Face Gallery

A woman in her mid-50s with partial splits of both earlobes.  She is shown before and again, 3 months after repair in the office, and immediately after re-piercing.

Discussion.  In addition to the partial split of each earlobe, the piercings are sited too low on her earlobe.  After repair and healing, we have the ability to place the new piercings in a more optimal position.

A woman of color in her early 40’s who had her ears pierced initially in Ethiopia when she was very young. She does not have a history of “gauges”, but her holes have always been large.  Because of their size, they are similar to correcting the deformity from gauges.  She is shown before and again, 3 months after repair under local anesthesia in the office.

A woman in her mid 60’s who is bothered by her facial appearance especially her jawline and weak chin.   She has had a “ thread lift”  to her jawline and face while in Florida and did not notice any difference.  She does not wish to have a facelift or chin implant at this time but wants some improvement if possible.

She is shown before and again, 3 weeks after 5 syringes of RHA 4 to the jawline and chin.  A good improvement is seen.  She also had Daxxify to the lateral canthal lines (crow feet area) and to the mentalis ( chin muscles- look “prune-like” on animation before)  She had Botox to the corrugator lines.

Discussion:  Although her jawline and chin are not perfect and as dramatic as we might obtain with a facelift, she has a nice improvement after 5 syringes of RHA -4.  Non-animal stabilized hyaluronic acid” = NASHA, and are dissolvable with the enzyme hyaluronidase if she were to have any problems with them.  High ” G’ prime” is a measure of the amount of “bounce” or firmness of the filler in pushing back against the tissue. I have used the other brands of high-g prime fillers in the chin and jawline of other patients with a similar effect.  The results with the RHA 4 can typically last for 22 months

I also did a “blended” or “hybrid” approach with her neurotoxin.  The Daxxify in my early (8 months) experience is stronger and has a more dramatic effect than the short-acting neurotoxins, and is especially powerful in the lateral canthal lines ( “crows feet”).  But one potential problem we have seen is a higher incidence of pseudoptosis of the eyelids:  both short-acting neurotoxins such as BOTOX brand and the first long-acting neurotoxin, Daxxify had a similar incidence of true ptosis or drooping of the eyelids in studies, about 1-2 %.  However, we have seen a significantly higher number of patients who have some subtle eyelid ptosis before treatment that is made more prominent by Daxxify and is therefore more bothersome to the patient after treatment.  Because this patient has some early eyelid ptosis ( drooping) on her left eyelid I used Botox instead for her corrugator lines.

A woman in her late teens who was bothered by the shape of her nose.  Her main concern was a dorsal hump and her second concern was the shape of her nasal tip.  The third concern was her nose being crooked.  She is shown before and again, one year after an open rhinoplasty.

Discussion: Studies show that the happiest patients after rhinoplasty are those with a dorsal hump, possibly because the correction is seen more quickly.  Tip refinement continues to improve for 3 years after surgery and is impacted by the thickness of the nasal skin- if the skin is thick it is difficult to see any detailed shape changes.  Her skin is relatively skin and as the swelling diminishes the created shape is better revealed.

It is difficult to fully correct a deviated nose because of residual forces in the nose that want to return to the original bend of the cartilage.  We were fortunate in her case to make the nose dramatically straighter, but this is not always predictable or possible.

Her chin is “weak”, falling behind an imaginary line dropping down from the lips (“Riedel’s line” which connects the most prominent points of the upper and lower lips and is a good guide to the most aesthetic projection of the chin) and her facial balance could be improved even further with a chin implant.

A woman in her early 20s who has a “weak”  chin, also called hypoplasia of the chin, did not want a chin implant or genioplasty.

She has elected for a “nonsurgical genioplasty” or “nonsurgical chin augmentation” which was performed in the office by placing two syringes of RHA-4.  This takes about 15 minutes in the office and is performed under topical anesthesia.  She reported some mild “bumpiness” for the first 10 days and some mild soreness and bruise for the first weeks but is thrilled with the dramatic improvement that appears natural.  RHA4 is a Non-Animal Stable Hyaluronic Acid filler (NASHA) that is reversible with an enzyme called hyaluronidase.  It is a high “G Prime” filler which means it is thicker and has more “bounce” than lower G prime fillers.  I have also used other brands of high G prime fillers such as Juvederm Voluma and Restylane Lyft to contour the jawline.

The RHA4 is typically expected to last 22 months or longer and we suggested that she consider returning for a “touch-up” in two years.

A woman in her middle 60’s who is bothered by an aged appearance, but is on a blood thinner, Eliquis.  After discussions, she elected to try nonsurgical facial improvement by replacing some of the age-related volume loss with Resilient Hyaluronic fillers, or RHA.  These are one line of Non-Animal Stabilized Hyaluronic Acid fillers distributed in the US by Revance.  Other NASHA lines include the Restylane line by Galderma and the Juvederm line by Allergan.  The NASHA fillers have the benefit of being reversible with the ability to dissolve them with an enzyme, hyaluronidase.  The RHA line has the added benefit of being especially flexible and resilient, which is a benefit in parts of the face that move.

In her case, I placed one syringe of Redensity (which would be RHA 1) in the “tear trough” area, where it is frequently used off-label in Europe.  I then placed 2 syringes of RHA 4 (firmer but flexible) in the cheeks, and 1 syringe of RHA 2 (firmer than 1, softer than 4 but still flexible ) in the upper nasolabial creases.

She did not have much problem with bruising despite being on Eliquis and returned for Daxxify, a long-acting neurotoxin for frown lines and crow feet lines, where I have found that it excels in both strength of effect and duration over the short-acting neurotoxins on the market.

The overall effect of these two treatments is dramatic and does not require surgery.

A woman in her later 60s was shown before and again, 5 months after an anterior hairline brow lift, upper and lower eyelid blepharoplasty, and fat grafting to the mid-face.

Discussion: She has significant brow ptosis but a high forehead.  If a traditional brow lift had been performed it would have pulled her hairline back and appeared even more unnatural.  Instead, an anterior hairline or “pretrichial” incision is used.  It is actually beveled and made in a wavy fashion so that the hairs grow up through the incision and help to camouflage it.  This actually lowers the hairline, making it more aesthetic and at the same time, it eliminates the heaviness of the eyebrows and smooths the forehead lines that are more prominent as the patient constantly activates the frontalis muscle to hold the brows up.

Some excess skin is taken out of the upper eyelids at the same time( upper eyelid blepharoplasty).  Blepharoplasty of the upper lid alone would not have looked as natural because it would not address the heaviness of the eyebrows from aging ( “brow ptosis”)

The lower eyelids can be the most challenging because she has a combination of prominent fat pads which were reduced here through the eyelid (transconjunctival approach”) but then just a small pinch of skin was excised to avoid pulling the lower eyelids down, and the volume loss from aging that gave a hollow look was corrected with fat grafting.  The combined result gives her a rested and refreshed but natural appearance.

Details: A woman in her later 30s with a complete split of her left ear for the past 13 years.  She had been sleeping with her earrings in.  She is shown before and again, 3 months after repair.  Scars are typically at their thickest and reddest at 6 weeks and then will fade and improve over the next year or longer.  By 3 months most patient’s earlobes are ready to re-pierce.

Details: A woman in her middle 80s is shown just after the removal of a Basal Cell carcinoma of her left nasal tip by Dr. Grande of Mohs surgery and again, 5 months after repair by Dr. Hall with a shin-fat composite graft.

Discussion: a full-thickness skin graft can work well on the upper nose but does not match the skin color or texture well on the lower nose.  A skin–fat composite graft leaves the fat on the graft and often looks like a “scab” in the first 2 months but the deep layers are taken and then after it heals generally leaves a good result and allows the patient to avoid a more extensive flap procedure.    Her skin fat composite graft was harvested from in front of her ear.