Blink by Malcolm Gladwell

I was attending a lecture by my colleague in St. Louis 2 weeks ago and I really liked how he envisioned the facial aging process. He likened it to the book, Blink, by Malcolm Gladwell. For those who have not read Blink or Gladwell’s other phenomenal book, The Tipping Point, I would highly recommend both reads.

Gladwell’s thesis is that we judge another individual or almost anything in a visceral blink of an eye. It does not take 5 minutes to figure out something but we can tell almost immediately about something and we are typically correct in our initial assumptions, which are also very hard to shake if we are wrong.

That is how we view each other when it comes to aging. We can almost instantaneously tell if the other person is older, younger, attractive, or unattractive. We can tell in a blink of an eye from 10 feet away. However, when people come in to fix something, usually they are focused on the minutiae that no other human being can even see. In particular, because women put makeup on, the tiny lines around the mouth (that no one can see. believe me.), the crepiness of the upper eyelid, the dot on the right cheek, the tiny asymmetry of the upper lip, etc. are on the top of the wish list for correction even though after paying all the money to do those things nothing really looks any better.

Instead, I truly believe that overall facial shape (geometry) and proportion is how we make a judgment about another person in a blink of the eye. So, when people come to see me, I would rather help them create a favorable blink impression on all those around them than try to fix the minor flaws that only they can see. If you want to understand how we view aging geometrically, you can watch the first part of my video lecture I gave 2 weeks ago in St. Louis that discusses in my opinion an original thesis on how we see aging. Here is the link to the video.

Btw, a patient of mine told me that Gladwell’s new book is coming out in a few weeks so I checked it out on Google, and it’s called Outliers, about how successful people are successful not just because of who they are but where they are from (at least that is what Amazon says).

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

prevelle silk

As mentioned in the last few blogs, new technology is always coming out quickly to the market. When I was in Chicago at the Fall Meeting of the American Academy of Facial Plastic & Reconstructive Surgery, I looked into Mentor’s new Prevelle Silk, which is another hyaluronic-acid (HA) based product to compete against Restylane, Perlane and Juvederm. The major benefit touted with this new product is that it contains Lidocaine in it to reduce the discomfort associated with injection. Although on the surface, this sounds good, I really do not encounter any discomfort with my patients owing to the short-acting block that I use during treatment.

Basically, Prevelle Silk contains 5.5 mg/cc of hyaluronic acid, which is a fourth of the content that is contained in Restylane, Perlane, and Juvederm. When I asked the Mentor rep in Chicago about this observation, I said, “Oh, that sounds like the exact amount that Captique had in their HA product.” He said, “Yeah, that’s because it is manufactured by Genzyme, who made Captique.” Aha! Prevelle basically is Captique with lidocaine. I used Captique in the past (which has fondly been called “Craptique”) because it simply lasts such a short time. With so little HA content in the product, longevity can be as short as 3 to 4 weeks in my experience. If you are lucky, perhaps 6 weeks or so. This is a product that I have no interest in incorporating into my practice at this time.

Here is a link to my video log on Evolence (if you missed that one) and on Prevelle Silk.

Two new cosmetic injectable fillers are arriving on the shelves: Evolence (Johnson and Johnson) and Prevelle Silk (Mentor). Today we will talk about Evolence and tomorrow we will address Prevelle Silk. Obviously, whenever a new filler hits the market, we are always interested in what this filler has to offer. Evolence has perhaps garnered the most attention in the media as a new, “longer lasting” injectable filler.

What is Evolence? Evolence comes from Israel and is a porcine product (that is, it comes from a pig). Reportedly, even though it is not “kosher” since a pig cannot be kosher, the killing of the animal follows prescribed rabbinical techniques for animal slaughter. The touted benefit of Evolence is that it may be lasting a bit longer than Restylane like close to a year. There is also reportedly less swelling during the first 3 days that follow the injection compared with Restylane and Perlane because hyaluronic acid products swell more in the first few days. Two major problems so far have already been bandied about (but may not be entirely accurate): it is hard to mold the product after the initial first few minutes to hours and it provides a lumpy injection. Speaking with a colleague of mine who has used the product, the latter criticism may be inaccurate because the product can be more evenly delivered when it is injected with the right needle, pressure, and depth. Finally, the big question out there is will an animal product create an early or late allergic reaction to it? No matter what data the company presents, I am still skeptical of the safety in regard to this issue.

Here are the reasons that I do not have any interest in offering the product (at least not for now): (1) I try not to use any animal products — not necessarily for humane purposes — but due to patient safety with the use of animal products as mentioned above (2) I really like how hyaluronic-acid based products like Restylane and Perlane are 100% reversible if you don’t like the result. That adds significant flexibility. (3) I don’t see a lot of swelling in the first few days with hyaluronic acids because I don’t put them in areas that lead to significant distortion like the lips. Since I use hyaluronic-acid products for volume balancing primarily, many patients actually do not mind the swelling because it looks closer to the volumes that I would use for fat transfer. In the long run, trading 2 to 3 days of mild swelling is worth it for a product that is not animal-based and can be easily reversed at any time. (4) The longevity that I have seen with Perlane is in many cases over a year, which competes effectively against Evolence. Also, I don’t believe that the product will last a year. I may believe it in a year from now when I talk with my colleauges not the company. For all of these reasons, I do not see any reason to use Evolence in my practice. I am not here to condemn a surgeon who decides to use the product but I am not going to be an early adopter on this one.

Here is a video log that I shot summarizing my thoughts on Evolence

I was very honored that my mentor said to me in Chicago, “Sam, you are really a great thinker. You are one of the thinkers in our Academy.” I had another individual whom I respect say to a vendor, “You must talk with Sam because he is a really respected thinker in the Academy.” Finally, I talked with another colleague of mine from Florida who said, “I really like the way you think.” I was very touched by these words and took them to heart. I think many times we pass through life “satisfied” with where we are and really don’t exercise the noggin a bit to see if what we are doing is the best thing that we could do.

In Chicago last week, I spent as much time in the exhibit hall looking at new technology as I did in the lecture hall listening to scientific papers. I will be doing the same today, as I am lecturing In St. Louis. What I have learned to develop over time is a critical skepticism about new technologies out there. It is great to go to the annual meeting and see what is the latest thing that is out there and before jumping head first to sit back and evaluate the efficacy, safety, and “long-term” benefits that a new technology may have.

I will be introducing a couple of new injectable fillers on Monday and Tuesday’s blogs that I have true skepticism about and I will tell you why. Does that mean I won’t ever be using these products? No. That may not be the case. I just want to have you understand where I see that technology today. I also was looking at some new laser/light technology that I am a year away from adopting if ever. I studiously evaluated each system by asking the individual about the pros and cons (which is obviously extremely prejudiced information) and then will be doing some clinical tests over the next year to see for myself any validity. There is a good saying, “Don’t be the first person on the block to do something and don’t be the last person on the block to do something.” Those are words to live by.

Two errors I made in the past by adopting technology too fast were the Threadlift and the Surgiwire. Both technologies proved to be useless and did not live up to the brand quality that I have established when you come to see me as a surgeon and practitioner. I have promised my patient base that I will not jump blindly into new technology but evaluate that technology over time to ensure that it is what it is touted to be. At the same time, many surgeons never go to a meeting, whereas I go to 10 to 12 meetings a year. So it is very important to keep up with the latest thinking and techniques but only to adopt that technology and technique when sufficient time has passed to see whether that technology merits incorporation into a plastic surgery practice. That is my promise to you.

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.

As some of you know, I submitted my book manuscript a couple of weeks ago but today I am doing a final edit on the fat grafting chapter and thought of a good blog idea. Many patients ask me, “How long is the recovery?” “What percentage of improvement can you think to achieve with this (fill in the blank)?” I have become increasingly wary answering these questions because I do not know what my patient really expects or how their expectations are in alignment with mine.

Oftentimes what happens is that when it comes to a percentage improvement or how long will my filler last, it is a natural tendency for almost every patient to remember the bigger number. For example, “I think your acne scarring will be improved between 30 to 70%.” In that individual’s mind, he/she hears “up to 70%”. That is troublesome. That is the problem with items on sale that read “up to 50% off”. Most likely, most things are 5 to 10% off with 1 or 2 items you don’t even want listed at 50% off. But what we hear is “everything is 50% off.” That is human nature. If I say, “Your filler should last between 6 months to a year.” People hear, “Oh good, it will last 1 year.” That is a problem. What if the filler lasts only 3 months? Then I have lied to the patient.

All of this is really hard. We all want general parameters, but after I give some parameters people tend to have their brain stick to a number. It is much easier to remember something concrete like a number and not my long discourse on why it may or may not fall within those parameters.

The converse is true. Let’s say I say “Your recovery should be between 7 to 10 days.” Well, what the heck does that mean? Discomfort, bruising, swelling, what? Patients tend to remember the lower number in this case. Oh, he said I could go back to work at 7 days. That is difficult too because I NEVER know when you will be happy. I had one lady after fat grafting say, “Doc, you lied to me. I do not look acceptable at 2 weeks.” I had another lady say at a month, “I can’t believe I look this way at a month. This is terrible.” I thought both looked great when I saw them but it really does not matter what I think. It matters what my patient thinks. These are very rare cases but at the same time I have now angered two patients (who actually were very happy only 2 weeks later for both of them.)

Finally, what the heck does “50 to 70% improvement” even mean? Acne scarring is one of the most difficult things I do because I know I will NEVER get it perfect. I can only improve on the situation. This lady at a year following silicone injections told me, “I thought I would get at least 50% improvement.” She looks so good, she is actually on my website so I was befuddled. Now, I am very frightened to give percentages.

I still give numbers out to help people think of rough parameters but I am careful to state with absolute clarity the absolute non-absoluteness of my comments absolutely!

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.

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.