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.
Relationship Building
September 15, 2008 by dr. lam · Leave a Comment
I was truly touched by so many nice words from so many nice people. I am also so happy when I see one of my patients come back to see me again. I was doing a facelift last week on a lady and her husband said to me, “Thank you Dr. Lam for your wonderful relationship you have with my wife.” I was really touched by his choice of words. As much as he and hopefully his wife saw it, I was engaged in a relationship with a patient not just an encounter.
In a relationship, there are few things that are very important that I do not violate. First and foremost is trust. I want you to be able to meet with me and know without a shadow of a doubt that I will not perform a procedure that I think will hurt you or waste your money. Sometime I get a bit too passionate about my work when I think you will injure yourself with something dangerous. I also carry that trust forward to state perhaps something you did not notice but that I would help you with. It is my fiduciary responsibility to mention to you what I see you need.
In this circumstance, when you build that level of trust with me, you know that I don’t “sell” you something. I educate you on your options and I really want to help you make responsible choices so that you make the right choice. I always say that during an initial encounter with me before you know me, I want to establish guidelines of what I am trying to achieve during the present and in the future, and those are “education” and “trust” not a “sale”, a term that I literally want to throw up when saying. Everything that I stand for is in opposition to that.
I also believe that your relationship with me extends far beyond me but to my staff as well. We hope that we are seen as part of your extended family. My culture of love, respect, and care permeates everything in my building. We are here out of passion and love. I just read 3 very touching cards that my patients sent to me that really have brought such a beaming smile on my face, you probably can see it from where you are sitting. Thank you to all my patients who have honored me for choosing me as your doctor.
The Structure of Scientific Revolutions: Shifting Paradigms
September 11, 2008 by dr. lam · Leave a Comment
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.