Val Lambros

Hyaluronic Acid Injections for Correction of the Tear Trough Deformity

Background: The tear trough, though small in physical dimensions, sits at the perceptual epicenter of the face. Because small changes here make large changes in how other people interpret one’s state of being, it would be beneficial to have a simple way of addressing the area. Despite the complexities of cause, the solution is to level the hollow and smooth the junction between the lid and the cheek. Methods: Hyaluronic acid injections are used to address the tear trough deformity. Very small quantities, 0.2 to 0.4 cc, are used per side, and the placement is in the orbicularis oculi muscle or at the periosteum. The key is to inject deep to the dermis and to massage the injected area smooth. Results: All patients were improved roughly in proportion to their skin quality. The best patients for the treatment are those with young, thick skin and a definite hollow. The duration of the effect is often more than 1 year at this location. Minor bruising and irregularities were self-limiting or treated with light massage. Large overfills or irregularities are correctable with injection of hyaluronidase. Conclusions: Tear trough injection with hyaluronic acid products is relatively simple, effective, and safe, and can offer significant improvement in this difficult area. It can be performed for primary deformities or to improve a surgical result.

Models of facial aging and implications for treatment.

In this article, which focuses on concepts rather than techniques, the author emphasizes that the best predictor of a good facelift outcome is an already attractive face that has good enough tissue quality to maintain a result past the swelling stage. The author notes that too often, surgeons gravitate toward a particular facial support technique and use it all the time, to often unsatisfactory results. He singles out different areas (the brows, the tear trough, the cheeks, and so forth) and shows how the addition of volume may give results better than traditional methods. As he points out, a less limited and ritualistic approach to the face seems to be how cosmetic surgery is evolving; all factors that might make a face better are reasonable to entertain.

Treatment of Hyaluronic Acid Filler–Induced Impending Necrosis With Hyaluronidase: Consensus Recommendations

Injection-induced necrosis is a rare but dreaded consequence of soft tissue augmentation with filler agents. It usually occurs as a result of injection of filler directly into an artery, but can also result from compression or injury. We provide recommendations on the use of hyaluronidase when vascular compromise is suspected. Consensus recommendations were developed by thorough discussion and debate amongst the authors at a roundtable meeting on Wednesday June 18, 2014 in Las Vegas, NV as well as significant ongoing written and verbal communications amongst the authors in the months prior to journal submission. All authors are experienced tertiary care providers. A prompt diagnosis and immediate treatment with high doses of hyaluronidase (at least 200 U) are critically important. It is not felt necessary to do a skin test in cases of impending necrosis. Some experts recommend dilution with saline to increase dispersion or lidocaine to aid vasodilation. Additional hyaluronidase should be injected if improvement is not seen within 60 minutes. A warm compress also aids vasodilation, and massage has been shown to help. Some experts advocate the use of nitroglycerin paste, although this area is controversial. Introducing an oral aspirin regimen should help prevent further clot formation due to vascular compromise. In our experience, patients who are diagnosed promptly and treated within 24 hours will usually have the best outcomes.

Rhinoplasty : the light reflexes

The physical characteristics of the light reflexes of the nasal tip are defined in large part by the studio lighting configuration. By varying the lighting configuration, it is possible to alter the light reflexes as regards their number, distance apart, symmetry, and size. For the plastic surgeon, the quarter light system of the medical photographer has definite advantages over the key light system of the portrait photographer. The quarter light system consists of two lights of equal intensity with symmetrical angles of incidence placed at 45 degrees to the camera subject axis. Measuring changes in the light reflexes as a method of determining the efficacy of surgical techniques is valid under very controlled conditions.

Fat injection for aesthetic facial rejuvenation

Val Lambros, MD, Santa Ana, CA , is a board-certified plastic surgeon. I believe that early facial aging is manifested by ptosis secondary to volume loss. Moreover, this volume loss creates changes in facial shape that conventional skin tightening procedures either do not address or make worse. Definition is achieved largely at the expense of soft tissue fill. For example, the eyebrows of young persons typically lie low and flat. The soft tissue over the entire superior third of the face is full. This fullness, with its large radius of anterior curvature, generates a reflective convexity. As make-up artists know, brighter features appear larger or closer and dark features appear smaller or receding. In youth, these shape and reflective characteristics give the impression of high-sitting eyebrows. In photographic images, the younger face appears to have a larger circumference at brow level than it does later in life. This feature contributes significantly to the top-heavy or heart-shaped configuration of the younger face. As the brow “deflates,” the skin settles against the upper lids and the eyebrow becomes foreshortened as it wraps around a smaller circumference. The brow lift elevates the brows by traction, but no corresponding changes in width occur. When the operative plane traverses temporal fat, frequently the result is local fat atrophy and narrowing of the face. Whereas some patients desire a youthful appearance, others also desire improvement in the aesthetics of their facial features. Facial implants can and have been used to improve both aging and developmental characteristics. However, the effects of these prostheses are localized, and size and shape options are limited. These devices are also associated with problems common …

The Plunging Tip: Analysis and Surgical Treatment

BACKGROUND The plunging tip refers to a deformity in which the nasal tip plunges on smiling. OBJECTIVES To understand the plunging tip, we have updated our series of 25 cosmetic rhinoplasty patients who complained of a plunging tip with a focus on the anatomic changes of the nose on smiling. METHODS Twenty-five female cosmetic primary rhinoplasty patients who complained of a nasal tip that plunged on smiling were photographed in static and smiling sequences preoperatively and one year postoperatively. Different nasal angles and landmarks were measured to study changes of the nose. RESULTS Pre- and postoperatively, there was no statistically significant difference in the changes in the nasal angles and landmarks on smiling. At one year postoperatively, 2 patients had nasal tips that continued to plunge on smiling; these patients had requested no increase in tip rotation preoperatively. Only 2 patients had columellar base muscles cut for reasons other than treating the plunging tip. CONCLUSIONS This is the first prospective, evidence-based study on the plunging tip. Measurements of the nose before and after surgery demonstrate that the nasal tip moves less than 1 mm and 1 degree on smiling. Treatment of the plunging tip illusion was effective by increasing the tip angle in repose. No columellar base muscles were cut to treat the plunging tip, and the nose moved just as much after surgery as before. Cutting or manipulating muscles is not necessary for treatment. To treat the illusion, the surgeon must increase tip rotation.

Discussion: Longevity of SMAS Facial Rejuvenation and Support

R of this article will already know that people have a universe of reasons for having a face lift. In practice, one commonly notes not only unhappiness with the mirror but also the loss of a spouse or the anticipation of finding one: the patient’s social milieu and group dynamics (face lifts as a rite of passage). Some people perceive an advantage in finding or maintaining employment, all reasons that may have little to do with the face itself but with life conditions of the person requesting the procedure. In other words, subjectivity and life forces are major factors, and the decision to have such a procedure may have little relationship to how the patient actually appears. Biological factors such as skin quality, facial weight, and the age at which the initial procedure is performed significantly affect both the quality of the initial result and its duration, and the same cultural and personal forces remain. There is no distinct tissue endpoint for undergoing a secondary lift, just as there is no distinct biological point at which a primary lift becomes “necessary.” With so many factors to be considered, the longevity of any type of face lift remains a difficult question to answer with any certainty. Focusing specifically on the longevity of a twolayer superficial musculoaponeurotic system (SMAS) face lift, Dr. Sundine et al. have retrospectively examined their personal experience involving 42 patients operated on previously in their practice who later underwent a secondary procedure. No mention is made of the time intervals of secondary lifts where the primary procedures were performed by other surgeons. They note that the average duration between primary and secondary procedures was 11.9 years, with most of their patients undergoing the initial procedure at approximately 50 years of age, followed by a secondary procedure in their early sixties. Regarding the technical approach to the secondary patients, the authors note that redissection of the SMAS was usually possible, with the SMAS flap reelevated in over 90 percent of secondary cases, although they noted a 11.9 percent paresis rate. They also describe a group of patients in which the postoperative result exhibits shorter duration, and found that approximately 20 percent of their patients required reoperation within 5 years. This article highlights two major issues regarding patients undergoing facial cosmetic surgery: longevity of result and the technical considerations in performing a successful secondary SMAS face lift. In our combined experience, we have noticed that there is a distribution of results and duration of effect when essentially the same SMAS dissection and fixation technique are used on different patients. There is a large group of patients who undergo a face lift procedure and never need another, although their necks may become a little untidy over the years. These people usually have snug, “good” skin already without much facial fat. Experienced surgeons know very quickly with a look and tug on the skin who will obtain a good result. With the same technique, patients with different configurations of facial fat, patterns of animation, and skin and bone structure do not do nearly as well. These faces do not respond as predicted to the mechanics of the procedure. We think that the main determinant of longevity of what is generally considered to be a pleasing result is not the technique (within limits) but on whom the procedure is performed. As we have observed, face lifts work best in the people who need them the least. Although the authors attribute the subgroup of patients exhibiting early relapse to poor skin quality and other environmental factors, it is apparent from their examples that patient selection itself is a major factor in longevity of result. These are not anomalies of face-lift surgery but typical of results in patients with certain types of faces and necks.

Commentary on: The Role of Gravity in Periorbital and Midfacial Aging

Mally et al1 have examined subjects in an upright and supine position, smiling and in repose. Observing that many of the signs of aging—cheek flattening, prominent nasolabial folds, malar bags, tear troughs, and steatoblepharon—were reduced by lying supine (recumbent) and smiling ( P = .0001), they conclude that the effects of gravity must therefore have caused these aging signs. They contend that because altering the direction of gravity’s pull by 90 (not 180) degrees makes the face look improved, the force of gravity must have created these changes of aging. If the question at hand is the effect of gravity and its reversal on the soft tissues of the midface, then one would expect to compare the upright face with the upside-down face. If so, there is a clear gravitational opposite, a model that might shed some light or at least some informed discussion on the question. By placing the patient in a recumbent position, the force of gravity pulls posteriorly on the face. This is an altogether different proposition. The soft tissues of the face are quite mobile2; a finger can push the skin of the face in ovals of various sizes, regardless of age. In an upright position, the face generally sits at its lowest limits of excursion, except for over the jowl, where there might be a few millimeters of give. When recumbent, the soft tissues slide posteriorly, much as a breast will slump laterally when supine.3 It is no accident that the authors found that the smile as well as recumbency had similar effects on the face. By the vagaries of evolution, the smile muscles have …

Discussion: Quantitative Evaluation of Volume Augmentation in the Tear Trough with a Hyaluronic Acid-Based Filler: A Three-Dimensional Analysis

T is no part of the face that conveys as much negative perceptual information in such a small area as the tear trough. Its presence can make one appear tired, dissipated, haggard, unhealthy, and worse. The tear trough is usually described as the medial part of the hollow between the lower lid and cheek. It may extend down the face as the nasojugal crease and also continue laterally, where it circles the lower lid, rising to the level of the bony orbital rim by the lateral canthus. This latter border is inconsistently named but is sometimes called the orbitcheek, or orbitomalar crease. As a depression that separates the lid from the cheek, it also fares well with injection, although that was not studied here. A few sets of factors create the tear trough: one is the difference in skin texture, thickness, and color present where the thin lid skin joins the thicker cheek. Sometimes, this light-dark, textural border alone appears like a tear trough but without an indentation that can be filled. Injections do not improve this group. Another factor is the shadow formed by the indentation of the tear trough itself and the overlying expansion of lower lid fat. This latter group will be improved by injecting the hollow, filling the indentation, and leveling the lid-cheek junction. Patients need to be told that color and texture differences will persist. As the tear tough and orbitomalar crease become more prominent with age, they appear to descend; however, longitudinal observation of faces shows that they are remarkably constant in position.1 Because hyaluronic fillers are mainly (and unimaginatively) used in the lips and nasolabial folds, clinicians have assumed that the duration of the products in these locations is a constant defined by their chemistry. Experience across the face shows that duration of hyaluronic products varies widely, depending on their site of placement.2,3 Although in the lips and nasolabial folds, duration varies from months to 1 year, visible effects of up to 3 years in the tear trough, temples, brow, and nasal tip have been documented. It seems reasonable to ascribe this difference in longevity to animation and motion; at least there is an association. We have not seen duration past 3 years, which may represent the biological longevity of this particular product. This study, though conducted with a small number of patients, corroborates these findings numerically, with use of the three-dimensional camera. These are remarkable instruments, here showing resolution of a few tenths of a cubic centimeter of volume difference in the face over time. The authors demonstrate the slow decay rate and persistence of product, in this case Restylane (Medicis Aesthetics, Scottsdale, Ariz.), to the end of the study period, along with continued clinical improvement. They make a number of other pertinent observations that will be familiar to clinicians performing injections in this area. I find that injecting product onto the periosteum is probably the technique of choice, at least in the medial tear trough. Duration and effect of volume with hyaluronic acids seem to be less lasting in men. It would be interesting to see what the three-dimensional camera shows in this population. Everyone who deals with the face and perceptions of it knows that patients forget how they used to appear, sometimes with shocking rapidity, leading some to think the effect has worn off before it actually has. As the authors observe, photographing the tear trough is sometimes difficult. By moving remote lights around or by bouncing the light of an on-camera flash from

Three-dimensional Facial Averaging: A Tool for Understanding Facial Aging.

Summary: The progression of facial shape with aging is the subject of various theories and assumptions but remains poorly understood. The authors have used the unique capabilities of the three-dimensional camera to average the faces of large numbers of subjects to understand this complex process. What the authors present here is a technique of analysis rather than detailed results.