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

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

Like the upper eyelid, I find myself performing many more fat transfers to correct the aging process than traditional eyelid surgery.  Further, if I perform a traditional lower-eyelid procedure I will almost always use some fat transferred to improve the result.  In fact, I look at traditional eyelid surgery as a complement to fat transfer, rather than the other way around.

There are two principal ways to manage the lower eyelid traditionally, either a skin-muscle procedure in which there is an external incision or through what is known as a transconjunctival approach that has no skin incision.  I prefer the latter approach not to limit the risk of scarring, which is pretty minimal, but to avoid changing the shape and contour of the lower eyelid.  When surgeons use a skin-muscle flap, they must tack the suture to the lining of the bone.  When that occurs, there can be slight inaccuracy or change during the healing process such that the canthus (where the upper eyelid meets the lower eyelid) can be altered so the person does not look the same or worse yet does not look natural.  For this reason, I almost never make an incision in the lower eyelid skin if I can avoid it.

I use the analogy of the typical eyebags as “rocks” that appear only when the tide (fat level) is low and so the way to manage the eyebag is to refill the tide (fat) to a higher level to cover it up.  This works in about 90% of individuals.  At times however the eyebag is so prominent that you simply cannot cover it up with fat.  In these cases, which are less than 10% of the time, I have to remove some fat at the same time that I add it below the existing fat.  This combination of reducing the rocks and increasing the tide can help effect the most favorable desired change for a smoother result in the lower eyelids.

I have been asked though what about the wrinkles?  That is a matter for neurotoxin (Botox) and laser skin resurfacing to help manage the aging of the skin.  I believe cutting away wrinkles surgically simply does not work and can contribute to the problem mentioned above of changing the eyelid shape, which is a terrible thing.

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.