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 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 have learned to be much more selective in what projects I choose to move forward with. In the past, whatever someone asked me to do, I would invariably say yes. In fact, up to about a month ago, I fail to remember whenever I said, “No.” That has led to a devastating compression of my personal life to zero.

In the past month alone, I have said, “No” three times. I was asked last week to write another chapter in the book, Master Techniques for Rhinoplasty and Nasal Reconstruction, on alar-base reduction because the editors loved my first chapter that I had already submitted. (Perhaps they loved the fact that I was one of the few authors to get the job done on time and done well.) I said, “No” to my distinguished colleague and friend who asked me to fly out to China as an honored guest speaker all expenses paid for his Rhinoplasty Workshop. I also said, “No” to my colleague who asked me to write yet another book. That is a world record for me. Not Michael Phelps but at least a personal milestone.

I don’t say no to everything. I said, “Yes” to my colleague who asked me to be the course director for a hair transplant workshop in St. Louis next year but I have reasons for saying yes. First, I am very interested in the project, since this will be a unique platform to advance hair restoration in a hands-on cadaver workshop that I think has never been offered before. Second, I like being challenged to be a course director, which is something that I don’t have a lot of experience with. Third, I have already finished the entire syllabus and speaker list in two short hours on Saturday. Efficiency is something that I am known for.

I assumed the Editor-in-Chief position last year for a consumer’s guide for facial plastic surgery, entitled, The Face Book (don’t worry, we copyrighted the first edition before facebook.com), which was something I really had no interest in doing. I did it because a senior member in the Academy basically asked me in front of 20 board members, “Sam, please do this. You are the only one that can do this.” I was honored and also in my state of never saying no last Fall. However, the project has now morphed into something that I think will radically alter the landscape of my field in that it is no longer targeted for surgeons’ reception areas (which is an untenable and antiquated concept) but now I am seeking a literary agent to push this into the mainstream and making it a major (hopefully) blockbuster.

My friend Robert said, “Sam, a wife and kids will be the worse thing for your career.” I think he may be right. However, I believe that our passions can remain unmitigated but we can choose what we want in life by following those passions and not following every opportunity presented to us simply because it was presented to us. I will never give up my passions, but I have learned to choose projects more wisely and I have learned to say, “No.”

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.

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.