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Having practiced the art of Plastic Surgery for well over two decades, I have seen many changes over the years. Expectedly, there is a constant evolution in technology; however more striking to me is the recognition of our changing aesthetic. I find this so interesting because, like Greek philosophical descriptions of beauty, I too believe there are somewhat immutable ideals. In classical studies of the human form there are well established proportions and harmonies inherent in perceived beauty. In fact, the curriculum in Plastic Surgical education teaches us to study these ideals to help frame our aesthetic and guide our plans for interventions. Yet in the pursuit of our craft today, we too often see trends toward unnatural and even dysaesthetic results.

Obvious examples of this are the recent propensities toward overly enlarged lips and unnaturally exaggerated cheeks. It behooves us as cosmetic doctors to help guide our patients and even ourselves to strive for more natural results, reestablishing the aesthetic normal. Lip augmentation procedures have become very popular and highly requested. Everyone remembers Goldie Hawn in “First Wives Club”, looking positively silly after a visit to a cosmetic surgeon. Done properly, lip enhancement is a wonderful procedure to create or return lips to a gentle, youthful fullness. Overdone, however, it can easily result in an awkward platypus like projection. The key to proper enhancement involves experience, judgement, and especially an understanding of how fillers are to be used in differing quantities and in specific subunits within the lip. Smaller amounts of filler used to define the “white roll” often frame the edges of the lips and provide remarkable enhancement without significant enlargement. This is similar to the way a good picture frame focuses ones attention on the painting. When injecting into the pink (vermillion) portion of the lip, location and quantity of fill is even more important. Youthful lips roll outward subtly due to the anatomical shape of the orbicularis muscle, and improper injections can over accentuate this subtle eversion causing a duck like appearance, especially on profile view. Another important consideration is maintaining a harmonious 1-1.6 ratio of upper lip to lower lip proportion. Ultimately it is important to understand that bulk filling of the lips for maximum volume is not the aesthetic ideal, and that we must strive for very specific enhancements outside of volume alone.

Similar to the too common tendency toward unnaturally large lips, we are seeing people with unnaturally augmented cheeks and mid-faces. As aesthetic physicians we have
come to correctly evaluate much of changes of facial aging as due to deflations and sagging in parts of the face, most notably over the cheekbones and below the eye sockets. We know that re-inflation of these of these areas not only restores youthful fullness, but more importantly provides lift to the cheeks in correcting symptoms of sagging such as deep nasolabial folds or hollows below the eyes. The problem comes when we overcorrect volume in an effort to compensate for extreme sagging. It is important to understand that youthful contour is due not only to volume, but also requires skin elasticity to shape that volume into natural, youthful ogee curves. Skin building programs, such as laser and other collagen restoring technologies must be employed along with filler to “shrink wrap” the facial envelope. Most importantly we must know when it is time to put down the syringe and pick up the scalpel. Not everything can be corrected properly without surgical intervention.

“Keeping it real” is about balancing the approach to rejuvenation. Using fillers gently, only restoring volume to normal proportions. It must be combined with skin tightening procedures in order to produce natural results. It has become my mantra that “natural results occur when we rebuild the structure that defines youth, rather than just camouflaging the signs of aging”.

Scott Wells, MD

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