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.

I think one thing that my mentor, Ed Williams, drilled into my brain because I think his mentor, Gene Tardy, drilled into his brain was that as surgeons we treat “patients” not “clients”. During the course of my fellowship year, I was oftentimes corrected for this mistake, which gradually became part of my vocabulary, which I in turn have passed on to my staff.

I think when we as aesthetic plastic surgeons begin to perform purely elective cosmetic work, we can inadvertently start to break down the physician-patient relationship and look at the prospective individual as a “client” or “customer” since we must cater to his or her every whim. Of course, that is important but I think I agree with Ed (perhaps through the repeated brainwashing), that we have what is known as a “fiduciary” responsibility for each individual who is served under us to maintain a proper, respectful, and trusting relationship.

We are not a used car salesman (oh, sorry pre-owned is the word we like today). We are responsible for a patient in the role as a physician. That responsibility should never be forgotten. By using the right word, “patient” rather than “client” I think we can better serve that purpose, especially for all individuals (front-office staff, nursing staff, medical assistants, surgical techs, etc.) who will be involved in that patient’s care.

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.

Well, it’s been exactly one year since I did my mother’s fat grafting. On the eve of her 69th birthday, I think she looks pretty good. My favorite line that my mom gave me this past year is that she forgot how to put makeup on. When the convexity and shape of the face are returned, little concealer or makeup is necessary. That is what is so great about creating the right facial shape. Remember fat grafting is not to fill in lines or plump lips up (which is what every other surgeon is trying to do and failing consistently). It is simply to create a better contoured face that resembles that of a younger individual. Her hands have held up well too. Happy Anniversary (so to speak). See you next year.

Okay, here’s another blog on Botox. I think Botox is one of the most misunderstood products and also one of the most important anti-aging treatments we have around but so under appreciated by everyone that more people could be benefiting from it if they could only bypass their misconceptions. I know I have facts and thoughts on Botox scattered all over this website but I thought I would like to review the 4 BIG misconceptions that plague prospective patients. (more…)

For those of you who did not read Part I of this blog on the subject of symmetry, please do so. I split the blog into two sections because it just got way too long. Okay, if symmetry is not so important, what makes one beautiful or attractive? In a word, harmony. What is harmony? Harmony is the balance of facial features in terms of relative size and distance. The best analogy that I like to use when I talk about harmony is picture a glass of water in your mind. If I ask you how big does this glass of water appear in your mind? You will probably not have a precise answer for me. However, if I asked you to picture a glass of water three times the size of the first glass of water, then how big does that original glass of water appear to you now? Probably pretty small. Conversely, if you picture a second glass of water that is 1/3 the size of the original, then I am certain you would state that the new glass of water appears much bigger than originally conceived. (more…)

Okay, ideas come to me in different ways. I just had a nice morning consultation over breakfast in Hong Kong with a gentleman who was desirous of some facial enhancement. As I discussed some ideas with him for enhancement, I thought about an idea that I tend to repeat almost on a daily basis that I thought would be beneficial to my readership here. Most women, in particular, are very obsessed with symmetry of the face really for two reasons. First, most women when they get up close to a mirror see minor flaws that are asymmetrical and therefore become interpreted as negatively impacting their beauty. Second, perhaps symmetry is the only language or vocabulary that a person may have toward understanding their own attractiveness. I would highly disagree that symmetry is important unless it reaches a critical level where there is a deformity. If you would like to see how I work with asymmetry when it is deforming, just look at my reconstructive photo gallery. Then, you will see when symmetry truly detracts from one’s attractiveness.

Then, Dr. Lam, why is it that I read all of these psychological studies that talk about symmetry being so important in terms of animals being attracted to other animals? (more…)

No, this does not mean that I am going to give you only a rip-off dose of Botox! Micro Botox is something that I learned about last year from a colleague in New York, who in turn learned about it in the Philippines. Essentially, micro Botox treatments require a lot of injections into the cheek area, for example, to make the pores of the skin start to shrink and the texture of the skin to start to appear better over time. I have not incorporated this Botox treatment into my practice as yet for a couple of concerns. First, it is extremely time consuming to perform. Second, there are some risks in terms of diffusion of the Botox from the cheek skin into the deeper structures like the zygomaticus muscle that could affect your speech.

That being said, I actually have been doing some thinking recently that incorporates some of the ideas from micro Botox treatments. Here are my thoughts. (more…)

Here’s my second blog entry. You may have read some scary news about recent infection rates in hospitals, surgery centers, and in the general community with a virulent bacteria called MRSA or methicillin resistant staph.aureus. I think the media has blown this thing out of proportion. However, I wanted to convey to you first that I have not seen any cases of MRSA let alone any real incidence of infections in my surgery center. Part of the reason that you should feel comfortable and confident in coming to my surgery center is that there are no other surgeons who operate in my space other than I. Further, I don’t do any body work, foot work, or GYN cases so what I do is very clean. Also, for the patients who know me, I do typically only 1 surgical case a day. At most 2 cases. That way, there really is not 5 or 10 patients moving in and out of the same room during a day and that minimizes the risk of cross contamination. Also, even though I maintain hospital privileges at Presbyterian Hospital of Plano, I do not operate there anymore (since I do not take insurance) and do not bring any patients from the hospital into my surgery center. For all of these reasons, I think I have probably one of the best shots at minimizing the possibility of an infection not to mention a more potent form of bacteria that may be present at larger hospitals and busy surgery centers. Hope this blog will alleviate some of the fear that may be unduly hyped in the media.

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I am writing my first blog from Hong Kong where I am lecturing now. I am explaining why I am making this blog. Read on…

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