Squirrels fill their cheeks from the inside. Humans tend to do it from the outside. Her cheeks looked great until she smiled. That’s what I thought, when I sat down to chat, with a new patient, about her face. I usually like not knowing the reason for the visit, so I can figure it out, cold. I’ve had reasonably good success in convincing Amanda not to tell me beforehand; but I have been wrong in guessing often enough to cast doubt on my ability to do this. There’s this story about what I assumed was an “obvious” need for rhinoplasty. In that I was right and wrong at the same time; but that’s for another time.
Anyway this woman had a lovely face; but when she smiled, I got the taillights on a ’62 Lancer. Cheeks are not supposed to look that way. They are not meant to compete with the nose for the most dominant projection on the human face.
So this brings up an interesting problem. Cosmetic procedures for the face are born in paradox. They are designed for the face at rest but are vetted when the face is in action. An airplane is designed on the ground but it has to fly, Spruce Goose notwithstanding.
So the resting position of the face is the obvious compromise. It’s not that the face is at rest most of the time; nor is it about the resting face being easier to design for. Rather, it’s the virtual impossibility of designing an operation that works with the infinite variety of human expression…with few exceptions. This was one.
Her smiling face exposes the dark side of that compromise. Cheek augmentation, (filling), is one of the occasions where I judge both how much and where to fill while trying to make the resting face and the smiling face, play nice together. The smile tells me, not so much about how much, as it tells me where not to fill. This was likely not done for this woman.
The answer to her overfill is something called Cosmetic Reconstruction – the things I have to do to fix something that didn’t turn out so well. These operations, and often more than one, are usually greater by far than the original procedure. Here, I’m being kind, but this is an error that shouldn’t happen. In this one the fillER did not study the fillEE.
So I knew what the problem was: remove some stuff; but it was not clear was how to do this. I was hoping the fill came by way of the Hyaluronic Acid molecule, (Restylane, Juvederm, Belotero) for which there is an enzyme – Hyaluronidase – that can dissolve and remove those guys. But if it were something more permanent the job would be large and difficult…and fairly expensive even if done on the basis of “time”.
Okey, a little anatomic background music. It’s painless and won’t be that long.
So the cheek has two parts:
There is the lower part, the Pars Vesicalaris, the balloon part, the part you see when Dizzy blows. It’s also the part that sags when age blows. I actually had to make up the name since I couldn’t find the annotation in the literature. I didn’t look all that hard, mostly because I happened to like my own name for it. Take that Linnaeus.
The other part, the upper part, is the Pars Malaris also my name, but it could be a lake in Sweden. Anyway it too is agreeable. This is the formed part of the cheek, that lives just below the lower eyelid, with which it should blend nicely – check out the next facelift. With the face at rest, the two parts become the blended cheek. It’s the smile that teases them apart.
So if the filler was one of those made with the justifiably popular Hyaluronic Acid molecule, there’s an enzyme – Hyaluronidase – that can dissolve and remove it. As in everything else I do, the kicker is about how much.
In chem talk, a word with “ase” on the end of it usually means an enzyme: something that enhances a reaction.
But if it wasn’t HA, but something more permanent the job would be large.. There are few generalizations in cosmetic surgery, but one might be “never fill the lower cheek, the pars vesicularis…it moves too much.
With age the upper Pars Malaris both atrophies (diminishes) and falls, (ptosis), sliding down and piling up against the Nasolabial Complex – that swath of skin and soft tissue extending from the upper side of the nose past the corner of the mouth and into the ditch at the front of the jowl.
In a virgin case, the idea is to lift and then fill. The order is important. If you fill first and then lift you got a problem, sort of like the one she has, yet always different. Her problem was filling for style, not age, and this is, like all style, always intimately personal, but no matter filling is filling and plays by the same rules: watch the smile.
The unsatisfying denouement was in her satisfaction with her cheeks. This, it turned out, was only my problem, and although I knew I was correct, it was irrelevant. So I shut up, and slinked back to my doctor chair, (slunk??) She liked her look, and who am I to say nay.
I accept my patient’s preference, until and unless my name is on the work. Then I nudge with a bit more force, and sometime a small victory. I do have a good eye for such things.
As it happened she was actually filled with HA, and so there was hope…maybe later.
Anyway she didn’t even come for that. We ended up doing a rhinoplasty, before which I tried, again, to suggest the tinyest of withdrawls She was having none of it.
Hope returned to the jar.
Thanks for listening