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.

Here is another study with beer. In Predictably Irrational, Ariely asked a group of individuals sitting down at a table in a bar to order from a limited list of beers: Summer Wheat Ale, Franklin Street Lager, India Pale Ale, and an Irish Stout. The first individual would call out his or her beer and then the ordering would progress around the table. At the conclusion of imbibing, the individuals would be asked to write down their rating of their beer. Interestingly, the person who asked for the beer first consistently rated his/her beer satisfaction to be the highest. The ratings would then go down proportionately to when the beer was ordered. The same experiment was tried by having individuals hand in their beer order silently without declaring their wishes aloud. Interestingly, almost every individual rated the satisfaction of their choice very highly. Also interestingly, when beers were ordered out loud, almost every person ordered a different type of beer; whereas when beers were ordered silently there was much more similarity in what was ordered. The same experiment was carried out in Hong Kong. However, in this case, when people ordered out loud, the second, third, etc. person would order most likely the same thing that the first person had ordered. As would be expected, their enjoyment was greatly less than what the first person ordered. What we learn from this experiment is that in the United States we value our maverick individualism even in spite of our best interest, and in Asia conformity is prized to a similar detriment. In summary, if you are going to order, order it first before everyone else so that you can enjoy your meal!

Sometimes in our society, we want to be different just for the sake of being different. Sometimes different is bad. Sometimes there is a reason why no one else is doing what you are doing. Sometimes different is good because the majority out there are doing things that are not good. We should fight against any of our cultural legacy (whether from the Occident or the Orient) that is our natural tendency to be “predictably irrational” so that we can make choices that are the right ones. In my field, I truly believe that too much lifting is being done for all the wrong reasons with absolutely dreadful results. As you know, I believe that the majority of docs out there who believe that lifting brows and cheeks is right are in a word wrong. However, I believe that Botox, almost despite its popularity, is so very right thing to do for long-term gains and to avoid what would otherwise be ineluctable aging. (If you don’t know what I am talking about, watch my 3 video logs: 1, 2, 3). I believe that Restylane and Perlane, which are the most popular fillers on the market in Europe and the U.S., are the most popular for a reason (which is corroborated by my clinical experience). Believe in the right thing whether it is popular or not, but don’t believe in something either because it is popular or because it is not.

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).

Thomas Kuhn's The Structure of Scientific Revolutions

Thomas Kuhn’s The Structure of Scientific Revolutions had a profound impact on my thinking as an undergraduate major in European history at Princeton University. Kuhn’s thesis focused on how scientific research and understanding are driven by a specific model of the universe, until a crack appears in that model, that will eventually cause it to be supplanted by a new model. An example is how Newtonian physics dominated our thinking of the laws that governed the physical world until Einstein poked holes in it when looking at the deficiencies of that theory at the outsized extremes, e.g., the speed of light. The concept of gravity was replaced with the perception of curved space and a space-time continuum. Quantum mechanics surfaced to create a newer model that differed from Einsteinian physics by focusing on the deficiencies of Einstein’s theory at the sub-atomic level. Einstein spent the remainder of his life failing to create a “unified theory” to marry the discrepancies of both theories. Super-string theory emerged to provide the mathematical unity that Einstein sought and that only now is becoming unraveled as a viable theory.

With Kuhn’s thesis firmly in mind, I wrote my new book, Aging Face: the New Paradigm, to express a new paradigm shift. As you know, fat grafting represents the core of the paradigm shift, i.e., getting surgeons to abandon browlifting and excessive facelifting (I do facelifts in those who would benefit from them. In fact, I am doing one combined with a fat transfer today) and to see faces from a volumetric standpoint rather than a purely gravitational model. Hair restoration using stronger-density grafts in the central midscalp and feathering that forward along the perimeter with finer grafts. The trend toward tinier and tinier grafts throughout have left patients with weaker density and no more natural a result. Also, vertical, purse-string, cranial-based, short-incision facelifts (which I am doing today) that change the paradigm from pulling backward (does that fix gravity?) to pulling upward to counteract the effects of gravity.

Although Lakatos argued against Kuhn’s thesis and proffered that change is more gradual, I am firmly in Kuhn’s camp and have built my new book on his theory. We as humans tend to need models to perceive “reality”, and especially in the world of scientific advancement and knowledge, I think models are indispensable. However, Kuhn’s theories have been a bit bastardized in non-scientific circles.

Fat Grafting Evolution Photos

In January of this year, I sat for my hair transplant board examinations in Houston, Texas and am fortunate to be one of about 120 diplomates of the American Board of Hair Restoration Surgery in the entire world. It was a very rigorous examination, testing me on every aspect of surgical and medical hair restoration but also on hair loss diseases and basic science information related to hair. The thing that I want to focus on in this blog that I got out of that examination is understanding how a “free graft” transplant works. This knowledge is applicable both for my hair transplant patients and my fat grafting patients. I oftentimes joke that I am no longer a plastic surgeon but a transplant surgeon now. Okay, that was not that funny.

In Unger’s magnificent book, Hair Transplantation (4th Edition) he has a drawing of a hair follicle start to get fully connected to the surrounding blood supply somewhere around 6 months postoperatively. This is the time that a hair transplant begins to take root so to speak and start to show significant growth that continues upwards of 18 months to 2 years following a hair transplant procedure.

Now the main purpose of this blog is not to talk about hair restoration but to use it as a model for one to understand how I perceive the evolution of a fat transfer. Fat grafting, like hair transplantation, relies on placing a “free graft”, i.e., a graft placed into the surrounding tissue that must take hold for it to grow. Unlike a microvascular free flap that has the blood supply actually sewn together, these free grafts must have enough blood supply over time to become a live graft.

This is why I inform my fat grafting patients that there can be a dip in the result between the early swelling of 3 to 5 weeks and the “result” that begins to appear after 6 months when the blood supply begins to take hold. Like a hair transplant the result begins to manifest about 6 months out and improves up to 2 years post. That is also why I put together the fat grafting evolution series in my before and after gallery to help you better understand this principle. The photo shown is of my patient that I just uploaded last Friday showing her before, 1 week after, 3 months after (the dip), and 1 year following (the result but still improving).

I know many patients have a great fear that the fat transplant will not last. Simply put, that is what happens with other surgeons who do not know how to handle and inject the fat well. My fat not only lasts but improves over time. I think many surgeons at 3 months encounter one of two problems. Either their fat is gone because the fat graft did not hold well, or the fat is in the “dip” phase and they decide to go back and do a touch-up. If the fat is going to hold, the individual will look grossly overcorrected at 1 to 2 years post. This is why I always say to my patients put your seatbelt on at 3 months and patiently wait. If you dip hard (20% do), you should be fine. If not, let’s do a touch-up at a year on my nickle.