In the aesthetic industry, we have been fixated on two principle manifestations of aging: wrinkles and gravity. We address wrinkles through a variety of methods including laser and light technology, dermabrasion and microdermabrasion, chemical peels of various strengths and types, botulinum toxin, and daily skin care regimens. Gravity has been the traditional territory of plastic surgeons that lift and pull until the sagging skin and muscles return to their desired youthful position. The problem with this paradigm is that it fails to incorporate one vital element in the aging process, the loss of soft-tissue volume.
Simply put, we don’t just sag, we deflate. An analogy that I like to use so that my prospective patients understand what I am talking about is that of the transformation of a youthful grape into a raisin. In youth, we are a luscious and full grape. As we age, we lose skin turgor and volume and begin slowly and inexorably to become a raisin. Unfortunately, just cutting away, pulling, and lifting tissues only makes that raisin into a pea. Well, a pea looks nothing like a grape! That is why we see so many people walking around town that look tighter but nothing like they used to look nor younger for that matter. Instead, what we need to do to achieve a youthful countenance that preserves rather than distorts one’s identity is to reinflate that collapsed raisin back into a youthful grape. This simplified metaphor is not meant to say that we don’t need skin-care therapies or lifting procedures but that volume loss is one essential component of the aging process that is almost always overlooked; and in my opinion is a cornerstone toward making someone more youthful in appearance.
The first order of business is to recalibrate our thinking of what constitutes beauty and youth. Most women tend to evaluate their faces using 8x or 10x magnifying mirrors with bright illumination, studying every minor flaw and imperfection that could be the reason for why they may look more tired and less youthful. In reality, no one sees these minor flaws except for the individual herself. What I try to do is help women evaluate themselves with standard overhead lighting at five to 10 feet away first, i.e., how other bystanders would see them. From this vantage, we can begin to ascertain what is truly important to achieve profound rejuvenation. At five to 10 feet away, what is instantly recognizable for even the most casual bystander is the person’s volume and shape. Surprisingly, volume and shape is what can define the key elements of youth even more than any other aspect.
A youthful face is typically heart shaped or triangular, which is also a very feminizing attribute. As the face matures, the cheeks, the eyes, and the chin deflate, and the jowls along the jawline become more prominent. This transformation of a triangle into a square signifies aging, and volume restoration of the volume depleted areas helps to rejuvenate the face to a marked degree. Is a facelift then still necessary? Absolutely. When the jowls and neck begin to sag, volume restoration just won’t cut it. However, before the neck begins to sag in the late 40s into the 50s, we begin to lose facial fullness even in our late 20s. We continue to lose volume around the eyes and become increasingly more sunken in appearance every decade that transpires. If you contemplate for a brief moment how we distinguish a 15-year-old, from a 25-year-old, from a 35-year-old face almost instantaneously even before we notice subtleties like mannerisms and styles of dress, you will remark on the importance that volume plays in our perception. As a teenager we have a lot of “baby fat”, which still looks quite full in our 20s. In fact, some women actually like the slightly more sculpted appearance that becomes evident in their early 30s. However, this slightly sculpted appearance becomes seemingly sunken looking in the late 30s and into the 40s making someone appear not only increasingly older but simply more tired.
The most important aspect of the face that must be addressed with volume restoration is the area around the eyes. The hollowness that develops around the eyes is the first sign of aging that occurs even in one’s 30s. This hollowness imparts a tired look that persists irrespective of one’s lifestyle or amount of sleep the night prior. Unfortunately, almost all methods of surgical eyelid rejuvenation are predicated upon tissue removal and cutting away further the hollowness that already exists, most often exacerbating rather than ameliorating the aged and tired look that we have. Although reduction of an “eyebag” or removal of some extra skin from the upper eyelids can be helpful in older individuals, volume restoration is oftentimes all that is needed for a younger individual seeking rejuvenation. If you review your old photographs, you will see that volume loss is most often the principal and earliest sign of aging. Every year and every decade that goes by, we lose facial fullness. Looking at the true textbooks that define our societal concept of beauty, namely Glamour, Allure, and Vogue, we can see that the ideal of a youthful face is fullness, not fatness, but fullness, around the eyes, the cheeks, and the chin. In fact, the upper eyelid and brow are so full in youth as oftentimes to cover part of the eye. Unfortunately, most of our rejuvenation efforts are focused on cutting away skin and lifting the brows higher, which can make someone look entirely different from the way he or she appeared in youth. When I first propose the idea that someone needs more fullness along the upper eyelid, the typical response is “No way, my eyes are already too heavy!” But what is improperly conceived is that the underlying tissue around the eyes actually deflates causing the skin to simply hang over the eyes as we age. Youthful eyes do not seem to hang or drape because they are in fact full and round. Just reviewing one’s own old photographs will prove the veracity of this statement. The second concern that many individuals express is “Please don’t make me look fatter!” In fact, facial volume enhancement in the right areas can make someone actually look less fat. The reason behind this observation is that a person looks fat when the jawline and neck are full, which unfortunately becomes more evident as we age. However, volume restoration around the eyes, cheeks, and chin not only makes someone look younger, it also de-emphasizes the fullness along the jawline and neck and thereby has the potential to make someone even look slimmer. That is why simply gaining weight won’t work because most of the fat resides in areas of the face that only makes someone look fat not young. In fact, we can tell an older, overweight individual from someone younger and heavier set because a younger individual is uniformly fuller, whereas someone older has pockets of fullness in all the wrong places and pockets of emptiness around the eyes, parts of the cheeks and chin where fullness defines youth.
How then do we accomplish volume restoration to make someone younger looking? In short, facial fat grafting, i.e., fat taken from the body and placed back into the deficient areas of the face. The process for doing so is entirely incisionless (for both the body and the face) and does not require any bandages anywhere or suture removal afterwards. Facial fat grafting facilitates profound facial rejuvenation in a natural way, even correcting individuals who have been over pulled and tissue depleted from previous surgery. A judicious combination of some conservative lifting procedures, skin therapies, and volume restoration can provide a harmonious and balanced rejuvenation of the face that is, of paramount importance, seamlessly natural and further that preserves one’s identity. Older techniques for fat grafting failed because the results simply did not last. With newer methods of gentle fat harvesting, processing, and placement, results are essentially permanent with the obvious caveat that overtime facial aging will continue ineluctably. Volume enhancement with fat grafting is like setting back the clock, at times five years but more often 10 to 20 years back in time. What is exciting is that the rejuvenation can oftentimes continue to improve over a period of five to 10 years following fat grafting. With the latest evidence, we are now seeing ongoing improvement in skin tone and texture, reduction of scars and wrinkles, and shrinking of pores and other skin pathologies in any area under which fat was transferred. This miracle may not happen for everyone undergoing fat transfer but is an exciting proposition that I have personally witnessed myself. Fat grafting combined with other methods of facial rejuvenation and then maintained with the support of an aesthetician will supplant the old thinking that has dominated established circles of how we perceive what is youthful and how we attain that youthful look.
Dr. Lam is a double board-certified facial plastic surgeon who has limited his practice to facial cosmetic surgery and hair restoration. He is the author of three textbooks, Comprehensive Facial Rejuvenation, Cosmetic Surgery of the Asian Face, and Complementary Fat Grafting. He has also written over 100 book chapters and scientific articles and has lectured over a 100 times nationally and internationally. He is the winner of the 2002 John Orlando Roe Prize awarded to him by the American Academy of Facial Plastic & Reconstructive Surgery for his basic science research into skin rejuvenation. He is the owner and director of the 27,000 square-foot Willow Bend Wellness Center in Plano, Texas. For more information about Dr. Lam, please visit www.lamfacialplastics.com.
