Thank you for your question.
You submitted several photos with your question.
And you describe the state of confusion you’re in after going to 3 facial plastic surgeons
and getting options about improving the area that involves the nasolabial folds.
And essentially you were advised to have a cheek implant, mid facelift and lower eyelid
blepharoplasty.
And you state your question as if it’s one or the other for each individual choice.
And certainly I can appreciate why you are confused as to what to do.
You also state in your question that you had Bellafill a few years ago, about 5 years earlier
and that you didn't like the result because it made your cheeks look too full when you
smiled.
Well, I can certainly share with you based on the photos you submitted my impression
of what the issues are and hopefully, it will give you some guidance that may or may not
have been clear from all the recommendations that were made.
A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon.
I have been in practice in Manhattan and Long Island for over 20 years.
It’s actually the specialty of oculofacial plastic surgery were amongst the first doctors
to introduce mid facelift in the mid to late 90s.
And certainly, helping this particular area has been a very big part of many different
specialty practices.
And I can certainly give you some ideas as to the thinking behind some of these recommendations.
So to begin with, let’s start with first the issue about the lower eyelid blepharoplasty
because I think that’s fairly straightforward.
The one photo where your face is kind of in a three quarters view, it appears that you
have puffiness under your eyes.
So I think that undergoing a lower eyelid blepharoplasty to help the puffiness is a
separate issue and not one that would address the nasolabial fold.
This lower eyelid puffiness being lower eyelid prolapse, I think from that perspective, lower
eyelid blepharoplasty is a reasonable procedure.
I would typically perform this procedure in what’s called a transconjunctival approach
doing it from the inside of the eyelids to help the puffy area.
Now when it comes to the question about cheek implants versus a mid facelift, well certainly
I think that one of the impressions that I think that every doctor has been making about
your appearance is that there appears to be lack of projection of the midface.
And so to one doctor, there is an opportunity to lift tissue and to another doctor is an
opportunity to restore volume.
Now understanding that from my perspective with the experience that I have with the concept
of face lifting, I think that in your scenario, the mid face has not dropped and therefore
I would respectfully disagree with the doctor who was recommending lifting.
As far as the choice of a cheek implant, I could tell you that, again from my impression
from your appearance that certainly midfacial volume augmentation can be performed and a
cheek implant is certainly a reasonable option.
I would also introduce to you another option which may be a choice to make before moving
forward with a procedure which is surgical and placement of an implant and this procedure
is called Structural Volumizing.
Now understanding that you had Bellafill placed in your cheek 5 years ago, the distinction
that I would help you try to make was that the Bellafill was placed where typically most
fillers are placed.
Whether it’s a filler like Radiesse or a filler in the hyaluronic acid family, Restylane
and Juvederm, it’s placed in the soft tissue of the cheek and it is a common complaint
of people especially those who have thin faces, when they get a filler placed in their cheek
which is well intended to add structure, it ends up hanging in the skin.
And when you smile, it goes upward.
Well with Structural Volumizing, we’re actually placing a long lasting filler such as Juvederm
Ultra Plus and Juvederm Voluma at the level of the bone where the structure needs enhancement.
When it’s placed at the bone level, the skin actually glides over the cheekbone.
Therefore, when you smile, the cheek doesn't look too full but rather when you are relaxed,
you look more balanced.
Now how is this beneficial to the nasolabial fold?
Well, the nasolabial fold is not always sagging or deepened because of overlap but rather,
it is a reflection often times of the balance between the cheek projection and the lower
third of the face.
So a lot of times when we place volume in the cheek, the nasolabial fold doesn't look
so deep.
So this is more of truly the art of balance and creating what is harmony in the facial
appearance.
So my approach to a situation like yours would be to consider doing a lower eyelid blepharoplasty
and volume augmentation of the cheek with Structural Volumizing.
This way you reduce the puffiness which takes away the tired looking eyes and improve the
volume of the midface.
Further, it’s less invasive.
As far as the choice of cheek implant, I can tell you that certainly the healing time for
the cheek implant and the stabilization of that appearance takes much longer than doing
an injectable.
When you do an injectable like Structural Volumizing, people look pretty good immediately
and we see our patients in follow-up 2 weeks later.
And further, for someone who has a relatively thin face and relatively thin skin, it is
also important to try to do something where the skin doesn't show the outline of the implant.
Now generally speaking, that’s not much of an issue when the implant is placed.
But I caution people to understand that as you get older, the soft tissue and skin thins
and that issue can become problematic later on.
Again, I would say that there are probably equivalent options of doing fillers compared
to cheek implants.
But I would say that reflective of my own practice where patients want to have enhancement
of the cheek area but often are averse to a facial implant, they love the idea of doing
Structural Volumizing.
Especially when you’re using a long lasting filler which can essentially be sculpted and
placed very precisely in a way that I would argue is very different from placement of
a facial implant.
There is nuance in asymmetry in everyone’s face that with injectables, you can control
much more readily and in a real time without the confusion that occurs when there is swelling
from anesthetic.
So I think that this is another opinion that might be worthwhile considering in determining
what’s optimal for your facial appearance.
I think that you are seeing what is truly the art of medicine and that it is always
going to be the case that doctors will look at the same patient with a different set of
experience or different perspectives based on their own experience and their own aesthetics.
And I think this is just why you can’t think of anything as being a commodity or equivalence
between doctors.
And so I think that if you’re not quite sure, get additional opinions.
And since it wasn't discussed with you by any of the doctors so far, the idea of lower
eyelid blepharoplasty with Structural Volumizing is worth discussing with another doctor so
you can get additional opinion.
So I hope that was helpful, I wish you the best of luck and thank you for your question.