Non surgical approaches to making the face look better

Traditional cosmetic surgery relies on pulling on skin or taking fat out. Sometimes, these approaches work well on the face, think pulling on your cheeks in the mirror. Sometimes these approaches look terrible, think of all of the odd looking people you see in the media or at the mall who have had too much plastic surgery. The scary thing is that people who look so strange after surgery think that they look terrific, but that is another entry.

Starting in 80’s I saw the need for filling some faces in some places to make them look better. In the early 90’s I started fat grafting by injection. This is a reasonable approach for some people in some places and if you happen to be in the operating room. But the principles of volume replacement in the face remain the same. With the advent of injectibles like Restylane Perlane,  Juvederm, Sculptra and Radiesse  the face may be treated in the exam room without having to go to the operating room.

Why would you fill in parts of the face?
Certain areas are commonly done and frequently overdone are the lips and the nasolabial folds, the folds which go from the nose down the side of the mouth. Here are a few examples of lips and folds:

She’s 22 and beautiful.

She has a thin upper lip which was treated with one cc of restylane.

She’s in her early 60’s and complains of thin lips and bleed lines. She was treated with one cc of Juvederm, which is preferred filler for lips at this time.

This lady in her 50’s was treated with Restylane in the nasolabial folds and the lines going from the corner of the mouth downward (marionette lines). I now usually use Juvederm in the lips, pts say that it feels softer. Fillers in the lips usually last 4-6 months, though occasionally they will go for much longer. I usually use Restylane when injecting for volume as it seems to have more projection and I think it lasts longer despite what companies may say in their advertising.

Do these hurt? I hear it hurts a lot.
One of my pet peeves is that doctors don’t treat patients like they would like to be treated themselves. Some doctors routinely treat patients in a brutal way as far as pain goes. No male doctor in the world would let someone inject him without some kind of anaesthesia. The fact that women will allow is a strong indication that they are the superior sex.   I find that numbing creams don’t work well in the lips and there are technical reasons why local anaesthesia has advantages. I numb everyone for everything. It doesn’t hurt. I have tricks.

Where else can you use fillers and volume in the face? I still don’t get it.

Let’s start at the eyes. Some eyes look better if the brows and lids are filled somewhat.
Look at this area called the Tear Trough. If there is a hollow there it can be filled, making the person look a lot less tired.  This is a difficult area to do and you should make sure that your surgeon has experience at it. I find that restylane lasts 2-3 years or more in a female patient in this location.

See the deep hollows below the eyes. This area is called the “tear-trough” and  is caused by the tissue indenting and by fat bulging forward, which casts a shadow. Traditional treatment of taking out the fat works in some people but is not always necessary. She was treated with a very small volume of  Restylane which is better than Juvederm here in my opinion. In this area it lasts 2 or more years.  It is a difficult area to do with  fillers and you should be sure that the person who does it here is experienced. Fortunately with Restylane and Juvederm the filler may be dissolved with an enzyme called hyaluronidase.  In my opinion fillers like radiesse and sculptra in this location shouldn’t be used here because they cannot be corrected. 

This patient had Restylane beneath her eyes  3 and one half years before. Look at how long lasting it is in this location.

Brows and upper lids
Look at the brows in these pts, They have been hollowed out from age or from surgery, which frequently makes people look older. Taking out more skin or fat only makes them look worse. See how much better thay look with some fill.

She is in her 60’s. Her eyes have gotten hollow with age. Look how much better the eyes look with one cc of Restylane in the brows. She no longer looks hollow. This picture is two years after her injection with one cc of restylane

This very attractive patient has had her lids done and fat was removed.

This is after restylane was injected into the brow.
Which eyes look younger?

Look at this patient in her 50’s. She wanted nothing surgical done on her face.

She was treated with restylane in the brows and under the eyes.

The second picture is more than two years after the original injections.

In some patients by filling in the upper lid and brow you use up some of the extra skin. She had her upper lids done some time before, even though it looks like there is extra it is mainly crinkly skin that she needs to close her eyes with.  By filling in her brows she looks less hollow and the Restylane has smoothed out her lid skin. This is 10 months later.

In some patients the hollow at the center-inside of the orbit parallels the eyebrows when they have a look of consternation or concern. They look anxious. Like this:

See what a difference a little restylane makes in this location.   The art of plastic surgery on the face is in seeing the curves that have meaning…that project emotions or states of being…. and correcting them.  She had one cc of restylane and needs more, but look at how different the emotional expression of the eyes is.

Cheeks
One of the areas that gets hollow early on is the area just below the cheekbone. About a cc of filler on each side makes a big difference.

Jawline: 
One of the very first areas to show aging is the jowl area. This happens to people as early as the 30’s. If you fill in front of the jowl it creates an illusion of the face being much younger than it actually is. You can’t really explain this to someone; they have to see it so I usually put in a little local anaesthesia which duplicates the effect of the filler in that location. I call this a local preview and it lets the patient see exactly what the visual effect of filling there will be. If the patient doesn’t like it the local anaesthetic will just go away in 45 minutes.

Noses:
One of the best areas to use fillers in is in noses that have been operated on already and need irregularities smoothed or flattening filled. Some noses, like this person didn’t want an operation and we filled in her tip just with a little restylane. The pictures here are three years apart.

Correction of facelift deformities:
If you hadn’t noticed many people who have too much facelift surgery (either too many times or pulling too hard) look decidedly strange. They are frequently in the public eye and were done by well-known and expensive plastic surgeons. This should tell you something about well known and expensive surgeons.  The treatment should primarily be by prevention and careful enough surgery to keep this from happening, but many of these people have deformities that can be perfectly corrected by the use of some volume in the face.

Look at these examples:   

This patient had an overaggressive facelift which left her with hollow cheeks.  She was treated with fat injections and is seen several years afterwards.

This patient in her 60’s had a similar problem: an over aggressive facelift. She looked obviously facelifted and pulled before she was treated with 3 cc of Restylane.  Here she is 5 months afterward.  In my experience,  Restylane in the cheeks on a female lasts a year to a year and a half.

I have been doing this a long time. It takes a long time to be able to understand the complexities of the face. Many people spend a lifetime and never see where the problems are, just doing standard procedures.

Most surgeons just look at the face as something to be pulled and don’t understand the use of fill in the face beyond the lips and nasolabial fold. Also they make more money by doing surgery rather than solving a problem with fillers which aren’t as lucrative.   Not everyone needs an operation. On the other hand the use of fillers has become sort of a fad and everyone is doing them from GP’s to OB-GYNS. They aren’t all the same and can be done poorly or well.  

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