I am a craniofacial trained plastic surgeon from Stanford University having provided craniofacial, cleft lip, and palate care to my patients in academia in North Carolina I then transitioned into private practice in Knoxville Tennessee. I currently no longer take on new pediatric patients in plastic surgery but I extend my love and support for children and their families who have to endure many years of surgical procedures to reach a state of normalcy. It certainly is an uphill battle and I am always amazed at the resiliency of these small children to endure very complex and long surgeries to achieve rehabilitation from congenital birth defects. I was always honored to be in a position to provide this care for families in need.
Currently I am mostly an aesthetic plastic surgeon. I very much value my training in the field of craniofacial surgery because it has given me such a unique insight into the normal form and function of the skeleton surrounding the eyes, face and nose as it interacts with the multiple muscles and fat pads creating the complex composite of how we appear to our friends and family. In depth study of the face through transitions in time from infancy to adulthood to the unwelcoming aging facial appearance provides me an aesthetic eye from which I can provide treatment plans to optimize facial balance of the skeletal form, soft tissue volume, and overlying skin to achieve a youthful face.
With aging the bony orbital volume increases resulting in changes in globe position, the soft tissue support mechanism of the eyelids and fat pads diminish resulting in looser lower eyelids and prominence of the lower eyelid fat pads increases. In regard to the upper eyelids and brows we see the temporal fat pads both above and below the muscle begin to waste away giving a skeletonize look to the upper lateral orbit and descent of the lateral brow that hangs over the upper eyelid. The actual upper eyelid skin becomes loose and redundant and the support mechanism of the upper inner fat pad decreases allowing it to be more visible.
Rejuvenation of the periorbital region all depends on the degree of the aging disorder. Early stages can be treated with filler agents such as an induction technique with Sculptra. This product when injected into the tissue results in an inflammatory mediated process to induce collagen production as a replacement for the fat lost in a given fat pad zone such as the temporal fat pads which, by restoring volume, can re-suspend the lateral brow tissue to reduce hooding over the upper eyelid. The areas of the lower eyelid such as the tear trough and the lower eyelid fat pad -cheek junction can often be smoothed similar to photo-shopping with the injection of hyaluronic acid fillers deep to the eyelid muscle as an enhancement of the skeletal rim. This may even change refraction of the light off of the skin of the lower eyelid, modestly reducing a dark appearance. However, if there is significant excess skin of the brow and upper and lower eyelid then an endoscopic brow lift with upper and lower eyelid surgery is generally required to achieve satisfactory results.
The midface is the area along the cheek bone and extending inferiorly down to the cheek fold line (nasolabial fold). This is an important anatomic region that houses a large fat pad. The shape and the projection of this area is dependent on the upper jaw bony structure as well as the volume of the fat pad. Unfortunately, the fat volume is programed with aging to shrink in size leading to less cheek projection and the deflated net result can lead to enhancement of the nasolabial fold and produce unwanted downward turning of the corners of the lips and jowling (hanging skin over the inside border of the jaw line lateral to the chin.) The number one most important intervention is restitution of the volume loss of the fat pad. This can be corrected with a very dense crosslinked hyaluronic acid filler agent like Restylane Lyft or Voluma. Another option is the induction technique of Sculptra if multiple areas need restoration simultaneously. If a face-lift is indicated I always replace the fat volume with a deep fat grafting injection in the same anatomic relationship of the fat pad.
And finally, a review of the lower face which, in my facial analysis, occupies the lips, lower jaw including the chin point, and the neck region. Once again the lips lose volume and definition with aging. The upper lip’s vertical columns extending from the base of the nose down to the cupid bow points flatten with age and the skin above the lips lose volume and become flat and can demonstrate vertical lines emanating above the vermillion. This is a dead give- away for aging on a women. Simultaneously the lower lips thin as well and the corners of the mouth turn inferiorly giving a sad appearance. Accurate and judicious restoration of volume in this area, with an appropriate aesthetic eye, is required to restore the vertical columns cupid bow points, the central tubercle as well as the two lateral tubercles and volumize the commissures of the mouth. Nothing is worse than a blown up upper lip without delicate definitions of the above mentioned points. I see many grotesquely enhanced lips today that don’t represent normal youthful anatomy. The other important component of the lower face is the underlying skeletal relationship between the upper and lower jaws. If there is a small lower jaw often the chin is retruded and there is an increased fold below the lower lip and chin due to lack of lip support by the lower incisor teeth. This weak jaw relationship also leads to an obtuse cervical –mental angle with loose hanging skin of the anterior lower neck. Skeletal correction with a screws retained implant or a small chin bone advancement can greatly improve the neck line. Vertical bands in the anterior neck can only be corrected with surgical correction as part of a lower face-neck lift with excellent long term results. If a person has excess fat in the neck with some lose skin and no vertical bands then a judicious removal of fat with liposuction can result in a tighter looking neck with less full appearance. I personally feel that other techniques like CoolSculpting is an expensive less effective technique because it does nothing to lead to skin tightening and has less precision of selective fat removal.
In summary, I feel that having a craniofacial surgery background provides me with unique skills of facial analysis and three dimensional correctional treatment options. These treatment options, which can correct or restore normal anatomy for better balance, provide a means to harmonize aging facial deformities to look more rested and youthful without leading to an abnormal appearance that would cause people to ponder what you had done.
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