of the teeth that I also target in some individuals. The outer portion of the buccal area that lies immediately below the outer cheek bone and in front of the ear I call a “backfill” zone which I target with fat transfer to create a more uniform transition from the augmented cheek downward.

I think we are so focused on the “midface” (cheek) and the lower face (jawline and neck), we forget to look at the importance of the watershed region that is situated between the mid and lower faces. Remember that a youthful face has very few transition zones. I look at fat transfer as a way to unify areas of the face that have separated and to rejoin these areas. It is almost like airbrush work. In essence, that is how I apply artistic interpretation to facial aging and truly target the face for optimal rejuvenation. So those surgeons out there who suck out the buccal zone in my opinion make no sense to me even if the area is full because it will become eventually depleted and will worsen one’s aging in many cases by doing so.

I have been thinking about writing this blog for the past year but have forgone writing it because I had so many other ideas floating around in my noggin to write about. However, last week when a patient who came into my office for Botox said, “Dr. Lam, I was thinking of fat grafting but I really don’t want that. I just want this,” then she lifted two fingers on her skin to show me the lifting effect that she desired. Ugh! I knew at that point I needed to commit thought to paper (or thought to keyboard in today’s parlance).

We oftentimes think that our fingers can relay to the plastic surgeon a feasible, realistic goal. “Heck, if I can just take two fingers to pull up on a certain part of the face, why can’t a skilled surgeon replicate such a maneuver?” The simple truth is that is what the threadlift that came out a few years ago was purported to accomplish. It would pull the skin upward in the trajectory accomplished by one’s fingers. The aesthetic result of such a maneuver, the threads and the company were short lived and so was my patience for these touted results.

Without making this blog interminably long, suffice it to say that the two-finger rule simply does not apply to reality. Surgeons can’t reproduce it to your satisfaction, and oftentimes it bespeaks the wrong intuition to begin with. I can’t remove pores, acne scars, definitively smooth out folds with a lifting maneuver that in many cases you simply do not need and that would worsen your condition or not help it. As a summary of my thoughts on facial gravity, please watch my video “Rethinking Gravity” in full to understand why our a priori notions of facial aging are pretty much screwed up so is that of 99% of plastic surgeons out there and their thoughts about what constitutes facial aging (of course, i am unbiased in my comments…not!).

I just got back last night from Los Angeles where I gave 3 lectures at Cedars-Sinai and had a fabulous time. I also learned a tremendous amount and would like to thank my friend, Babak Azzizadeh, for inviting me to speak there. I was particularly enlightened by Val Lambros’ lecture on understanding the evolution of facial aging in which he used superimposed images of an individual at youth and after aging with morphed animations between the two images controlling for facial position. What was remarkable is how the upper and midface DO NOT FALL but just lose volume and deflate.

I like what he said which was, “The brows do not fall as much as we pick them up.” When he showed images of the brow over time, some came down literally only 1 or 2 mm, others stayed the same height, and still others actually went upward with aging as the skin retracted upward. Therefore, even for the occasional brow that came down 1 to 2 mm, a browlift would oftentimes exaggerate the brow position upward making the eyelid look different and unrejuvenated. He also mentioned that (and he demonstrated this on himself) when he lifted his brow up with his finger his eye actually looked smaller, making him look older. The fuller outer brow contributes to the lengthening of the eye shape further outward, which is similar to the shape in youth.

Let’s discuss eye shape in youth. He mentioned that in most individuals, Caucasian, Asian, or any race, there is a relatively almond-shaped eye that becomes increasingly rounder as the lateral canthus (outer part of the eye) starts to move inward toward the nose. This beadier, smaller, rounder eye is less attractive than the more open, almond eye shape that is more prevalent in youth. As mentioned, by exposing the narrowness of the outer eye by lifting the brow, the eye can look smaller and thereby more aged. That is why a traditional lower-eyelid surgery that involves cutting of the lower eyelid skin and tightening the skin thereafter further constricts the outer eye and can make the eye look even older. By filling the outer brow, you visually extend the outer eye shape to make it appear younger since the eye appears wider. Okay, this is really hard to explain but a simply brilliant thesis predicated on empirical evidence of aging using unequivocal superimposed images from youth to aging. In addition, a fuller framed brow is simply what exists in youth. For all of these reasons (both illusory and real), a browlift can actually age someone further.

He evaluated positions of moles and other static landmarks during the aging process. He found that moles simply do not change direction gravitationally downward. The moles that did migrate with facial aging did so in a radial fashion along muscular pull lines, i.e., almost horizontally that would indicate that the face is radially contracting, i.e., deflating, rather than falling downward. Again, remarkable insight using powerful superimposed young and old photographs of the same individual.

Unfortunately, for the neck and jawline, oftentimes a facelift is still required to accomplish the required rejuvenation. However, what he also showed was that the jawline matched out from youth to aging actually shows the jowl because the surrounding tissues are lost. That is the soft-tissue in front of and behind the jowl begin to disappear to reveal the jowl. At times bringing the jawline down with fat transfer in front of and behind the jowl could actually be better in certain circumstances. I think with a very prominent jowl and neck descent, a facelift is still mandatory to get the desired results. However, I have come to appreciate the power of filling the outer jawline in select patients who would benefit from this fill both for the sake of facial rejuvenation as well as for creating a better-balanced face. All of these ideas represent a remarkable revolution in thinking that justifies volume replacement as the singular technique for upper, midfacial, and parts of or the entirety of lower facial rejuvenation.

Blink by Malcolm Gladwell

I was attending a lecture by my colleague in St. Louis 2 weeks ago and I really liked how he envisioned the facial aging process. He likened it to the book, Blink, by Malcolm Gladwell. For those who have not read Blink or Gladwell’s other phenomenal book, The Tipping Point, I would highly recommend both reads.

Gladwell’s thesis is that we judge another individual or almost anything in a visceral blink of an eye. It does not take 5 minutes to figure out something but we can tell almost immediately about something and we are typically correct in our initial assumptions, which are also very hard to shake if we are wrong.

That is how we view each other when it comes to aging. We can almost instantaneously tell if the other person is older, younger, attractive, or unattractive. We can tell in a blink of an eye from 10 feet away. However, when people come in to fix something, usually they are focused on the minutiae that no other human being can even see. In particular, because women put makeup on, the tiny lines around the mouth (that no one can see. believe me.), the crepiness of the upper eyelid, the dot on the right cheek, the tiny asymmetry of the upper lip, etc. are on the top of the wish list for correction even though after paying all the money to do those things nothing really looks any better.

Instead, I truly believe that overall facial shape (geometry) and proportion is how we make a judgment about another person in a blink of the eye. So, when people come to see me, I would rather help them create a favorable blink impression on all those around them than try to fix the minor flaws that only they can see. If you want to understand how we view aging geometrically, you can watch the first part of my video lecture I gave 2 weeks ago in St. Louis that discusses in my opinion an original thesis on how we see aging. Here is the link to the video.

Btw, a patient of mine told me that Gladwell’s new book is coming out in a few weeks so I checked it out on Google, and it’s called Outliers, about how successful people are successful not just because of who they are but where they are from (at least that is what Amazon says).

prevelle silk

As mentioned in the last few blogs, new technology is always coming out quickly to the market. When I was in Chicago at the Fall Meeting of the American Academy of Facial Plastic & Reconstructive Surgery, I looked into Mentor’s new Prevelle Silk, which is another hyaluronic-acid (HA) based product to compete against Restylane, Perlane and Juvederm. The major benefit touted with this new product is that it contains Lidocaine in it to reduce the discomfort associated with injection. Although on the surface, this sounds good, I really do not encounter any discomfort with my patients owing to the short-acting block that I use during treatment.

Basically, Prevelle Silk contains 5.5 mg/cc of hyaluronic acid, which is a fourth of the content that is contained in Restylane, Perlane, and Juvederm. When I asked the Mentor rep in Chicago about this observation, I said, “Oh, that sounds like the exact amount that Captique had in their HA product.” He said, “Yeah, that’s because it is manufactured by Genzyme, who made Captique.” Aha! Prevelle basically is Captique with lidocaine. I used Captique in the past (which has fondly been called “Craptique”) because it simply lasts such a short time. With so little HA content in the product, longevity can be as short as 3 to 4 weeks in my experience. If you are lucky, perhaps 6 weeks or so. This is a product that I have no interest in incorporating into my practice at this time.

Here is a link to my video log on Evolence (if you missed that one) and on Prevelle Silk.

I was very honored that my mentor said to me in Chicago, “Sam, you are really a great thinker. You are one of the thinkers in our Academy.” I had another individual whom I respect say to a vendor, “You must talk with Sam because he is a really respected thinker in the Academy.” Finally, I talked with another colleague of mine from Florida who said, “I really like the way you think.” I was very touched by these words and took them to heart. I think many times we pass through life “satisfied” with where we are and really don’t exercise the noggin a bit to see if what we are doing is the best thing that we could do.

In Chicago last week, I spent as much time in the exhibit hall looking at new technology as I did in the lecture hall listening to scientific papers. I will be doing the same today, as I am lecturing In St. Louis. What I have learned to develop over time is a critical skepticism about new technologies out there. It is great to go to the annual meeting and see what is the latest thing that is out there and before jumping head first to sit back and evaluate the efficacy, safety, and “long-term” benefits that a new technology may have.

I will be introducing a couple of new injectable fillers on Monday and Tuesday’s blogs that I have true skepticism about and I will tell you why. Does that mean I won’t ever be using these products? No. That may not be the case. I just want to have you understand where I see that technology today. I also was looking at some new laser/light technology that I am a year away from adopting if ever. I studiously evaluated each system by asking the individual about the pros and cons (which is obviously extremely prejudiced information) and then will be doing some clinical tests over the next year to see for myself any validity. There is a good saying, “Don’t be the first person on the block to do something and don’t be the last person on the block to do something.” Those are words to live by.

Two errors I made in the past by adopting technology too fast were the Threadlift and the Surgiwire. Both technologies proved to be useless and did not live up to the brand quality that I have established when you come to see me as a surgeon and practitioner. I have promised my patient base that I will not jump blindly into new technology but evaluate that technology over time to ensure that it is what it is touted to be. At the same time, many surgeons never go to a meeting, whereas I go to 10 to 12 meetings a year. So it is very important to keep up with the latest thinking and techniques but only to adopt that technology and technique when sufficient time has passed to see whether that technology merits incorporation into a plastic surgery practice. That is my promise to you.

In my quest to continually understand the nature of fat transfer and any kind of free graft, I am constantly thinking about the evolution of a result. Not just the result at a short time point like 1 month out but how does that result shape up over time. I am happy to report after coming back from Chicago and listening to a talk that a colleague of mine gave on long-term volumetric changes with fat transfer using computer modeling, the longevity of fat transfer is now unequivocal.

Using advanced computer modeling software, a single session of fat transfer was evaluated before the procedure, at 3 months and followed up to 18 months after the procedure. What was interesting was that at times there was such a significant dip in the result at 3 months that the volumes shown on the computer were the same as before the procedure. Nevertheless, in every case where the 3-month dip was present, the volumes steadily increased until 18 months.

This study is the first conclusive, scientific proof that validates 3 important findings that I have been observing clinically but only had photographic evidence of my thinking, namely: 1) fat transfer can dip mildly to significantly at 3 months following a procedure (and therefore a touch-up procedure should not be performed too quickly), 2) that fat grafting continues to improve between 6 months to 18 months, and 3) that a single session of fat grafting has unequivocal longevity.

Obviously, safe and long-lasting fat grafting is completely technique dependent. Many practitioners out there simply cannot attain longevity or safe, smooth results so I want to be careful with the information provided in this study. Further, the artistic interpretation is critical to attaining a balanced, youthful, and attractive result. Fat transfer is not just about making a big cheek or filling in the hollow eye. It is about a face that expresses natural beauty by emphasizing harmonious structures.

I am really proud to inform all the local Dallasites that my anti-aging center will be featured tonight on the 10 o’clock news on Channel 8, WFAA ABC.  Macie Jepson will be reporting on male hormone dysfunction and libido issues.  For those of you in Dallas, don’t miss it.  For those of you outside of Dallas and who are interested, I am sure that they will post it on their site soon. BTW, MY TELEMUNDO APPEARANCE ON FEMALE HAIR LOSS FROM A COUPLE OF WEEKS AGO IS NOW POSTED ON THIS SITE. HERE IS THE LINK TO THE VIDEO.