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.

In Predictably Irrational, Ariely gave a certain subset of participants in an experiment a vinegar-tainted beer to try while disclosing to these individuals in advance that the beer would be laced with vinegar. Almost all subjects who tried the beer reacted instantaneously in a negative way and refused to continue drinking the beer after the initial sip. In a second subset, the participants were told they were going to drink a quality brew and after consuming the first tastes, they were asked what they thought of the beer. After they finished drinking the beer, they were informed that balsamic vinegar had been added to enhance the taste of the beer. Almost all of the participants in this group did not change their mind about the taste of the beer when told of this unusual addition. Then, group one who had been informed in advance of the presence of vinegar was offered the chance to add the right amount of vinegar to help enhance the taste of the beer, which was two dropperfuls for every ounce of beer. Not suprisingly, no one accepted the offer to add the vinegar. When group 2 was offered the chance to enhance their beer with vinegar, most of them actually added the vinegar to the beer to make it more flavorful. This is a powerful study to show how perceived expectations can alter our enjoyment of an item, event, etc.

As you probably know, I tend to err on the side of conservative expectations rather than simply creating a false and uneducated bias toward how rosy everything will be. I outline for you in great detail all the limitations of any procedure you choose with me because I want to make sure that expectations are met rather than not. I tell you the vinegar in advance of your drinking the beer, so to speak. Perhaps not how marketers would recommend engaging in business, but this is plastic surgery not selling couches. I tend to create as realistic an expectation on the front end as humanly possible, as many of you who have sat in on a consultation with me know full well.

A great video log that I shot discusses the differences between education, expectations, and excuses. In short, an education is the same thing as an excuse, except that it was told to a patient before a procedure rather than afterward. Creating realistic expectations is critical. I always say that the only thing that I can predict about human nature is that it is absolutely unpredictable. That being said, expectations are so very hard to define. “Hey doc, will anyone notice your work at one week following a procedure?” How would you honestly answer that question? Who knows???!!! I simply cannot account for all facets of human responses. However, I help guide you to calibrate proper expectations by asking willing patients to film themselves during their recovery through diaries and journeys, shooting videos entitled companions to help you wade through the psychological dimensions you need to know, and to ask countless questions in the forum and shoot as many educational videos as possible. Even with all of this work, I still sometimes fall short of trying to capture every single patient’s expectations appropriately.

One of the psychological experiments mentioned in the book, Predictably Irrational, concerned how Duke University students viewed the value of tickets for the Final Four in which Duke would be participating. A lottery was instituted in which a certain lucky number of students won tickets gratis for this event, whereas others obviously were resigned to watch it from a sports bar or their dorm room. Ariely then called the abject losers of the lottery to see how much they would fork over for the right to see the event live. Somehow almost all of those polled arrived at a figure of about $170 some odd dollars. Ariely asked them how did they come up with this amount? The typical response was that they could easily watch the event at a sports bar and that is how much it would cost them in drinks, food, and also a bit on the side to purchase CDs and other frivolities that would make up the difference of not seeing the game in person. Ariely then asked the winning lottery holders to see how much they would accept as a reasonable offer for their tickets. Most ticket holders settled on a sum that hit approximately $2400 without much variance. He then asked the winners how did they arrive at such a figure. The responses involved how that Final Four event would define their entire 4-year time at Duke and how they would be able to pass that cherished memory down to their children and their grandchildren. How did their rarified view of the event stand in such stark contrast to the more pedestrian perception of the non ticket holders?

There in lies the rub. We oftentimes hold ownership at a much higher level than the non-owner. Accordingly, be careful about the 30-day, money-back guarantee. The couch you just bought that you might have had only passing interest in has now become your personal possession which you could not bear to forgo after the expiration of the 30-day period elapses. The gold digital cable connection that you were given as a 90-day trial period becomes part of your privileged right that you can no longer part with to accept the more mundane silver package lacking 4 HD channels as well as some other premium channels (that you conveniently never watch).

When I talk about aesthetics of the face, there is oftentimes a misalignment of perceptions regarding the magnitude of a problem or the lack thereof. For instance, I had a lady come in who wanted her eyelids managed when all I could see were her over-inflated lips staring back at me. I think the corpulent nature of her lips probably obstructed her vision as much as any eyelid issues she might have had. Most surgeons are trained to simply give a patient what he or she wants. I simply refuse to do that. My goal is to help you see what other people perhaps more clearly see but simply won’t tell you owing to genteel discretion.

Alternatively, you also are aware that I tend to help calibrate perception of a problem by de-emphasizing what many women perceive is the problem, which is invariably some small lines around their mouth, a small upper lip, or asymmetry of their upper lip. Simply put, 99.99999% of other people looking at you do not see that deficiency. Of course, I can manage it but I would like to help someone see the big picture of what is the problem so that I can help provide a more balanced appraisal in order that whatever money you spend there can be a wow effect from the observer. We are social creatures and we tend to cherish approbation from another and become crestfallen at any negative observations from a third party (or the absence of another’s perception of the benefits of a particular treatment.) My goal during a consultation is to help you be educated on what may be priority #1 in terms of what any person would see is making you look not as attractive, rested, or youthful as you could be. In fact, it is my fiduciary responsibility to help you perceive the relative value in something by putting it into perspective and prioritizing what I see would most likely benefit you.

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!).

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.

Satisfaction and complacency are not words that I know. I am grateful for the stellar reviews of this website, but I want to continue to refine and make this website more user friendly and more extensive in its scope. With that, I am rolling out the beginning of some major additions and changes to this site that will probably take 6 months to a year to complete in full. I have been working on some of these preliminary elements for over 6 months now with my webmaster with a focus specifically to help out-of-town patients get in and get out of Dallas more easily and to make their stay more seamless, enjoyable, and less difficult.

As a huge percentage of my patients come in from out of town, I am trying to help them out. In fact, I cannot remember a day in the last 3 to 4 months that a patient did not come in from somewhere out of town, state, or country. With that in mind, I have aimed to streamline this large percentage of my practice in a unique way through a custom-built “hospitality kit”. I would like to thank Jeff from Chicago who came up with and executed in great detail his idea of a “hospitality kit”, which in short is intended to help the out-of-town visitor truly be able to visit Dallas effortlessly and with less trepidation. He was the $5000 contest winner with his elaborate idea of the hospitality kit, which I am presenting today.

Some of the features of the hospitality kit include 360 virtual tours of the various hotel rooms in Plano and the immediate surrounding area that I personally shot and edited; a video tour through the hotels and attractions as well as my building to familiarize you with the Plano area; a custom-built map that permits you to view Plano and attractions that include restaurants, hotels, laundry services, tech services, atms, banks, book stores, etc.; full menus from area restaurants that feature takeout and delivery focused on the recovering patient; a peer-to-peer (P2P) sharing on travel assistance so that an experienced patient can help a prospective one; a list of DVD movies that you can rent from me including a player for no charge; a new concierge service that is both reasonably priced and offers such amenities as fully stocking your refrigerator with items you request in advance of your stay; and the whole shebang can be downloaded as a single pdf file for your convenience to help in planning your trip to DFW (the pdf feature should be live within 1 to 2 days).

Btw, even though my hospitality kit launches today, it is already in need of an update! I just learned of two new hotels opening in West Plano that I have not had time to explore but look absolutely amazing: Aloft and Nylo. For the first time, West Plano is getting extremely COOL hotels here! I am really excited. I have already made some comments in the new Patient Submitted (in this case I submitted) Travel Assistance section.

In addition, you can now see additional features (that we are still working on at this time) including web tutorials in which I personally navigate you through parts of this website that may interest you but you cannot find given that this website has now expanded beyond 3,500 total pages (I have just finished shooting all those videos last night. My webmaster just needs to upload them and put the page together). An updates section that automatically lists each day what sections have been recently updated (this should be up today or tomorrow). Besides the blogs and forum section, I update many sections almost daily so you might not know, for example, that I added a new video testimonial or photos from Emina’s trip to Tibet (which i just did) but now you will not have to scour the site for those changes. It will be listed with a direct link to the change in the updates section. Many thoughtful visitors have sent an email to me or my staff about problems they were facing with videos, text, pages, etc. not loading correctly. Now, that problem can be sent directly to the webmaster through “Report Bug” in which the problem page is already flagged when the message is sent. (Also, I will be radically overhauling your video experience in the coming months to make some of the infrequent problems much less frequent or eliminated all together.) I hope these changes will make your visit to LFP a much more enriching, educational, and enjoyable experience!

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.

I am interrupting my blog for today (the 2nd part on defining culture, which will be postponed until tomorrow but this blog is actually rather on target for this theme) to announce the results from Allergan’s independent patient satisfaction survey and the rare distinction we received for our 2008 Patient Satisfaction Award. Congratulations to all of my hard-working staff members at LFP for their great work and for winning this prestigious award.

We scored almost perfect 5.0s across the board and received incredible written words of support from our randomly selected patients. What is great is Jan, our Allergan rep, said our results look so good that it almost looks as if we “cherry picked” the best patients for opinions. But she witnessed several times how the surveys we sent out were entirely random. Just as a reminder our STAFF satisfaction score last year was a perfect 10: Jan said that was the first time in her 12 year history doing this job that she every saw a perfect 10 across the board from every staff member on satisfaction.

Too often, many companies pay lip service to quality customer service but they have no metrics on defining customer satisfaction. Here at LFP, customer service is job #1 and we have proved our merit with the 2008 survey results, which I have published in their entirety. Also, watch my video log summarizing the results.

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).