Facial Rejuvenation Tutorial

Facial rejuvenation is a very broad topic that encompasses everything from wrinkles, effects of gravity, volume loss, volume gain, eyebags, etc. This tutorial will not address all the myriad manifestations of the aging face but help espouse a unified philosophy of Dr. Lam’s toward how the face ages and how to achieve a global yet natural rejuvenation.

In fact, certain elements of the aging face will be expressly left out. Anything to do with wrinkles, skin folds, and poor skin texture and tone will be covered more appropriately in the Skin Rejuvenation and BOTOX ®Tutorials. Why leave skin rejuvenation out of this section? For two reasons, first this section is already detailed enough and it would be easier to address the aging of the skin as a separate topic, especially considering the number of treatments that are available today including BOTOX ®, injectable fillers, plasma resurfacing, PIXEL microfractionated technology, etc. The second reason to leave out skin rejuvenation is to focus the attention on surgical rather than non-surgical treatments for the aging face, the latter of which is covered instead in the Skin Rejuvenation and BOTOX ® Tutorials. Before beginning, remember that surgical options today are more minimally invasive than ever and in some cases are entirely incisionless. Grouping all of the surgical options together rather than individually listing each technique as presented in the main page for facial rejuvenation is intended to facilitate a global perspective toward the aging process.

Let’s begin with an understanding of what Dr. Lam considers the most important attributes of facial rejuvenation, namely, establishing a frame to the eye and achieving a balanced, harmonious and youthful volume and shape to the face.

Framing the Eye

The eyes are perhaps the most important area to rejuvenate, as they are the target of attention during almost all conversation. If the eyes still look tired after a facial rejuvenation procedure, then the surgical endeavor can be counted as a failure. Unfortunately, most kinds of eyelid rejuvenation can make someone look totally different from who he or she was in the past or even make that person look older afterwards. This is a real problem. In order to understand how Dr. Lam approaches eyelid rejuvenation, you must understand his concept of framing the eye.

Most eyelid rejuvenation procedures like browlifting, and upper-eyelid skin and fat removal (upper blepharoplasty), and lower-eyelid skin and fat removal (lower blepharoplasty) actually subtract or destroy the frame around the eye, making someone look worse, different, or unnatural. Dr. Lam frequently must undo the very “done look” that is prevalent after traditional plastic surgery. Removing the stigma of an overly lifted and hollowed face is unfortunately a very common procedure for Dr. Lam.

This Hispanic woman underwent browlift and upper and lower eyelid cosmetic surgery by another plastic surgeon in Dallas, leaving her feeling that her identity was taken away from her and that she looked older and worse than before. Dr. Lam began the consultation process with her by evaluating carefully her old photographs of herself to see where her identity was so that he could restore her identity. She is shown 14 months after Dr. Lam’s fat grafting procedure that helped restore the lost frame around the eye.

The reason for this outcome is the failure of almost all plastic surgeons to understand what constitutes a youthful eyelid shape and contour. Cutting and lifting procedures are oftentimes unnecessary and can lead to unfavorable outcomes. The first place to begin to understand what makes a young face look young is in three places:

  • look at your old photographs
  • look at your chiildren’s faces
  • look at other young faces, especially ideals of youth that are found in magazines like Glamour, Allure, and Vogue

When you come in for your consultation with Dr. Lam it is a good idea to bring in representative photographs of yourself when you were younger from every decade of your life. Remember that Dr. Lam is not trying to suggest that if you bring in a photograph of yourself at 30 years of age that he can make you look that age and in many cases people don’t even want that at all. However, starting with your old photographs will help you understand what you used to look like and how Dr. Lam can make you look closer to who you were (rather than less like yourself). This is a very different approach compared with any other plastic surgeon.

Let’s study youthful and vibrant eyes that are found in photographs of attractive models.

As you can see in these models of youth, they all have a fully padded and rounded brow contour not an elevated and skeletonized eyelid shape that would arise from browlifting and upper eyelid procedures alone. The reason that one’s upper eyelid starts to appear more tired looking as we age is the brow and upper eyelid actually become deflated over time and then hang and droop. Occasionally, some extra skin of the upper eyelid and some lower eyelid fat need to be removed to attain the best results but almost always in conjunction with adding the volume back around the eyes. Dr. Lam likes to say whatever he takes away he will put back in good measure. Without doing so, the eye can be over skeletonized and actually appear older and also make you look different afterward. The best way to understand the changes that have occurred in your eyelid area is to carefully study your old photographs and bring them in for your consultation so that you can review them with Dr. Lam. Oftentimes in one’s late 30’s, you may begin to look slightly tired and you can’t figure it out. Usually, but not always, this change in appearance is due to slight loss of volume around the eyes, which fat grafting can restore. You oftentimes do not need skin or fat removal until your late 40’s and sometimes never. A consultation with Dr. Lam will better help you understand what would be the best treatment in your case.

This woman shows quite advanced aging with significant volume loss around her eyes. Would traditional browlift and skin and fat removal work for her? Of course not, there is no brow to lift, no skin left, and no fat at all. This extreme case of facial aging helps one to understand that facial fat loss around the eyes is the principal mechanism for the aging process for the area around the eyes and cheek.

This woman came to Dr. Lam for eyelid rejuvenation. Although at first glance, she appears to require a browlift and upper-eyelid skin removal, all she had was fat grafting around the eyes and removal of her eyebags, both of which were entirely incisionless procedures.

In addition, as Dr. Lam photographs his patients without flash photography, you can observe each patient as you would see that individual in a social environment, i.e., with only overhead lighting. If you can see, there is tremendous brightness to the face afterwards that not only makes the face look rested but also significantly younger in appearance.

Volume and Shape: Inverting the Triangle

Too often, women envision the world through the myopic lens of an 8x or 10x magnifying mirror with bright illumination and at a distance of only 2 to 3 inches. Why? Because that is the way most women put on makeup. By doing so, women oftentimes may see things in a distorted way that the rest of the world (men and women included) do not observe in you at social distances and encounters.

The primary objective in understanding what fundamentally defines the aging process is not so much the fine wrinkles and lines (all of which Dr. Lam can manage, see the Skin Rejuvenation Tutorial) but the overall shape and volume of your face. In youth, we notice a very full face, almost round and baby like, hence the term “baby fat”. In fact, many women, in particular, do not care for the way their faces appear in their twenties because they may deem their face too fat and round even though it is a very youthful look. Some women begin to like their faces more in their early thirties when they lose some of this “baby fat” and begin to develop a leaner, more sculpted look. Unfortunately, in one’s late 30’s and beyond, the face begins to lose even more fat around the eyes in particular to make the face look overly gaunt and tired looking.

With further aging into the forties and beyond, oftentimes we don’t only lose volume around the eyes to make us sag but we begin to gain volume in the lower half of the face, further detracting our attention from the beauty and allure of one’s eyes to the heavier jawline. As we pass into our late forties and early fifties, we now not only have further hollowing of our eyes, and volume (fat) gain around our lower cheek and jawline but we now begin to suffer from the signs of gravity with our neck becoming looser and hanging.

Let’s take a step back and evaluate the aging process again. In our thirties, we begin to lose volume around the eyes. In youth, we have a more youthful triangle in which the eyes are lusciously framed with fat and our anterior (front) chin is padded with fat. Along with this volume, there is tremendous “luminosity”, i.e., light that bounces off our brow, cheek, and chin that defines a youthful face. As we get older this triangle slowly inverts so that we have a fuller outer jowl and jawline and we lose volume around the eyes. Again, our attention is diverted to the neckline. As gravity also adds to the effects of aging, we have a greater degree of fullness in our neck and jawline that pulls even more of our attention away from the eyes. The inversion of a triangle is one of the principal changes to the face as we get older. By restoring a youthful triangle with the apex at the chin, we recreate a youthful face that is beautiful and alluring.

This woman underwent a facelift to remove the heaviness of the jawline and neck along with facial fat grafting in order to invert the triangle back to a youthful heart-shaped face. Removing the heaviness of the lower face through liposuction, microliposuction and a face and neck lift in combination with restoring fullness into the cheeks, around the eyes and frontal jawline can truly make the face appear more youthful and invert the triangle back to a youthful shape.

The myth in thinking that fat grafting makes someone appear fatter is simply that, a myth. What makes someone appear heavier is the lower cheek and jawline that become heavier. In fact, Dr. Lam oftentimes combines selective microliposuction to improve these heavier areas along with re-establishing the hallmarks of a youthful-shaped face. This woman underwent facial fat grafting and appears slimmer afterward and also has her triangle inverted back to the ideal heart shaped face.

Another important attribute of a young face is that there are no transition zones between various parts of the face. With an older face, you can see where the eyelid transitions into the cheek bone, which then transitions into the cheek, and then into the jawline. In a youthful face, the face appears very bright due to the fullness of the face in all the right places and there are no transition zones between the lower eyelid, the upper cheek, lower cheek, and jawline. This individual who has undergone prior plastic surgery elsewhere does not have a rejuvenated appearance and may even look slightly “done”. Dr. Lam reunited all the parts of the face with facial fat grafting and now he has a seamlessly undetectable rejuvenation of his face.

If we are trying to achieve that heart-shaped face, do cheek and chin implants work then? The answer is simply no. As you can see in the woman below who had cheek and chin implants along with a facelift by another plastic surgeon, she simply does not appear rejuvenated. In fact, cheek implants can cause the lower eyelid to appear even hollower and the eye to look even more tired. As you can see, Dr. Lam’s fat grafting helped to blend all of the areas of the face so that no transition zones exist anymore between the lower eyelid, the cheek, and the jawline. As a result, the patient looks refreshed, feminine, younger and more balanced.

It is so very confusing nowadays with the incredible number of procedures that someone can choose from including the wide range of surgical and non-surgical options that continue to change and increase each month. Dr. Lam has put together this very simplified chart, “the Rejuvenation Procedure Timetable” to help guide your understanding. People age differently based on varying amount of sun exposure, lifestyle, genetics, race, and gender. For all of these reasons, this simplified timetable is not in any way meant to be thought of as absolute but instead as a framework with which to think about the evolution of the aging process. As mentioned, non-surgical options are discussed in the Skin Rejuvenation tutorial.

Using Old Photographs: Preserving Identity

The three concerns that patients express when coming to Dr. Lam regarding plastic surgery are as follows:

  1. Will I look different?
  2. Will I look surgical?
  3. Are there large incisions?

Here are the answers: As mentioned, Dr. Lam uses old photographs to help establish mutual dialogue with you as to how you used to look so that you will not look “different” afterwards. In fact, a good percentage of his work is correcting the over hollowing and lifting of other plastic surgeons. In addition, tiny to no incisions are used for his procedure. For example, fat transfer is entirely incisionless. Dr. Lam’s neck lift is performed entirely through a 3 cm incision to achieve profound improvement in the neck contour without a facelift. Dr. Lam’s facelift helps improve the jawline contour with incisions that are about a third the length of traditional facelift incisions without the long recovery or the risk of hair loss.

Here are some examples of patients who exhibit the inversion of the triangle and in whom Dr. Lam corrected with a combination of procedures to restore a youthful look that entirely matches their former identity.

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