We are striving to find our real selves not a fabricated one.  We oftentimes short change ourselves and feel that we are inferior because of certain something or another.  Maltz argues that there is no such thing as a superiority complex because someone who feels superior is most likely covering their own inferiority about something.  We must escape our own self sabotage by envisioning where we want to be using a visualization exercise through a mental movie we talked about.

Focus vividly and concretely in your mind where you want to be in life.  Sometimes it is easier to have your image projected on a movie screen that you are watching.  Then for 30 minutes a day watch this movie and fill in all the details so that it becomes seemingly reality.  Rather than force of will (which is our conscious mind), use your imagination so that your unconscious mind will begin to take over and effortlessly fulfill what you desire to be.  Creating the right self image means first eliminating all of your false beliefs.   More about that coming up.

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***NEWS FLASH***
I was featured on Channel 33 9 pm News last night.  For those interested, here is the video segment entitled “Facial Fillers: The New Face of Hollywood, Patients Flock To North Dallas For Procedure”:

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!).

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

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.

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.

As some of you know, I wrote a blog last week or so on the nature of a transplant comparing fat grafting with hair transplant in terms of understanding the dip and the growth of a result. Here is the link to that blog if you would like.

Getting back from the ISHRS (International Society of Hair Restoration Surgery) meeting last week in Montreal, I was fascinated to learn about how transplanted hair grafts placed into a scarred region can actually over time repair the scalp skin and make it look normal again. That was really exciting news. Along thoe lines, I have seen consistently nice skin changes in my fat grafting patients a year out but couldn’t document the changes with absolute certainty…until now.

I did a charity case exactly a year ago in a nice young lady who had a car accident and was left with scarring despite operations to fix it. I did a single session of fat grafting for her and besides making her face more balanced, I put the fat under her scars, most notably, her right nasolabial groove (smile line), and as you can see a year after, the scar is significantly improved using standardized photography (Please click on the image to blow it up further. It is important you see the image in full resolution and fuller size to appreciate the change). My patient noticed that too and said, “Yeah, I was wondering about that. My scar was starting to look good but I couldn’t understand why.” I think it will continue to improve for another year so I am excited to post another blog in a year to see how her scar looks 2 years out.

The reason for this change is not entirely clear. However, the purported thinking is that the transplanted tissues have a “stem cell” change to the overlying and underlying structures that not only heal tissues but provide ongoing rejuvenation on a cellular level. That is really, extremely and profoundly cool to me.

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.