The Two-Finger Rule
December 12, 2008 by dr. lam · 6 Comments
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!).
Life in Perspective Part 1 of 4: Your Past
November 24, 2008 by dr. lam · 2 Comments
This week we will only have 4 blogs in respect for the deserved respite that you will share with your loved ones over Thanksgiving holidays. In that spirit, I thought that I would turn reflective on one’s life overall. Today we will cover your past, tomorrow your present, the following day your future, and on Thanksgiving Day, your entire life in synopsis.
This blog was spurred on by a forum question that led me to think in a more structured format about what our lives mean and how we can get the most out of our lives. This blog was also inspired by a few patients whom I saw this past week and who really helped me realize that I needed to write something to help more individuals out there who desperately need it.
One woman had come to me from another state after having experienced a burn injury on her face from a medical treatment I believe over a year ago or so. She had sought plastic surgery intervention to correct this problem using Fraxel and Restylane treatments. When I received the initial email correspondence from her, I was alarmed at what I saw concerning the degree of the burn. However, when she came in I could barely see a trace of the injury. Yes, with the makeup off and with my getting up close I could see what was going on but it was a work for me to see the problem. That was a good sign. The only residual problem that I saw was some redness and fullness of her nose left by the plastic surgeon who was trying to correct the problem in the first place. I saw that she was visibly distraught and quite depressed. She said that she was sad about the situation. I informed her that I did not actually see a problem and that others probably did not as well. She said her family was upset about it. I informed her that most likely her family was upset about it because she was overly focused on the problem, leading to their reactions of negativity.
I told her that she had created her own living hell and was fully ensconced in her past. I said that you can live in your own past, but for me I have chosen to live in the present and the future. We can’t change the past, and every intervention that we engage in is undertaken to correct the past further pushes us into an uncorrectable past. Every time she passes a mirror or takes a photograph I am certain that she is staring at it to see if she sees the deformity. It will always be there and no one will be able to correct it to her satisfaction because she will always seek to see if the problem will still be there and, of course, it will be. I can probably tell you a million stories like that one. I actually plan on shooting a video to recount some of these stories to help someone learn from it.
I learned one thing from my mentor, “Happiness comes from within.” I love this saying because it is true. Plastic surgery will not give one happiness. You have to want happiness. Some people love being depressed. Some have allowed themselves to sit within a deep depression because they can’t get out of their own past. They are buried in it out of their own volition. Did the plastic surgeon create the problem? Well, in certain circumstances, yes. I saw a lady who had 17 eyelid surgeries to fix a problem that the first surgeon created. I had to remove a lump of fat out of her face from bad fat grafting she had done elsewhere. I told her the moment I saw her we needed to fix this thing because it was truly a deformity. This circumstance was a disaster that needed correcting. Other times, I see that the patient created his or her own future by living in the past.
The past cannot be changed but it can be valuable tool for us to learn from. As they say, “Fool me once, shame on you. Fool me twice, shame on me.” I believe that. We are not perfect creatures (surgeons and patients alike). However, we can learn from our mistakes and move forward to live in the present to define the betterment of our future. The past is valuable but only as a resource for not repeating it (if it was a mistake) but not to live within it so as to shadow our present and future. More about that tomorrow.
Rethinking Gravity: Using Superimposed Aging Photos as a Model
October 27, 2008 by dr. lam · Leave a Comment
Before we begin, I would like to thank Mike again for quickly accomplishing a request I made. If you notice on the bottom of this blog, you can now subscribe to my blogs so that you don’t have to keep checking back in to see if I have posted my blog. Most often I have my blogs posted in the morning before I go off to surgery. However, I sometimes forget or don’t have it done on time so it comes later in the day. Now, you can receive an email (if you so desire) informing you the exact moment a new blog is posted and can then link you straight to the new blog. It also allows you to send an interesting blog straight to a friend who might be interested in the topic covered. You can also post my blog to various social media outlets as you see fit. Now on to today’s blog:
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.
Blinking Beauty
October 10, 2008 by dr. lam · Leave a Comment
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).
Exploring Silicone Part III, Silicone Versus Fat as a Permanent Filler
October 7, 2008 by dr. lam · Leave a Comment
The patient on the left is shown AFTER a facelift by another dallas plastic surgeon. On the right the patient is shown one year after a single session of fat transfer to the face and 3 serial injections of silicone into her lips and facial folds.
To conclude this 3 part series on understanding silicone, we should explore how I envision silicone versus fat use in my practice. If I am to perform a permanent filler in someone I would love to know the long-term safety of that product as well as its efficacy. As mentioned before, medical-grade silicone injections have been used for cosmetic enhancement since the 1960s. The first fat transfer was performed in 1898, and the first fat transfer using micro-injections done since the 1970s. Most of the new permanent injectable fillers have only been around a year to 15 years with many of the ones which have been around for 15 years undergoing constant purification, refinement, and other changes due to long-term problems. That does not sound safe to me, and I have no interest in using any other product other than silicone and fat transfer as permanent fillers.
In answering my forum questions, I realize truly how difficult it is to understand when I use one product or the other and why. I will first describe how I use each product and why then offer a short table to have the reader better understand these principles in a synopsis format. First, fat transfer is NOT a bio-inert substance. It is in fact a live “graft”. It survives based on blood supply and can fluctuate due to weight and blood supply take. Therefore, fat transfer should be used in this fashion with respect. I use fat grafting solely for volume contouring of the aging face but not to fix a little scar here or there. By putting fat in entirely asymmetrically you risk that the fat will grow disproportionately. You should not have to worry about that with silicone. Second, fat is very soft and fails in my opinion to make much change in the folds and lines of the face, whereas silicone works much better for that. I think fat transfer also leads to significant prolonged distortion of the lips with high resorption. Therefore, I always have the simple mnemonic “fat is not good for lips and lines” to help my prospective patient understand where fat fails. Interestingly, these are the two areas where most surgeons use fat. I use silicone to fix scars, to augment lips, and to correct folds of the face. Another way to look at it is that I use fat over large areas of the face and silicone over tiny areas of the face.
Over the long-term, subtle changes (typically positive) can occur with each product but for different reasons. With the micro-droplet silicone technique, collagen builds with each treatment so you will see changes after a few months particularly with acne scarring that can help you see positive changes. With fat transfer, remarkable stem cell changes have been witnessed (I have seen it) that shows skin texture improvements, scar reductions, etc.
These two permanent fillers have very distinct qualities, properties, limitations and must be used skillfully, as they are both permanent. Here is a quick summary:
Liquid Silicone Versus Fat Grafting