In my effort to find the best filler experience for an individual, I am constantly evolving my injection filler methods and the preferred products that I use to accomplish those goals.  In the past, I was a big advocate of Restylane but of late have found a real passion for Juvederm.  Is Juvederm great for the entire face?  Absolutely not.  It tends to bleed into the surrounding areas much more than Restylane, which stays put more.  Is that a good thing then?  Well, depends.  Because I am truly designing very advanced areas that I would like to blend in more naturally with the surrounding tissues I have been liking Juvederm in specific areas where blending is more important:  outer cheeks, brows, temples, smile lines, buccal area, and anterior chin.   These are almost all the areas save the lower eyelid where I still believe Restylane is better but not ideal.  In the lower eyelid, I have found Artefill to be the best solution for someone wanting a lower-eyelid filler because I believe hyaluronic-acid based products (Restylane and Juvederm) have several drawbacks that I don’t like:  Tyndall Effect (grayish visible color), lumpiness when overfilled and when smiling, more swelling, and a loss of some of the result after a week or so since the product moves a slight bit.  These are my latest thoughts that I am sure will be refined as I continue to think about the right product in the right area for the right patient.  These biases are not meant to be absolute since obviously they tend on how one uses the product and who is performing the procedure.  These biases are mine alone and should not reflect negatively on the physician who chooses to use one product over another or on the manufacturer of a product.

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’ Injectable Facial Filler procedures or to ask Dr Lam a question please visit his Injectables and Fillers Forum.

The Outer Face:  Converting Double Concavities into Convexities

The one thing that I cannot stand is seeing a face that appears disjointed, i.e., part of the face has been over augmented relative to another.  Perhaps the two biggest problem areas that I see are the lips and the cheeks.  In fact, I have come up with the title, “Lip an Cheek Syndrome” for these malformed faces that I oftentimes see on the streets and in my conferences.  The isolated augmentation of the cheek in particular is a misunderstanding of how to enhance a face naturally.  I have come to truly see that many parts of the face must blend into the cheek to make it look natural and attractive.  In 2011, I was very focused on the buccal area (the area where if you suck in your cheeks you see it go inward, or the area just below the central anterior cheek.)  A carefully augmented buccal area can help make a face look considerably more youthful and attractive and it helps to blend the face.

This year I have been obsessed with the temple and “subzygomatic” area, which are two concavities above and below the zygomatic or cheek arch.  You can see these concavities from the frontal view, which is the most important view because that is how you see another individual when you look at him or her.  Many times, individuals believe that these concavities do not have major impact on the face’s youthfulness and attractiveness but they are very wrong.  They make a major impact on how the face appears and allows one to truly look youthful, bright and attractive.  It affects the soul of the subconscious and allows one to see that the face is beautiful.  It acts as an outside frame, if you will, and it has become a major if not the major obsession in my work this past year.  By filling in these shadow I am able to create a smooth oval arc for the face that is simply very attractive.  Using new improved microcannulas, I have been able to sculpt the face with considerable accuracy and finesse.  I have particularly liked using Artefill and Juvederm to do the trick.  As with all things, subtlety is what provides the brilliant result and differentiates it from an ugly, unattractive one.

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’ facial rejuvenation procedures or to ask Dr Lam a question please visit his facial rejuvenation forum.

Cannulas for Facial Fillers:  The Evolution of My Technique

Although I would estimate that only 1% of injectors currently use cannulas rather than standard needles to perform facial fillers, I truly believe that they have become the standard of care in my practice and I would hope the industry soon.  I have been using cannulas for injecting soft-tissue fillers like Restylane, Juvéderm, Artefill, etc. since October 2010, before which I have affectionately called “The Dark Ages”.  I have been able now to deliver better, smoother, safer, and less bruised results with cannulas than I ever could with needles.

What is a cannula?  That is perhaps what many of you are wondering.  A cannula differs from a needle in that it has a blunt end with a small side port hole through which product is infiltrated.  The standard needle, by contrast, is sharp at the end with a hole at that sharp end, as all of you know.  The true advantage of a cannula is that I can slide the cannula into areas like underneath the eye in the tear trough region and fill it without the risk of a significant bruise, especially without having what I call a “devastating bruise” that when I was using needles could rarely last 6 weeks to 3 months.  With a sharp end, the cannula simply does not lacerate or tear a vessel so long-term bruising is exceedingly rare and I cannot even remember a case of it since I switched over from needles to cannulas.

Cannulas however are very hard to use for the novice injector since they are longer and bend a lot.   A needle can be considerably easier but really offers such an inferior way of doing things that I cannot imagine going back to it.  Further, cannulas offer unparalleled safety (in the right hands).  Because the cannula does not have a sharp end, it is virtually impossible to place a cannula tip inside a vessel.  Besides limiting bruising, the cannula really should not cause a “vascular compromise”.  What this means is in the very rare case that a needle enters a major facial vessel, it can stop the blood flow to the point that there can be disastrous loss of skin tissue.  Cannulas really make this risk almost impossible.

Are all cannulas made alike?  No.  I started with Dermasculpt cannulas but found them to be too fragile to push through thicker products like Artefill and Perlane when using very small cannulas that are 27-Gauge in size.  I try never to use anything larger like a 25-Gauge cannula that could otherwise cause more tissue injury but more importantly greater discomfort.  I switched over last year to a Japanese company called TSK that allowed me to pass amazingly thicker product through a very thin cannula.  However, the one design flaw was that the TSK cannula was so thin-walled that it would bend way to easily and make it hard for me to direct the product where I wanted it.  Since June 2012, I have started using Soft-Fill cannulas that have literally blown my mind.  I can use the 27G cannula to pass thicker products through it but now the cannula wall no longer bends.  In fact, I can now use this improved cannula to work in the lower face like the smile lines etc., where simply put I could not venture into that area with the TSK. What that means to you is that your injection is far safer and major bruising is significantly reduced.  I cannot imagine my injectable practice without cannulas.

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’ facial filler procedures or to ask Dr Lam a question please visit his cosmetic injectable and fillers forum.

Fat Grafting:  A Little Everywhere

Good taste with clothing means that the items one wears are in harmony, possess style, cut well, and made of good material.  Good facial cosmetic surgery is very similar.  The products (materials) one uses can determine the outcome and certain fillers, e.g., fat, Artefill, Restylane, and Juvederm, work better in certain parts of the face.  Just like a suit that is “cut well”, a procedure must be executed technically well to look good.  The final ingredient having harmony and having style are all about the artistic sensibility of the surgeon performing the procedure, and it is why one procedure no matter if the same steps are followed look completely differently when two different surgeons perform it.

When it comes to fat transfer, the art of harmony is to understand that aging occurs in a lot of little areas rather than one big one.  Many times, individuals come to me with the desire to just have their lower eyelids rejuvenated or just to fix the tiny lines around their mouth.  What they don’t see are the small temple hollow, the cheek hollow, the areas around the mouth and buccal area, etc.  Besides wrinkles and some gravity, the key to understanding aging is the interplay of light and shadow and how much bone is exposed.  When bone is adequately covered and there is a uniformity of light and an absence of telltale shadows then the face simply looks radiant and attractive.  These little tiny changes are the key to make a face look natural, youthful, and attractive.  The overfilling of one particular area is in fact the reason why results can look absolutely fake.  A key area where I see this is in the cheek area.  There is just too much filling in that one area and people simply look fake.  Beautiful work is about filling a little bit in all the right areas to make the face look more youthful and bright.  A little bit in all the right areas goes a long 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’ fat transfer procedures or to ask Dr Lam a question please visit his face and hand rejuvenation forum.

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.