Hollywood’s Pillow Face is a Problem

Cameron Diaz's Chipmunk Cheeks

As many of you know, I love facial volumization in which lost soft tissue of the face from aging is restored using fat grafting and/or injectable fillers.  The word that has dominated the media is a “pillow face” to describe this facial fullness.  I am very adverse to this moniker, as I believe Hollywood (like most things) has taken volumization to an unsightly extreme.  Faces that lose volume, especially in the late thirties and early forties, do not lose that much volume but they are overplumped up.  They do not look fat, just weird.  I think when surgeons lack taste and artistic discretion they overpull people that do not need that much pulling.  Similarly, women are now overfilled when they did not need that much to begin with.  Further, just filling out a cheek, which is what I oftentimes see to be the case, makes people look like chipmunks and creates overall facial imbalance.  When I perform facial fillers or fat transfer I balance the entire face so that it looks natural and youthful.  Just making a cheek big looks like you have had bad dental work or are storing nuts for the winter.  Judgment, taste and artistry are what separate good work from the ridiculous.  A lesson I hope Hollywood learns soon.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forums.

Fill vs. Lift in Facial Cosmetic Enhancement

This article is a corollary to my other article called the “Two-Finger Rule”. In the article on the “Two-Finger Rule”, I argued that taking two fingers and gently pulling up on the skin would not be achievable with any type of cosmetic procedure since it cannot be exactly reproduced by any lifting or filling technique. Similarly, when a patient asks me whether filling a part of the face in will help to lift that structure up I respond simply, “No.” The two are not the same thing. Filling a part of the face will not lift it and if it is reasonably filled up also should not make it heavier to create any sagging.

The most common question is if I fill the cheek in will that lift the smile line.  The answer is emphatically no.  It won’t.  Sometimes just filling the cheek in can cast a greater shadow on the fold and at times make it appear deeper but not substantially so.  It seems intuitive that if you enlarge something that it would stretch out the areas around it to lift it but this simply is not the case.  I had also a question on my forum that if an injectable filler could be placed near the bone so that it would provide more structure as compared with placing it close to the skin where it would add more weight.  I countered this by explaining that a filler placed deeply should not provide better structure and one placed close to the skin should not provide greater weight.

This patient had facial fillers to fill areas of hollowness. Even though the face looks lifted, it is an optical illusion of the filling.

The optical illusion that is created is that something filled in changes the way that light reflexes on it making it look lifted just by virtue that there is now more light and less shadow on the structure.   But there is no net lifting effect.  In summary, this article is intended to dispel a misconception and to provide a better understanding for a prospective patient that filling fills and lifting lifts but one does not help the other.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. Call (972) 312-8188 to schedule a consultation or to ask Dr Lam a question about facial rejuvenation procedures please visit his plastic surgery forums.

Trusting My Expertise in Facial Plastic Surgery

I was giving a lecture a few years ago in Hilton Head when the surgeon before me who is about 30 years older than I am said, “Give a patient what they want not what they need.” I went on stage right after him and said, “I give a patient what they need not what they want.” What the other surgeon meant by this is that if you do something that you want to do and the patient does not like it, she may be angry at you for doing something you wanted and she didn’t. However, I believe that my expertise in this field allows me to create beautiful changes in your face in ways that you simply could not even imagine.

Dr. Sam Lam, Dallas Plastic Surgeon

I use the example of a shoe salesperson. If you want a type of shoe, and the salesperson says that it will hurt your feet, you should probably trust him because that is all he does all day. He lives, breathes, eats, and sleeps shoes. I do the same with faces. An example is a lady that I just saw two days ago who had recently moved from Los Angeles. She had googled cheek augmentation and found me and came to my office wanting more cheeks. All I could see were these very unnatural full cheeks and sunken eyes and chin. I rebuilt her entire face except the cheeks with fillers and now her face is completely balanced and natural. She looks amazing. If I had listened to her, I would have made her look even more unnatural and not rejuvenated but I chose to help her see what I saw, which she could only appreciate when I was done with it. Am I taking a risk? Sure, but it is worth it because I truly know what will help your face oftentimes more than even you do because all I do is live, breath, eat, and sleep the face.

Samuel M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To learn more about Dr Lam’s cheek augmentation or facial rejuvenation procedures please call (972) 312-8188 to schedule a consultation. If you would like to ask Dr Lam a question about facial plastic surgery please visit our Plastic Surgery Forum.

Fillers Versus Fat: Shifting Sand Concept

Many of my patients try to weigh the merits of fat grafting versus fillers since they both seem to be equally beneficial to fill in the hollows of an aging face.  However, I would disagree.  For younger faces still replete with enough fat and in whom I worry about weight gain with aging, I think fillers are more than adequate to accomplish the intended goals.  However, for someone with stable weight, older than mid-30s and done with childbirth (if possible), nothing looks better than the soft, radiant effect that fat transfer offers.  Is there a stem-cell effect with fat grafting?   I don’t know but I can attest that my patients continue to look better and better over time minus the effects of ongoing aging.

In many individuals fat grafting provides a more global rejuvenation than is possible with fillers and for this patient actually more economical.

What I have found that really becomes the dividing factor for those who choose to have fat grafting and those who choose to have fillers is simply put cost.  Those who can afford to have fat transfer should seriously consider it, as it offers unparalleled improvement in facial rejuvenation.  In addition, doing facial fillers first as a “test” or as a trial first is less than ideal.   A huge reason for this is that with enough facial fillers placed into the face, it makes adding fat grafting later on a less than desirable endeavor. With sufficient fillers in the face, it is always hard to know how much is left over when putting fat on top of the fillers.  If using fillers like Restylane or Juvederm, i.e., hyaluronic acid based fillers, theoretically they can be dissolved but that is hard to do when multiple syringes have been used over many parts of the face.  Therefore, putting fat (a permanent filler) on top of hyaluronic acid (a temporary filler) is like building a house on shifting sand, i.e., a permanent structure on an unstable one.  In addition, I have noticed that when I do 3 to 4 syringes of filler product, most people simply want more because it looks really good.  In that case, over time I continually do more to make the face look more rejuvenated.

In summary, if someone can afford to do fat grafting and that person meets the safety criteria outlined above, I highly recommend for them to consider having a fat transfer.  For those who do not have the budget to consider fat grafting (or who do not fit into the safety profile mentioned above), then I recommend fillers and for that person to continue to do fillers and not worry about doing fat grafting.  Hopefully, this explanation of my philosophy of when to do fat grafting versus fillers makes practical sense.

Samuel M. Lam, MD, FACS is a board certified Dallas plastic surgeon. To learn more about Dr Lam’s facial plastic surgery procedures please visit our website www.LamFacialPlastics.com or call (972) 312-8188 to schedule a consultation.

The Importance of the Buccal Zone: Joining the Mid to Lower Face

The buccal area is defined as the part of the face where if you sucked in your cheeks they would suck inward.  It is the area that in a very skinny person can make one look gaunt, and the buccal area resides in the region below the cheekbone.  When someone starts to get older from say late 30s and beyond, the buccal area is one of the prime zones that can be affected with hollowing.  In overweight people, the buccal area can be plumply filled out and would not need to be filled.  However, in the great majority of individuals of normal weight, the buccal area tends to hollow out.

When looking at an individual from the oblique, ¾ view, you can see 2 to 3 little circular dips in the skin.  The area that is most typically affected is the central area right in the middle of the cheek.  The second most commonly affected portion of the buccal area is the area in front of the ear and below the bony cheek area that causes a dip appearance near the ear just below the bony protuberance of the cheekbone when someone is viewed from the front.  The final, circular, buccal hollow is not always present, being situated near the lips and occurring more in advanced aging, especially when there has been resorption of bone from bad dental care.

This woman is shown before and 2 years after a single session of fat transfer with a good aesthetic outcome. As one can see, the buccal area is entirely hollow from front to back and filling this area was critical to soften the transition from the mid- to the lower face.

Many times the buccal area is entirely ignored during a fat transfer by many practitioners who may focus just on the hollow lower eyelids or the central cheek area.  I think that the buccal area should be considered an important bridge area from the central midface to the lower face.  Why is softening the transition from one part of the face over to another so important?  There are a few reasons.  First, if the central cheek is augmented by itself it can look too big because it is not properly blended into the buccal area.  Second, the already gaunt buccal area can now look even gaunter vis-à-vis the augmented cheek, which can in turn further exacerbate the effect of aging.  Third, one reason to perform fat transfer is to soften the many shadows of the face, and the buccal area can be an important part of this overall strategy.

Not everyone needs to have their buccal area filled and when doing so it is important to know just how much and in what distribution to create the most aesthetically pleasing results.  Filling too much in the buccal area can make one look overweight or disproportionate.  Filling just the right amount in the appropriate combination of central, lateral, and medial buccal areas can lead to the most balanced rejuvenation for the face possible.  Focusing on the artistic side of fat transfer is a critical element in creating natural and aesthetically pleasing results for the aging face.

Click to learn more about Dr Lam’s facial rejuvenation procedures, including photos, videos, forums and FAQs or call (972) 312-8188 to schedule a consultation .