Breaking down the Cheek into Aesthetic Subunits: Avoiding Chipmunk Cheeks

There is nothing uglier than big, chipmunk cheeks other than perhaps a devil looking arched brow or a duck-like lip.  How do you avoid this problem?  Should one not fill the cheeks at all then?  The answer is no since the cheek is one of the most important areas to fill to make an individual look much more youthful.  The answer is understanding that filling the cheek requires one to fill all the areas around the cheek as well so that it does not stand out like a weird, unnatural entity.

A few days ago a patient of mine who was starting to model for the first time in her 50s I think due to what I was able to do for her face with fillers said her new boyfriend warned her not to do any fillers because she would look unnatural like her friend.  However, little did he know she has had probably 25 syringes of fillers so far but he could not tell because I applied them not just to the cheek but to every little nook and cranny of the face to create a seamless, balanced, and natural result.

In order to create a balanced cheek result, one must understand all of the subcomponents of the cheek starting with the famed anterior cheek, where everyone tends to overfill it.  The lateral cheek to me is critical since it covers the cheekbone and allows the anterior cheek to blend seamlessly laterally.  Below the zygomatic arch near the ear the sunken concavity must be filled to create a better result. Further down below the cheek, I fill various parts of the buccal area (the area where you suck your cheeks inward) and subdivide this area to the central region, the region further back near the ear and the medial part near the mouth where it becomes hollower with more advanced aging.  My medical assistants are so adept at seeing these facial hollows that they are always helping me look for these transitions to create the best and most natural results.

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 forum

Type 1 and Type 2 Eyelids

One of my colleagues came up with the distinction between two types of youthful eyelids.  Type 1 is a very full upper eyelid that hangs almost over the eyeball itself (not quite).  Type 2 eyelid is an eyelid that is much hollower but at the same time still distinguishes itself from an older eyelid in that the orbital bony rim is still covered with a rim of soft tissue over it.  In general, Type 1 eyelids are more sensuous, feminine and more youthful but they are not omnipresent.  When working with an individual who is starting to age, it is important to go back to one’s old photographs to determine to what extent a person has a Type 1 or a Type 2 eyelid so that the surgeon can preserve and enhance one’s youth without changing one’s identity.  That being said, if one desires to have more of a Type 1 eyelid even though one started with a Type 2 appearance, it can be easily done without truly making someone look radically different.  With the long expanse of intervening years from aging, one can have a Type 1 eyelid even if one had a Type 2 eyelid without major, negative consequence.

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 forum

Breaking the Brow into Subunits: Designing a Brow for Cosmetic Improvement

In a previous blog we discussed why low, full brows are sexy, youthful and attractive. In this blog, we will delve into the exact subcomponents of a brow that need to be filled to achieve that look.  I break the brow into multiple points depending on whom I am filling and to what extent in each area.  To summarize some basic goals, I am trying to create visible soft-tissue convexity in just the right areas and to manage areas of depression and bone exposure.  What bone exposure I am talking about is the bone of the orbital rim (think of a skull).  The bone around the eye that starts to become visible over time actually looks quite dreadful and older, and believe it or not but our brains can actually make the distinction between what is soft tissue and what is hard tissue (or bone).

Perhaps the most important area to fill is the lateral brow (the area of the brow outside toward the ear).  When I speak of the brow, I am not talking about the hairy eyebrow but the entire complex of soft tissue that resides between the hairy eyebrow and the upper eyelid.  This soft-tissue convexity when present creates a youthful appearance that captures light beautifully as it bounces off of it.  If you don’t understand this, find a youthful, attractive face and look for this feature that should almost always be present.

Another area of importance is the transition between the brow to the upper eyelid, i.e., the bone line that can be seen as one goes over the upper bony orbital rim.  This shadow of bone to me is very important to soften and to augment so that the concavity and bone exposure is filled in nicely.  Further inward toward the nose (what we call medial as physicians), there can be a dip that looks like an A shape, which we call an A-frame deformity.  This deformity exists in individuals with advanced aging who are very, very hollow or interestingly enough in those who have had traditional blepharoplasty in which a lot of skin and fat have been excessively removed.  Yes, I believe that traditional eyelid surgery can actually age a person further rather than make one look younger.

Deciding what to fill and how much clearly is a decision based on artistry and design that I execute almost on a daily basis.  I use both fat and fillers (temporary and permanent) to create works of art in which individuals look better and more youthful but always look like themselves.

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 forum

Botox: Understanding Balance

One of the most common things that I hear when I am working on a new patient for Botox is either “Don’t give me those Spock eyes” or “Don’t make me look too frozen.”  Although Botox has become one of the most commoditized items in the cosmetic world, I believe that by delivering quality (more natural results that appear more aesthetically rejuvenative) and value (that lasts longer and helps to promote better long-term skin healing) then Botox can help define one’s cosmetic practice.  For example, I have a gentleman that flies in from Hong Kong every three months just for me to do his Botox and then he flies right back out to go home.  I have another individual who flies in from New York to get Botox even though his significant other offers him free Botox treatments.

Is Botox just about wrinkle reduction?  In short, no.  One must take a step back and understand how injecting Botox in one muscle can have favorable or unfavorable results in surrounding muscles.  The frontalis muscle of one’s forehead is the only elevator of the forehead.  If one just blocks the frontalis muscle, there is a good chance that all the depressor muscles will pull the brow downward unopposed.  This is why I am very careful not to just treat one’s forehead muscles even if that is the only area of wrinkles.  In fact, if there are many more wrinkles in the forehead I have to be extremely careful not to over inject it since wrinkles in the forehead signal to me that someone is trying to lift one’s brows a lot and knocking that ability out and further lowering the brows could make someone quite angry at me.

Conversely, if I inject only the depressor muscles like the frowning muscles (the corrugator and procerus muscle) and the smiling muscles (the orbicularis oculi), sometimes the sides of the eyebrows can lift too much and cause a Spock-like or Jack Nicholson-like effect.  Treating a small degree in the forehead can help balance the result.  When I see a patient I put together all the things that I see:  how bad the habits of movement are, where the brow and eyelid position sits, and other anatomic features along with what a patient desires.  I do this when coming up with a game plan on how I will help a patient look better in a balanced and natural way.

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 forum

When Do I Do an Upper-Eyelid Blepharoplasty and How?

But should we always just add fillers or fat to the upper frame of the eyelid and never remove any tissues?  The answer is no.  If the eyelid skin is above the eyelash margin, I rarely if ever remove skin.  Filling fat or fillers into the upper eyelid and soft-tissue of the brow is sufficient to make the eyelid look more youthful, even if this is not immediately intuitive.  If the eyelid skin edge is crêpey in appearance or hangs low, a combination of some skin removal with fat transfer is ideal for the best results.  However, if I had a choice based on a patient’s budget I would still rely on fat grafting as the principal method to make the upper eyelid better.  Because I remove so little skin and never fat or muscle from the upper eyelid, the eyelid crease height should change very little from its current and youthful position (which preserves identity and enhances youth) but also the individual can still close her eyes.  Unfortunately, I see too many individuals who have been subjected to traditional eyelid surgery that prevents their eyelids from closing, which can be dangerous especially when one is sleeping.

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 forum