Cheek Augmentation

It has always been my impression that a good looking, balanced face is more square than oval. This necessitates having well developed cheeks and angles to the jaw. For a face to look more feminine, the cheeks are stronger than the angles. And vice versa for a face to be more masculine. To this end, we usually augment the cheeks with either the person’s own fat, injectable fillers or synthetic cheek implants. The implants I use are made of silicone and are screwed to the cheekbone with a tiny titanium steel screw. This ensures that stability and symmetry will be maintained and not change over time. The approach is under the upper lip, and either a malar implant is used to augment the cheekbone area or a combined implant is used to augment both the cheekbone and sub-cheekbone areas.

Cheek augmentation (before & after)

Browlift in the MtF TS patient

The female eyebrow is arched compared to the flat eyebrow in the male. The ends of the eyebrow (the club and the tail) are at the same level, and the highpoint of the arch is between the outside of the iris and the corner of the eye. Since many MtF TS patients have their supra-orbital ridges reduced, the eyebrows can be elevated at the same time by pulling the forehead skin upward in this open approach. On the other hand, if brow bossing is not an issue, endoscopic (closed) browlifting or even brow elevation through an upper eyelid incision can be performed. This latter technique would be a good approach if upper eyelid surgery were also being performed and most of the elevation that was needed was on the outside or lateral aspect of the eyebrow without significant drooping of the inside or medial aspect of the eyebrow.

Browlift (before & after)

THE VERTICAL FACELIFT IN BEVERLY HILLS

Facelifts go by many names—some technical and some not-so-technical. There is the subcutaneous facelift, the SMAS facelift, the deep-plane facelift, the composite facelift, the MACS facelift, the mini-facelift, the mid-facelift, the endoscopic facelift, the S facelift, the thread facelift, the Lifestyle facelift, the short scar facelift, and, most recently, the vertical facelift. Many of these are just variations or limited versions of the others or just different access approaches to elevate the same tissues.

I would like to discuss the so-called vertical facelift because it has gotten much attention lately as the “best” approach to reversing the downward effects of gravity. Though the actual term may mean different things to different surgeons, the basic idea is to elevate some, if not most, of the tissue straight up. While this may seem to be the obvious approach to reversing facial aging, it is not that simple. Due to the various connective tissue attachments under the skin and the differences in mobility to the various parts of the face, there appears to be a forward as well as a downward descent. This is all too apparent when we look at the oblique fold of tissue going from the nostril to the corner of the mouth. Complicating this picture of facial aging is the atrophy or loss of the subcutaneous fat that also occurs in some areas, leaving a void or depression that looks as though tissue has fallen away. It appears that the best approach to reversing facial aging is a combination of some vertical as well posterior lifting, coupled with augmentation via fat or implants, if atrophy is also present. The vertical component of the lift can be in the deep subperiosteal plane or more superficially in the SMAS plane or even the subcutaneous plane. But it almost always gives a more natural result if there is some element of posterior lifting, as well. To that end, some surgeons are combining a vertical subperiosteal mid-facelift with a posterior-superior vector SMAS or subcutaneous facelift. Alternatively, others combine a posterior-superior vector MACS (minimal access cranial suspension)lift or SMAS facelift with a vertical subcutaneous facelift.

Evaluating a Facelift Result

Though many facelifts are performed in Beverly Hills, the percentage of those that would be considered “excellent” or even “good” is not as high as one would expect. But rather than going into why this is the case, I would like to discuss what constitutes an excellent result. It goes without saying that there should be no serious complications, such as permanent sensory or motor nerve injury or loss of skin with resultant scarring. The result should make you look younger and refreshed. In many instances, colleagues at work will comment that you “look good” or “well rested” and that maybe you should take more “vacations”, like the one they think you just returned from. It should not look like you recently had surgery! The incisions should be imperceptible or well hidden. There should be no distortion of your features, like the corners of the mouth or eyes or the ears. There should be no significant asymmetries between the two sides of the face,  and improvement in the face should be matched by a similar improvement in the neck.

Finally, there should be no “lumps” or “depressions” following the surgery, nor should there be localized discolorations or edema, suggestive of damage to the vascular or lymphatic networks under the skin.