What to do about those dreaded jowls?? Early on, they’re often caused by volume loss in the face, especially some of that 20% of skull mass that we eventually (and quite normally) lose over our lives. This is how it works: There’s a little ligament, about ½ inch wide, on each side of the chin just where those “marionette lines” form. It’s very tight between the bone and the skin – and it stays tight as our skull starts to become smaller, a process that generally begins after about age 25. This is mostly what creates that first indentation of a marionette line and also the indentation on either side of our chin at the jawline that makes the area just next to it look like a jowl. This is what we call a “pseudo-jowl” and it usually can be smoothed out nicely with a filler. As we proceed to age not only does that process continue, but we also accumulate some fat at the jowl, and other tissues stretch and slide down to form a real, live standard issue, pseudo-no-more jowl. Sometimes people attempt to keep filling the indentation up as the jowl enlarges. That’s when the face can look boxy and distorted – we’ve all seen it – because the actual cause hasn’t been addressed. This is when gravity has superseded the volume loss issue and a facelift is indicated. The volume still needs to be addressed or people can look windblown, but the important thing is for your doctor to know the difference, address the proper condition and do it safely, skillfully and with artistic vision.
If you need help deciding between a facelift or fillers, click here to contact us for an appointment.
This is a question I hear all the time. It’s an understandable question, especially since some fillers tout their “natural” look in ads. There are differences among the various fillers, but with rare exceptions, how natural they look has almost nothing to do with the filler and everything to do with the technique of the doctor injecting the filler.
Every face is different, and most faces are different from one side to the other. That’s why it’s absolutely imperative that your physician has an artistic eye, a passion for detail and the thorough, in-depth knowledge of facial anatomy that come only with years of training.
Also, some fillers work better in one part of the face, while another may be more appropriate for another part of the face. That’s one of the reasons why we may use different fillers on the same face in different areas.
A major difference among fillers is their longevity. Fillers can last a few months, many months – and up to many years. Some fillers are essentially permanent, and they require faultless technique and an eminently conservative approach. However, when done properly and with an eye to future structural changes in the face, they can be a godsend to people, particularly after trauma.
So remember, the soft, natural and beautiful improvement that we can have with the optimal use of fillers is all about the knowledge, skill, artistry and integrity of your doctor. The claims of a more natural look by ads trying to sell you their own brand is, to put it kindly, a bit misleading.
With the New Year almost always come new plans for our habits, our attitudes, our appearance or any number of different aspects of our lives. My practice of course, deals with improving the appearance of our faces, but often the conversation in the exam room turns to seemingly unrelated subjects. I love to read and I love to help my patients in any way I can. This has eventuated in my writing down book names for people numerous times, mostly on the back of an appointment card. So to start 2016 I thought I’d share some of those titles with you in hopes that you’ll find the same delight and inspiration in those you choose as I did.We’ll start with some well-researched and ultimately beautiful books that pull together the science that proves our connectedness. This is a particularly important subject this year as the upcoming elections are going to pull us into a quagmire of vitriol from both sides. After over 22 years and thousands of patients, I wish to remind us all that good people can come to different conclusions, and the more we appreciate our collective connectedness in the midst of our differences, ultimately the more peaceful our lives will be.Three of my favorites are by an American journalist living in the U.K. She has interviewed scientists from all over the world and has pulled their information together in a well-referenced book called simply, The Field. After writing this excellent book, so many people wanted to know how to apply its discoveries to their own lives that she wrote a great follow-up, The Intention Experiment. Her third book, which specifically articulates the science behind our connectedness is called The Bond.There is a fabulous author, Gregg Braden with whom many of my patients have been unfamiliar, but his books are amazing, fun to read and fascinating page-turners. He is a former aerospace computer systems designer who has been all over the world to gather as much information on “who we are” as he can. A quick Google search will give you a list of all his books, but my favorites are:
Gregg Braden’s good friend, Bruce Lipton, PhD, is a molecular biologist who has written an inspiring and science-based book called The Biology of Belief.I’m always glad to offer interesting sources on diet, exercise and health in general. But I wanted to start the year with nourishment from the inside. May every happiness be with you in this exciting coming year!
A. It’s not your imagination. First I’ll tell you what happens, and then I’ll tell you what to do about it. If you’re young, listen up, because prevention is almost always the best cure.
There are basically three reasons why our eyes appear smaller as we mature. First, our skulls shrink. And all the holes in our skull, for instance the eye sockets (the orbits in medical terms), get larger as the bone shrinks away. We also tend to lose some of the fat in our orbits over time, so both the loss of bone and fat at the orbits cause the eyes to sink back and down a bit, making them appear smaller. If you’ve had an eyelid tuck (blepharoplasty) with older techniques in the past, that can exacerbate the situation as well, as those techniques tended to remove a lot of fat. The newer techniques don’t do that, and if your lids are droopy, that alone can make your eyes seem smaller and sad-looking.
This is the third reason, and one you can help prevent. At the risk of sounding simplistic, let me offer a picture. Imagine that your eyelid margins are like a hammock strung between two trees. The corners of your eyelids (the ends of the hammock) have tendons that are attached to the rims of your orbital bones (the trees). Over time, those tendons tend to weaken and stretch, so the corners of the eyes aren’t as taut as they once were; the eyelid margins then become shorter horizontally and more round. Some of this can be genetic and some of it is inevitable, but unfortunately we tend to move that process along, for instance by rubbing the eyes or by pulling at the corners or lid margins to apply contact lenses or eyeliner. The situation is also exacerbated by years of a less than gentle touch when we remove eye make-up and wash our faces. Treat the eyelids gently. As I always tell my patients, “Try not to moooove the skin!”
Use a cleanser or make-up remover with a lot of slip around the eyes, avoid waterproof mascara as much as you can, insert your contact lenses without stretching your lids (I can show you how) and no matter how good it feels for that particular minute in time, do not rub your eyes. None of this stretching happens overnight, but over the years it catches up with you, as so many of our bad habits are wont to do.
Just as I mentioned in last month’s blog (click here to read) regarding using make-up to help give the illusion of lashes, extending the outer corners of the eyes with eyeliner or shadow will help restore a more youthful and elongated appearance to the lids. Just keep it soft and well-blended. If you want help with this, Jill, our aesthetician can show you how to make the effect work beautifully for you.
Finally, if you would benefit from my tightening things up, I have several techniques, depending on the individual, that can usually be done with a local anesthetic if you wish, and very little downtime.
BoTox/Dysport injections are the most common nonsurgical cosmetic procedure performed in the United States. Yet the effects are pretty subtle compared with some other procedures, and the most common objection I hear to the procedure is that, “BoTox lasts only a few months and I want something permanent.” Here are a few things you may want to know about BoTox/Dysport – and if you want to skip down, I’m saving the best for last.
It's the only game in townRight now, there just isn’t anything else other than some form of Botulinum A (BoTox and Dysport being the most commonly used in the USA) that is going to relax your muscles other than cutting them. There may be other things going on in a face requiring other procedures, but if it’s muscle movement that’s contributing to something you don’t like (like frown lines between your brows), basically the only way to treat those muscles is BoTox/Dysport.
The more the betterThis isn’t about big doses; it’s about repetition. Certainly one BoTox session can be helpful for a special event, but the real beauty of how it works is in keeping to a schedule and repeating the injections so the muscles don’t have the ability to regain their strength. Indeed, this may be every few months for a year or two, but just as with any other muscle we work out in the body, if it remains unexercised long enough, it will undergo “disuse atrophy”, a good thing for muscles whose only purpose in life is to pull our faces down and in. As this atrophy happens, and I have seen this over and over in my 20+ years of giving BoTox, the BoTox doesn’t have as much of a battle to fight and often we eventually can reduce the effective dosage and/or significantly extend the time between treatments.
And the other side of that coin?With certain parts of the face, the muscles that pull the face down have opposite muscles that pull the face up – the “happy” muscles. As the muscles we treat get weaker over time, the happy muscles no longer have the “sad, angry” muscles working against them, and the happy muscles contract more and get stronger. At some point that area of the face just gets a bit of a lift that the single session of BoTox would never have been able to achieve. This is particularly amazing at the corners of the mouth!
Our brains get the hintWith the exception of the part of the closing muscle of the eyelids (the orbicularis oculi) that contracts with a natural smile, the facial muscles that we treat with BoTox/Dysport have voluntary and habitual components to them. This means that if we treat a muscle and keep it relaxed long enough, our brains tend to forget that contracting that muscle is part of our repertoire and we tend not to use it as much. Again, this is something that happens over time and is a side effect of BoTox/Dysport that often eventuates in needing less and/or extending the time between injections.
It's often effective for depression and anxietyDid you know that researchers have found that when someone holds a pencil in their teeth, forcing a sort of smile, they find cartoons to be funnier? And when a person is asked to put on a frown they rate photographs more negatively? That is because of a link between facial muscles and nerve pathways through the “emotion” part of our brain that then affects our mood. This evidence supports the idea that “the emotion follows the expression”. Indeed, research has shown that BoTox/Dysport placed in the frown muscles (the corrugator muscles) between the eyebrows compares in effectiveness with anti-depressant medications in treating depression. You can try this yourself. Sit quietly, relax your face and put on a little smile. Holding this relaxed expression is incompatible with negative thoughts. If they bubble up, your face will tighten and the smile goes away. Those of you who meditate know all about this. If you’re interested, a short and excellent article with this research information appears in Aesthetic Surgery Journal (35) 6, page 759 and is by Dr. Steven Dayan.
There’s a little axiom among many of my colleagues who specialize in facial rejuvenation, and it goes like this:
What do women stress out about most when they look at themselves? Their necks.What is everyone else looking at? Their eyes.
That’s true, but it’s only partially true. There’s plenty of research out there now that’s been facilitated by our friends the computers. Basically, researchers will throw up a photograph of a person from the shoulders up and show the photos to observers. With the computer, the researchers can track the eye movements of the observers to see what they’re looking at and where their eyes settle for the longest amount of time when shown the photos.
As it turns out, the area that people are looking at is in the shape of an inverted triangle that essentially has its base across the brows and has its tip at the center of the chin. The features that observers look at the most are the eyes and the lips.
This is not to say that our concerns about our necks aren’t important. Especially from the side, someone can look much more vital with a firm, smooth neck. Also, the healthiest reason to have rejuvenation procedures done is for our own sense of well-being. Moreover, our skin is what people notice first. That said, this research may help us to prioritize when we’re thinking about “having something done”.
Reading all the kind reviews from my clients makes my job so much more rewarding. Thank you to all who take the time to submit your feedback and kind words. Here are some client testimonials from recently.
• Doctor Barbour treats me as if I were her only patient. I know in my heart all others entering this door receive the same care and feel the personal attention I experience upon each visit. It's a joy to know I'm in the most professional care.
• Everything Dr Barbour does is EXCELLENT. Not only is her work excellent but her personality and understanding makes the experience extremely gratifying.
• Dr. Barbour is a delightful person and an outstanding surgeon, sculpting and correcting the neck and face.
• Dr Barbour is without a doubt one of the most professional and yet personable doctors I have ever had the pleasure of having contact with. She is a true artist in her profession. I would recommend her to anyone that wants a beautiful, believable radiant look! Thank you Dr. Holly Barbour for your wonderful skill, God given talent and my new confidence.
• Dr. Barbour is so wonderful and very knowledgable. Another bonus is she is sweet and kind. She is very unique she spends time with you and really listens to your needs. I have been with her for seven years and I will continue coming to see her. I drive over an hour to see her she is that wonderful. I would highly recommend anyone to visit the office, I know they will be wowed at the experience. The entire staff is just wonderful and they all go above and beyond. They are all wonderful and help make your experience unique by working as a great team.
Thank you to the many clients who have taken the time to write comments and feedback about the work I've done. It really means a lot to read how happy you all are and it is the reason I do what I do. Here are some of the wonderful comments you all have left me.
• It has been my pleasure to know and be treated by Dr. Holly Barbour for some years. I am happy to report that I have enjoyed both the process and the result. Dr. Barbour has used her innate artistry to create a program that enhances my best features and reduces the perception of my flaws. I always feel that I am in the best possible hands!
• Dr. Barbour is a caring, warm, wonderful physician who treats her patient's face as if it were a canvas for beautiful artwork. I trust her implicitly to make the perfect suggestions for my face.
• I have been coming to Dr. Holly for 10+ years and she is absolutely the only person that I would ever let touch my face. I started with fillers in the smile lines and a bit to plump my upper lip and did the CO2 laser. Because of the amazing care and technique she used on me 10 years ago I have not needed a single thing until now. People think that I am at a minimum 10-12 years younger than my actual age. Now she is doing fillers around the eye and temple area to address age related changes. Even though I know what an artist she is I almost started to cry when I saw what a beautifully dramatic change it made in the look of my entire face! I hope that she never retires, I could never go to anyone else because she is such a true artist in regards to the minute proportions and dimensions of the face...and she has become a friend because she is as kind and caring as she is amazingly talented. She is one in a million!
• Dr. Barbour is always willing to take the time to answer questions. She is meticulous in her work and a perfectionist in what she does.
• I just love Dr. Barbour. I have been going to her for years. She is very sweet but most importantly very thorough with my cosmetic procedures. I look forward to my visits and to her office from start to finish; a pure pleasure.
In our last blog, I highlighted the pros of using permanent fillers. You can refer to that before reading this if you’d like, by clicking here.
This is going to sound unbearably snarky, but it’s just plain true. The vast majority of people who are administering fillers shouldn’t be doing it. I’ve seen a lot less of the good than I have of the bad and the ugly, and this is at least partly irrespective of the person’s credentials or “training”.
First of all, unless a physician has finished their residency/fellowship in the core specialties in the past ten years (and even if they have), it’s unlikely that they had any training in fillers at all other then a course where they got “certified” over a weekend or so. And although there are probably some exceptions to this, most people who are not surgeons in the core specialties have not had advanced education in facial embryology (how the face develops in the fetus) or facial anatomy. You have to know it cold. By the way, there are still textbooks being written on this with, believe it or not, new information. One of the major ones was just published in 2012 with a lot of information we didn’t know about before. On top of that, I’ve seen over and over again where the healthcare professional has wisely stayed away from the area around the eyes (because if you don’t have that anatomy down, you take more of a chance of causing visual loss), but then has thrown off the proportion of the face by placing the filler too low on the cheek, giving a heavy, unnatural look to the face. Actually, if done well, filler around the eye area is one of the most beautiful places to put it.
So why isn’t “training” the ticket? Because:
• This is literally sculpting soft tissue from the inside out, on a face, where unlike anything below the neck, every millimeter shows. Plus almost all of us are asymmetric to begin with, so there’s the extra challenge of not only seeing that on an individual, but then being able to correct that asymmetry as much as possible. This requires artistic vision, artistic skill and an eye and a passion for the tiniest detail. That vision is either there or it’s not – you can “train” a little of that into someone, but not a lot.
• In my world, fillers are not to be considered an “ancillary” procedure that is passed on to “ancillary” help. They are to be considered small surgical implants with all the respect and care that any surgeon should take with a surgical implant. This includes meticulous attention to aseptic technique (making sure we don’t drive bacteria or make-up particles under the skin). The consequences of that kind of sloppiness are bad in any situation, but with permanent fillers, the consequences are even more formidable than with temporary fillers.
Given the above, thank goodness most practitioners are not using permanent fillers on their patients. If they were, repairing the damage would be next to impossible and attempts to repair the damage would come with considerably more risk. In my revision patients where nonpermanent fillers have been used, there is a stepwise procedure that I follow, beginning with seeing the person periodically and treating as the old filler wears away -- and then I am always grateful for nonpermanent fillers.
I just returned from a national conference of the Foundation for Facial Aesthetic Surgery, a symposium attended by physicians in the three core specialties trained in this field. They are Oculofacial Plastic, ENT/Facial and General Plastic surgeons. This is a forum where generally the more enlightened surgeons, those who believe that instead of being competitors and guarding our “turf” (so last century) we and our patients benefit more by our getting together and sharing ideas from our various perspectives. Because this kind of mindset requires confidence, there were many nationally and internationally known surgeons in attendance, and the meeting was absolutely fascinating.
I had been asked to speak on integrating fillers and “neuromodulators” (BoTox, Dysport, etc.) for restoration of the face, but I asked to speak instead on permanent fillers, knowing that it would be a much more controversial and compelling topic. Besides, the issue of permanent fillers is one I feel more passionate about, both pro and con. Here are a few of the pros:
PROS• I’m happy to stand corrected on this, but I have conferred with a few surgeons regarding the statistic, and they agree that after the age of 30 we lose about 1cc of volume from the face each year. That’s 5cc per year (this would include both bone and soft tissue). Each syringe of filler that we use to correct volume loss contains between 0.8 and 1.5cc of product. Depending on the filler, these syringes run between about $450 and $1,000 a syringe for our patients. It doesn’t take much arithmetic to realize that this becomes prohibitively expensive for our patients unless they have unlimited resources, are content to chase their tails forever, or eventually just give up and/or age out of the process with little to show for it if nonpermanent fillers have been used.
• People generally don’t like having needles in their faces.
• Sadly, I do a considerable amount of “repair work” on poorly done surgery and fillers. Having suffered the results of that work usually involves some psychological trauma for the patient. Where fillers are concerned, the advantage of permanency is that once the repair work is done the patient can put the event behind them and move on rather than having to revisit the memory over and over as the “repair” wears away.
• We’re going to age anyway, and replacing lost volume in smaller increments rather than having to start essentially from square one each time, especially as the aging process becomes more profound, results in a better outcome.
• Most people want the attractive facial curves of youth, but they don’t necessarily want the world to know that they’re having something done to get them. With permanency, again we can do little bits at a time so that the upkeep attendant to the aging process is virtually undetectable.
We’ll look at the arguments against permanent fillers in our next blog. Check out our website to see client testimonials and to learn more about how permanent fillers could be right for you.
Oculofacial Plastic Surgeon, Sarasota, Florida
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