Archives: Transcript

Can you be too old for a facelift?
Throughout my training and much of my
career I considered the facelift in conjunction with eyelid surgery to be
the ultimate solution for facial rejuvenation in my practice I developed
my own techniques and systems to achieve optimal results with local anesthesia
and LITE IV sedation with quicker recovery than traditional surgery my
facelift patients have ranged from age 37 to age 87 when I’m asked the question
can you be too old for a facelift makes me think first about whether a facelift
is the best option for what the patient wants and would the results be worth the
investment in time money and recovery I’ll discuss how I consider the option
of facelift for my patients in my practice and how age is factored into
this discussion I’m Dr. Amiya Prasad I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic
and reconstructive surgeon I’ve been in practice in Manhattan and Long Island
for over 20 years I perform all types of phases of procedures in my practice from
short scar mini lifts to deep plane facelift if we look into the past of the
options to address facial aging where the skin and soft-tissue sagged
resulting in gels and loose neck skin it makes sense to operate in order to lift
and reposition the sagging tissue it should also be recognized that there has
been a wide range of proposed best facelift surgery options from minimally
aggressive to highly aggressive in our field attending medical conferences has
been unintentionally amusing for me as colleagues passionately advocate
procedures at one time and then years later they abandoned the same procedures
they advocated for so passionately so what happened what happened was that
regardless of technique there have always been challenges with face lifting
in terms of complications and long-term benefit the ideal procedure is one that
is safe and predictable with minimal complications interestingly I’ve
observed several of my senior colleagues evolved their surgical approaches such
that they look very similar to what I advocated for years ago I think it’s
reasonable to conclude that they came to the same conclusion I did about safety
and predictability in my opinion one of the core limitations of any face of
procedure is the bone volume loss associated with facial aging the pillars
of the face which define the facial structure include the cheekbones the
chin, jawline, and jaw angle in a facelift operation the more defined these
structures are preoperatively the better the facelift results are this means that
for people whose facial structure are not as strong preoperatively within a
relatively short period of time they often look like they still need a
facelift being aware of this variable I often advocated for the placement of
cheek and chin implants at the same time I performed face of surgery but many
patients were not comfortable with having facial implants many were okay
with getting a chin implant another variable is the quality of the
skin the fatty layer under the skin and the SMAS or the superficial musculoaponeurotic system which is often referred to as the muscle and needs to
be addressed to do a proper facelift the SMAS is actually a layer of tissue
connecting the underlying facial muscles to the skin if these tissues are thin or
fragile the face of procedure may not come out as well as the patient would
like I make a point to communicate with my patients about these issues so they
can make an informed decision when considering a facelift patients often
come in for a facelift surgery because they feel that their face is drooping
when they look at the mirror and when they pushed their face upwards with
their hands they conclude that they look better others come in to have a facelift
because they don’t want to have fillers and just want to get that one procedure
that’ll keep them looking good forever I look at my patient during consultation
to determine what aspect of facial aging is dominating in their situation is
their facial aging issues caused more by bone volume loss or by facial soft
tissue sagging or is it a combination of both I look at facial aging from the
inside outward which means I look at the bone structure as the foundation if
there is no significant sagging I recommend volumizing the bone structure
but instead of facial implants I recommend long lasting hyaluronic acid
fillers such as Juvederm Ultra Plus or Juvederm Voluma instead of performing
surgery I use blunt cannulas to place volume at the bone structure level in my
exam room within a few minutes they appear to look as if they had a facelift
this is not the overused and inaccurate term liquid facelift I’m using the
principles I know from performing facial implant surgery for the placement of
thicker hyaluronic acid fillers at the bone level typically with no bruising
and minimal swelling if the soft tissue sagging is so advanced that the filler
placement would not have a significant impact I
recommend facelift surgery but I explained to the patient that they will
still need structural volumizing to address their bone loss after they’ve
healed to get the best results I do in some situations perform a combination of
facelift with structural volumizing at the same time a facelift is part of an
overall facial rejuvenation plan and is not the definitive final step this
awareness of the challenges of lifting sagging tissue over diminished bone
structure makes me particularly disheartened by the claims made by
advocates of threads and thermal energy devices I make more of an impact with
Structural Volumizing in a matter of minutes than any thermal energy device
or thread lifting procedure where patients are told to wait four months to
see the benefit of their treatment which still don’t come close to being
comparable to what I do in evaluating a candidate for face of surgery I look at
age as a variable from a perspective of physical health bone structure and
tissue quality I mentioned earlier my oldest facelift patient being 87 years
old when I did her surgery she was physically strong had no medical issues
no medications and she was healthier than people decades younger than her her
bone structure and tissue quality was great as I do for any patient I look at
the face as a whole and provide my patient with a detailed understanding of
all the aspects of the face contributing to them looking not as good as they can
this includes their eyebrows upper eyelids lower eyelids cheekbones chin
jawline and jaw angle as well as the lips in the area around the mouth of
course I look for the presence of jowls and sagging
neck skin can I suggest a strategy based on what I feel will be the most impactful
for their situation I find that it’s often the case that people focus on
something they don’t like such as their neck skin sagging and then they lose
perspective of the areas of the face that are more significant during social
interaction I call this area of social interaction the beauty triangle which
includes the brows eyes cheekbones lips and chin it’s by no accident that the
cosmetic industry creates countless products to enhance these areas in
summary age is a factor for a facelift in the context of health bone structure
and tissue quality most important is to determine what is the best approach to
help you look your best with the lowest risk minimal downtime and the most
benefit I hope you found this information helpful thank you for your
question

Corset plastysmaplasty and choking phobia.
Surgeon recommends corset platysmaplasty. Have a choking phobia. Does post-op tightness of corset plastysmaplasty feel like choking? Is this procedure typically done under general or local anesthesia? Doctor uses a certified registered nurse anesthetist and not a medical doctor anesthesiologist. Is this okay?
Thank you for your question.
You submitted your question with a single photo focused on your neck from the front
view. And you’re stating in your question that your surgeon recommends a corset platysmaplasty
and you’re concerned about a choking phobia or the perception of tightness and a choking
feeling after platysmaplasty. You’re also asking whether or not this procedure is done
typically under general or local anesthesia as well as a question about whether it’s
safe to have this done with a nurse anesthetist as opposed to a medical doctor or an anesthesiologist.
Well, certainly I can share with you my personal approach in helping my patients understand
the pros and cons of both the surgical approach as well as the type of sedation that’s optimal.
A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island
for over 20 years. Helping people with aging neck and improve the appearance of their neck
and face has been a significant part of my practice over the duration of 20 years with
continuous evolution of this very challenging area which is reflective of the many different
elements that it takes to try to get the best result possible for an individual patient.
So to begin with, let’s understand a little bit about what the purpose is of a corset
platysmaplasty. Now in my practice, generally speaking, rarely do a corset platysmaplasty
as an isolated procedure. And the reason is that the goal is to certainly improve neck
contour by defining the area between the chin and the neck angle as well as the overall
sharpness of the side view of the neck. However, generally speaking, at the same time, there’s
laxity and sagging of the facial tissue which is often done in conjunction with a facelift.
And if there is a significant amount of extra skin, then it’s also done with a combination
of a face and neck lifting procedure. So in terms of using those particular words and
terminology, there are many ways to do all those procedures.
Now specifically, one of the challenges of helping people with the platysmal bands which
is generally one of the indications of corset platysmaplasty is that whether you’re using
different types of suture material and the techniques in which you close the platysma
that is divided and various types of maneuvers to maximize the result, there is the possibility
of a tight feeling. I would say that it’s very rare for someone to feel like they’re
choking but it is certainly possible to feel a tightness. You can certainly discuss this
with your doctor. They can share with you their experience in what they generally find.
I think that one of the things to at least understand is that even though things are
done very tightly during surgery, the tissue has a natural relaxation. And what that means
of course is that the muscles stretch a little bit, the skin stretches a little bit. And
so with time, there is an equilibrium that ultimately settles out. So things that are
maybe tight in the beginning tend to stretch a little bit with just facial movement and
tissue elasticity.
And of the things to also discuss is of course whether or not it’s indicated to have another
procedure in addition to just the corset platysmaplasty whether it’s facelift or face and neck lift.
Just as a side note, if you look at the plastic surgery literature, to this day, almost every
year, there are significant numbers of journal articles about the best way to do face lifting,
neck lifting and platysmaplasty. I shouldn’t say best ways but new approaches which again,
as I said earlier, reflective of the certain limitation of working with the human body
and what you do in surgery ultimately settles out over the course of time.
Now as far as something is done under general anesthesia versus local versus local with
sedation, in my practice, we do something called LITE™ anesthesia which is basically
local anesthetic which means making the area numb with local anesthetic like you would
like a dentist. And you also get LITE™ intravenous sedation. We generally avoid general anesthesia.
This is something that has worked out very well for me in my practice in the way we do
things. I avoid essentially the many risks and challenges of general anesthesia. My patients
are very comfortable and get up and walk away without having any of the usual or often side-effects
after using general anesthesia. So it’s really the surgeon’s preference. Many surgeons
prefer general anesthesia versus local and sedation and they have their reasons and this
is something that you should discuss with your doctor.
Now as far as a nurse anesthetist versus an anesthesiologist, I think again it’s important
for you to discuss this with your surgeon. I think that every surgeon who has like what
we have in our practice, we have our own facility, we’re certified by the Joint Commission,
the staff that I work with is very comfortable with me and the way I do my surgeries. I think
it works both ways. A surgeon can work very comfortably with an anesthesia provider whether
it’s a nurse anesthetist or anesthesiologist. And so if your surgeon feels comfortable then
I think it’s reasonable for you to feel comfortable and I think that there shouldn’t
be any particular bias based on this particular qualification. I think experience is critically
important and depending on the relative risk of complications related to anesthesia, that’s
also an important factor to understand. So if I feel someone is not a patient that I
would feel comfortable with doing it in my office facility then I’ll either bring them
to a surgery center or hospital or I’ll just not do the surgery. So discuss this with
your doctor since your medical history is not part of your question.
So I hope that was helpful, I wish you the best of luck and thank you for your question.

Do i need a neck lift, neck lipo, a chin implant? Something else?
Thank you for your question.
You submitted your question with 2 photos of the lower part of your face.
One with you appearing to look straight ahead and one with your chin downward.
And you stated in your question that from the side, you look pretty good when your face
is looking straight.
And then when your chin goes down, there’s all this appearance of extra skin so you want
to know do you need neck liposuction, chin implant or what essentially is the solution
for your appearance of your neck when your chin is moved downward.
Well, I can certainly share with you how I have this discussion with my patients who
frequently have comparable and similar concerns.
A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon.
I have been in practice in Manhattan and Long Island for over 20 years.
And helping people improve the appearance of their neck has been a big part of my practice,
doing everything from face lifting, face and neck lifting, liposuction, chin implants as
well as injectable fillers to help improve the appearance of this area.
So I can tell you that in my career over the course of these past 20 plus years, there
is certainly greater understanding of what are some of the anatomic issues that are responsible
for this change which is typically associated with facial aging.
So to begin with, it’s important to understand that there is a certain element of this that
is or significant part of this issue which has to do with the skin’s elasticity.
And what I mean by that is that as we get older and the soft tissue under the skin gets
thinner, the skin’s elasticity, the relative proportions of different types of collagen
and other proteins in the skin changes.
So very often, people, as they are getting into their 40s and older, will come to me
and pull their skin and watch that the skin doesn’t retract as well and go, “What am
I supposed to do with this?”
And they think, “Why can’t you just tuck it or pull it all the way from the back of
the neck?”
And so certainly, in the earlier part of my career, the approach would typically be to
do some kind of face lifting procedure.
Basically, what you’re doing with the facelift procedure is you are taking care of any redundant
skin and you are increasing the tone of that area.
That doesn’t mean you eliminate everything when your chin goes downward, it improves
it.
I’m not saying that’s necessarily the right thing for you because there are other
areas that also have to be evaluated before making that decision.
One of the things that I have also noticed as time has gone on having been around for
the pre-internet era and seeing what has transpired as everyone is looking at their smartphones
is that generally, I’m finding that posture has incredible impact on this area in what
people see when they look in the mirror.
I feel that people’s postures in terms of their back and shoulders are getting more
rounded.
They’re rounding forward, holding their phones closer, their necks are extended forward,
and they’re hunched over.
You can look around and notice how many people have changed their posture, and that contributes
a lot to this appearance of excess.
I have taken a patient with a similar concern, and I just adjusted their posture, not anything
chiropractic, but just have them bring their shoulders back, and their chin up, and aligned
their ear to the shoulder, then a considerable amount of neck skin has miraculously improved.
Now that being said, the other element of facial aging that I think is really relevant
here is also having to do with relative bone loss.
And a lot of times and again, judging is based on a limited photo, but assuming that the
photo is representative of someone who has a relatively thin face and is in their 40s
or older, there is an approach where you are actually adding volume to the diminishing
structure.
What I’m saying is essentially, as we get older, this is documented in the plastic surgery
literature, there’s bone loss and with that bone loss, comes this relative deflation of
the foundation of the face and the skin appears to be excess.
So what we do is we do something called Structural Volumizing which means we are using fillers
that are on the thicker side such as Juvederm Ultra Plus and Juvederm Voluma and placing
it strategically such as in the cheekbone area, the jawline, the jaw angle, the chin.
You are actually restoring a lot of the structure and it has the effect that can be comparable
in many ways to a facelift.
So a strategy essentially is, you’re looking at is something to tighten the skin relative
to the underlying structure versus adding volume to the structure and restoring some
of that support.
Now of course, there are many ways to improve skin elasticity up to a certain limit.
And the challenge I find in my practice is of course helping patients get the best value
for their investment in resources and time.
A lot of times, people look to try to get tightening of their skin and even if you get
the skin a little bit tighter through a non-surgical approach whether it’s a radiofrequency or
laser device, if it doesn’t tighten that significantly and the before and after is not that dramatic,
well it’s hard to justify that.
So I find myself gravitating towards restoring volume more than trying to tighten the skin.
And again, it’s always customized on an individual basis.
Everyone comes with different anatomy, skin types, history such as cigarette smoking,
sun exposure, etc.
There really is a customization necessary for every individual case.
And then we have to figure out what is the most practical.
So learn about these options such as Structural Volumizing.
I think that a full facial evaluation is necessary.
A physical examination is necessary but I think there is certainly an opportunity.
And also, don’t forget about looking at your own posture and seeing if there is any potential
benefit there and I suspect, you might find some use in that little pearl.
So I hope that was helpful, I wish you the best of luck and thank you for your question.

What is the best (and longest-lasting) facelift technique to lift heavy jowls?
Thank you for the question.
You are asking what is the best and longest lasting way to treat heavy jowls and you ask
on your question about the various techniques from high SMAS, SMASectomy, MACS lift, deep
plane basically a provider of a list of all the different techniques.
And you state that you see in this medium that people, after full SMAS facelifts have
recovered jowls.
Well the type of question you are asking is the kind of question that people who do this
type of surgery have been asking for decades and the best technique doesn’t really exist
because the human body is going to have a lot of variability.
And the reason, I will explain this further, as a background I’m a board certified cosmetic
surgeon and fellowship trained oculofacial plastic and reconstructive surgeon.
I specialize in helping people look better specifically in the area of facial aging and
I do all those procedures.
And I’ve been in practice for over 20 years in Manhattan and Long Island and I treat patients
who come for these procedures who come from all over the world.
I can say that the marketing elements of face lifting surgery which further confuses matters
and there are doctors who claim that they only do deep plane facelifts implying that
the other doctors that don’t do those procedures or that they are doing something that is complicated
than other people are not as brilliant as they are that’s just not the case.
Every surgeon who performs face lifting surgery who is properly trained and has experience
can do all those procedures that you just listed.
And more, and when it comes to it, at a certain level and experience, you really are customizing
even further because you are using your knowledge and experience to get the best result for
that patient.
And so, that essentially means that there is something missing in the equation as to
why you noticed that people do get recurrent jowls and there are a few things.
So the limitations of face lifting have to do with the realities of what the factors
are related to facial aging.
And facial aging is basically two things: it’s volumetric loss which means loss of
bones, muscle, fat and soft tissues and it’s also sagging, descent and weakening of soft
tissue.
So that means you’re lifting against a structure that has less volume and you are lifting with
tissue that is more elastic.
A colleague of ours once said that the skin is like taffy and it is very stretchable so
whether you go very deep or whether you go superficial, in the end, you are still lifting
the foundation of the face called the SMAS.
But the weakest link in the chain is the tissue quality.
And so there is invariably a certain amount of regression which the skin in the neck can
stretch a little bit.
You turn your head up and down, it’s going to stretch a little bit.
The face will stretch a little bit just normal movement expression.
So I explain to my patients that if you are a candidate for a facelift, my job first is
to reposition and put everything back as to where it should be but it doesn’t mean volume
correction is not going to be appropriate.
Now volume correction can be the use of chin implants, cheek implants to restore volume.
Or volume correction can be the application of fillers, structural volumizing, placement
of thicker hyaluronic acid filler at the deeper levels so that after the facelift is done,
you can also get this volume restored.
And in fact, I would do a limited facelift and combine it with injectable fillers to
restore volume concurrently.
There is a lot of art to this type of practice and there is a lot of finesse and there is
a lot of variation and the personal style of different doctors.
Imagine if there was just one way to do the best job possible then everybody would do
it exactly the same way and that is just not a reality of there is one way to do a facelift
and that the best way you can be sure is someone who trains in this field would do exactly
that.
I think what you are dealing with is just the elasticity of the human body and the variabilities
in the ways we can lift the face and neck area.
So I think that if you are interested in doing anything, meet with different doctors, explore
different options and learn about the different anesthesia scenarios.
Every doctor comes to this in a way with the perspective of doing the best job they can
with knowledge and experience they have and there are problems when doctors engage in
turf battles and disparaging other doctors stating they are capable or better qualified.
It just serves to confuse people unnecessarily because I think majority of the time, people
who often do these procedures do have appropriate experience and it is just a matter of finding
the right fit in terms of this style of the procedure, in terms of the anesthesia, in
terms of the overall vision the you and the doctor share about the outcome.
So I hope that was helpful, I wish you the best of luck and thank you for your question!

What are the risks associated with eye bag removal surgery?
Eye bags are a concern for many people who come to my practice.
Mostly their concerns are centered around how tired or older their eye bags make them
look, and how often they are subjected to friends and family asking about whether they’re
getting enough rest or having a bad day.
The most common statement patients tell me is how tired they are of looking tired.
In reality, eye bags that are always present have nothing to do with how much sleep you
are getting.
Eye bags are an anatomic issue caused by something called lower eyelid fat prolapse.
Lower eyelid prolapse means the fat pockets around the eyes have pushed forward, resulting
in a bulge or herniation of fat that gives that puffy, tired appearance.
There are a few ways to address under eye bags depending on how severe they are.
Mild under eye bags can be improved by injecting filler into the hollow areas of the tear trough,
thereby camouflaging the puffiness.
More pronounced under eye bags, however, will require surgery.
Concerns about the risks of under eye bag surgery is something I address every day in
my practice.
I’m Dr. Amiya Prasad.
I’m a Board Certified Cosmetic Surgeon and Fellowship Trained Oculofacial Plastic & Reconstructive
Surgeon.
I’ve been in practice in Manhattan and Long Island for over 20 years.
I first trained in eye surgery before training in cosmetic and reconstructive surgery of
the eyes.
Helping people improve the appearance of their under eye area is a major area of focus in
my practice.
Eye bag surgery is a very common procedure I perform in my practice routinely pretty
much every day.
As mentioned earlier, significant under eye bags cannot be treated with filler in the
same way that mild under eye bags can.
This is because placing more volume into an area with a prominent eye bag will only make
it look puffier than it already is.
Surgery is the most definitive procedure for constantly puffy eye bags, and can help prominent
eye bags more effectively than an injectable filler can hide.
The objective of eye bag surgery is to remove and sculpt the fat pockets for a smoother
contour, as if you never had under eye bags.
Eye bag surgery can be approached in two different ways — via the transcutaneous method or
transconjunctival method.
The transcutaneous approach involves making an incision on the outside of the lower eyelid,
right beneath the eyelashes, through which the fat pockets are addressed.
This is in contrast to the transconjunctival method, where fat pockets are addressed through
the inside of the lower eyelid, so no external incision is made,
In my practice, I typically prefer using the transconjunctival method.
Although it can be technicality more challenging , I have found this approach to have consistently
successful outcomes.
Oftentimes, when doctors operate via the transcutaneous method, fat is removed, and what is seen as
excess skin is trimmed to reduce wrinkles, then sutures are placed to close the lower
eyelid incision.
This approach to the lower eyelid, can compromise the delicate support system.
While a well-performed surgery can make the external incision barely noticeable, a scar
of varying visibility is still present where the incision was closed.
Unnecessary skin removal can cause a skin shortage that ultimately leads to complications
such as ectropion and contribute to eyelid retraction.
Ectropion is what occurs when the lower eyelid becomes everted, or turned outwards,.
Eyelid retraction is the downward displacement of the lower eyelid, resulting in a rounded
look to the lower eyelids, and too much of the white part of the eyes being exposed called
scleral show.
In some cases, the eyelids are unable to fully close and the natural distribution of tears
is affected, leaving the inner eyelid and eye itself prone to irritation or infection.
As I mentioned earlier, I prefer the transconjunctival approach.
It’s a technically advance minimally invasive strategy.
This method allows me to address the fat pockets without compromising the integrity of the
support structures in the lower eyelid.
The natural eye shape is better preserved, there is less trauma around the eyes which
minimizes bruising and swelling.
Since there is no external incision, there is no scar, you can look natural, even from
up close, like you’ve never had the eye bags.
Instead of removing skin to improve wrinkles, I approach under eye wrinkles as an issue
of skin quality, not skin quantity.
I use platelet-rich plasma, or PRP, which is derived from your own blood, and contains
wound healing and growth factors that can stimulate collagen and increased blood supply
to the under eye area, improving the health and quality of thin eyelid skin, and make
it thicker.
I also use laser or radiofrequency treatment to resurface and tighten the under eye skin.
In my practice, I perform transconjunctival blepharoplasty under local anesthesia with
LITE IV sedation.
This is as opposed to general anesthesia, which means that my patients are able to recover
faster and can go home after the procedure.
In fact a good number of my patients say that if they knew it was this easy for them, they
would have had the surgery much sooner.
Typically, patients return to work and daily life in one week’s time, sometimes even
less.
In most cases, our patients come back in a week and have minimal swelling and almost
no bruising.
There are risks with eye bag surgery, as with any type of surgery.
These risks can be minimized by choosing a doctor with a high level of expertise, experience
and artistry.
I hope you found this information helpful, and thank you for your question.

Can I choose between a parallel or tapered crease for my Asian double eyelid surgery?
Double eyelid surgery also called Asian eyelid surgery or Asian double eyelid surgery is a very
popular procedure worldwide it’s generally understood that about half of the people of
Asian descent are born without an eyelid crease which applies to people who are
Chinese Japanese Korean as well as other Asian ethnicities it’s often observed that the
absence of an eyelid crease can make the eyes appear smaller and even look tired or
possibly even angry this means that double eyelid surgery can make the eyes look bigger and brighter
people considering double eyelid surgery become aware of the different types of eyelid creases
for example the parallel crease is where the eyelid crease runs parallel
to the eyelid margin of the upper eyelid the tapered or nasally tapered crease it literally
tapers in towards the inner corner of the eye although most of my patients are interested in a
natural result I do find that it’s helpful to show my patients the difference between
these two types of creases and what my recommendations are for their specific situation
I’m Dr Amiya Prasad I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon I’ve been in practice in New York City and Long Island for
over 25 years I routinely perform all types of cosmetic eyelid surgeries such as helping people
who have under eye bags and hooded upper eyelids I also perform specialized cosmetic oculoplastic
procedures such as eyelid ptosis correction I’m well known for performing Asian double eyelid
surgery and as mentioned earlier i there are about 50 percent of Asians are born without an eyelid
crease of course this particular characteristic can apply to other ethnicities who have Asian
features now during consultation I’ll show the patient by using an instrument or a Q-Tip and
push back the eyelid skin where a natural crease would have formed if they had been
born with one now pushing the skin back this way also shows how the patient’s natural anatomy
would have determined whether their natural crease would have been parallel or nasally tapered
as far as a patient requesting a type of crease in my opinion forcing a type of crease that does not
fit your natural anatomy can result in an unnatural looking crease and make you appear
kind of plastic upon determining what kind of eyelid crease looks natural the next step is to
determine what kind of surgical procedure should be performed generally speaking there are two
types of double eyelid surgery approaches there’s an incisional or a non-incisional
option incisional surgery is usually performed in the presence of excessive skin fat or combination
of the two younger patients in their 20s and 30s usually don’t have excess skin or fat so I
usually perform non-incisional Asian eyelid surgeries for these patients with this technique
small openings are made in the upper eyelid so sutures can be passed through these openings to
in order to create a connection between the upper eyelid skin and the muscle that lifts the eyelid
called the levator muscle the area where the connection is made is where the eyelid skin folds
when the eyes opened thereby creating a crease where there wasn’t one before for older patients
who have some eyelid skin laxity due to aging and some prolapsed fat behind the upper eyelid
some eyelid skin and fat can be reduced so that these patients can have a proper crease
now sutures are placed to close the incision and like the non-incisional approach the incisional
procedure the crease is formed where the suture makes a connection between the eyelid skin
and the levator muscle I perform all my eyelid surgeries in my office operating facilities
using local anesthesia with LITE IV sedation thereby avoiding the risks and complications
associated with general anesthesia most of my patients are able to return to work in one week
or less with minimal swelling so although it’s possible to pursue a nasally tapered or parallel
crease by choice in my opinion it’s better to work within your natural anatomy so that
the eyelid crease you have after surgery appears natural and consistent with your facial features
I hope you found this information helpful thank you for your question

What’s the best procedure for eye bags? This question is an indication of the
level of confusion in the marketplace where physicians non-physicians device
manufacturers pharmaceutical companies and cosmetics manufacturers are
overwhelming the internet social media radio and television with claims of
offering the best solution for under-eye bags as an expert in helping people with
under eye bags since the early 1990s I’ll share with you my experience with
people who come to me after trying a lot of these new and improved ways to treat
under eye bags I’ll discuss my approach to evaluating under-eye bags and the
treatment strategies I developed for my patients I’m Dr. Amiya Prasad I’m a
Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic
and reconstructive surgeon I’ve been in practice in Manhattan and Long Island
for over 20 years I perform procedures to help people with their under eye bags
every day in my practice these procedures include lower eyelid surgery
and under eye filler treatments as well as lasers radiofrequency and PRP
procedures which are used to improve the under eye skin I also specialize in
revision procedures for treatments done by physicians and non-physicians these
procedures include dissolving under-eye fillers and addressing complications of
lower eyelid from I back surgeries such as lower eyelid retraction and ectropion
during consultation for under-eye bags I find that a lot of my patients come in
with a list of solutions which they learn after doing lengthy internet
research another group of patients come in after they’ve tried several
so-called non-invasive procedures which either didn’t work or actually made them
look even worse in the course of these discussions there is a common element to
these stories typically they report that they went to someone and that they were
recommended to have a procedure with a new device or an injectable as a shotgun
approach these so-called latest breakthroughs are aggressively promoted
and not surprisingly discounted as an incentive if something works so well why
should you need an incentive other than a successful result
so what was missing what was missing was a proper analysis of the anatomy and an
unbiased discussion about what are the factors which contribute to them looking
tired with under-eye bags so what I say to my patients is let’s clearly define
the problem before we plan the solution when you have under-eye bags which are
constantly present regardless of the amount you sleep the anatomic issue is
most often lower eyelid fat prolapse lower eyelid fat prolapse means that the
fact that is under your eyes herniates forward which we call fat herniation
this problem is generally associated with genetics as well as aging and other
variables such as allergies and sinus problems staying on anatomy I also look
at the bone structure in particular the cheekbone structure I often see prolapse
of fat forward occurring at the same time there is a deficiency in cheek
projection when referring to the cheek I mean the area just below the lower
eyelid seen from a front view as well as the cheek bone which is the high point
on the side next to the eye it’s not unusual for me to see a patient who
feels that they have under eye hollowness as their primary issue
the presence of under-eye bags this makes sense when you understand that the
relationship of the cheek projection to their fat prolapse this perception of
hollow is also caused by the contrast between the height of the under-eye bag
which is like a hill next to the hollow which is a valley resulting in the
perception of a hollow appearance the higher the hill the deeper the valley or
hollow in addition I look at the skin quality in terms of wrinkles tone and
discolorations it’s important to understand that the eyelid skin is the
thinnest skin in the body at about 1/2 millimeter in thickness the
recommendations I make to my patients is based on my experience as a cosmetic
eyelid surgery specialist with experience in multiple surgical and
non-surgical approaches I also own several lasers and radiofrequency
devices and I personally perform injectable treatments such as hyaluronic
acid fillers and neurotoxins the point is that I don’t have a bias based on any
limitation in education or training I select with my patients the approach
which I feel is in their best interest to achieve an outcome that they will
likely to be satisfied with I don’t lease any devices and I have no other
pressures which would make the recommendations I make if I think a
device or technology is effective I buy it outright and I use it when it’s
appropriate that being said let’s look at what defines an effective solution
for under eye bags or any cosmetic procedure in my opinion the procedure
should be one that I would do for myself or a member of my family
this means it should be safe predictable and have minimal downtime safe is
defined by minimal risk of complication from the procedure itself and anything
that could be a risk to your health predictable means that as your doctor I
can confidently anticipate a level of improvement which can be
shown to you in before-and-after photos minimal downtime means being able to go
back to your normal life quickly without a protracted recovery period where
you’ll look at yourself for weeks and months after the procedure and wonder
when you’ll finally look the way you want so here’s what goes on in my mind
when I see a patient who comes in with puffy eyes is there puffiness slight
enough with the bone structure anatomy which would allow me to effectively
camouflage their puffiness with under eye filler much is promoting about
the use of hyaluronic acid fillers as a non-surgical solution for under-eye bags
there are certain anatomic limitations to this approach the term tear trough is
now something anyone doing internet research becomes familiar with this
trough has two boundaries the boundary closer to the eye is the prolapse fat
the other boundary is a bone structure called the anterior lacrimal crest which
is part of a larger bone called the maxilla this bone defines how much you
can fill the tear trough before you exceed the capacity of the trough from
the front the height or projection of the prolapse fat defines the limit of
the fillers ability to diminish the relative prominence of the fat pocket
when the fat pocket and the anterior lateral crest are at about the same
height and there is a deep tear trough I can place a filler such as Restylane
with a blunt cannula and get a very nice result I often see people who had filler
place to camouflage their eye bags which resulted in their eye bags actually
looking worse I see this occur a lot when people insist that a doctor use
fillers when the fat pockets are much too prominent with no space for filler
placement these are the same people who believe
that they know enough to instruct the practitioner on how they should place
the fillers they end up looking worse and then they blame the practitioner for
their outcome when they really needed surgery and refused to accept the
reality that that’s the case I also see people who had too much filler placed
not only in the tear trough but also in the cheek from the front and sides
resulting in a disfiguring and unnaturally swollen appearance this
filler after being placed in the skin much too excessively causes swelling and
probably affects the lymphatic drainage system which further aggravates the
swelling in these patients I have to use large amounts of hyaluronidase to
dissolve the hyaluronic acid filler before doing anything else I often see
patients who did fillers for a few years to camouflage their under eye bags and
found that the fillers weren’t working so well as the fat prolapse became worse
and as facial volume loss from weight loss and aging progressed the next
question after establishing that the eye bags are caused by lower eyelid fat
prolapse is to what extent the individual fat compartments are
significantly herniating forward in the lower eyelid there are three compartment
which are also have deeper extensions and sub compartments the compartments
are the medial central and lateral fat pockets I have the patient look up in
several directions which make these fat pockets become more prominent I also
look at the supporting structure of the lower eyelid particularly the tendon
that is attached to the bone structure called the lateral canthal tendon when
the fat pockets are so prominent that filler cannot effectively be used for
blending a surgical option is appropriate
surgery is often portrayed particularly by non-surgeons as something to be
avoided at all costs I emphasize the word costs since these practitioners
cost their patients thousands upon thousands of dollars in useless
treatments it’s understandable that there are plenty of examples of
so-called botched plastic surgery in the media which contribute to this fear of
surgery I point out to my patients that the people who look natural after eyelid
surgery simply don’t draw attention so the fearful patient doesn’t get to
appreciate good cosmetic surgery results after so many years in practice a lot of
my patients come because they know someone I operated on and they like the
way the person I operated on looks resistance to surgery is also driven by
the fears related to anesthesia and anesthesia related complications in my
practice I perform eyelid surgery under local anesthesia with the LITE IV
sedation as opposed to general anesthesia where you’re paralyzed and
placed on a respirator to keep you alive my patients recover quickly and walk out
comfortable and happily thanking my staff before they go home as far as the
type of surgery is concerned my preferred approach to under-eye bags is
called transconjunctival blepharoplasty this is an approach where I address the
fat pockets from the inside of the eyelids in my hands my patients are able
to maintain the natural shape of their eyes which allows for retaining the
character of their eyes my objective when performing this type of eyelid
surgery is to create the appearance than you would have had if you never had
prolapsing fat pockets my patients recover quickly and go back to work in a
week often without any bruising as a side note I’ve seen patients who
reported having fillers done elsewhere and having been bruised for weeks
while my patients have minimal to no bruising one week after surgery
the next part is skin evaluation if you have lighter skin with wrinkles and
discolorations I often recommend fractional CO2 or erbium laser to
improve the skin quality and texture I also use PRP or platelet-rich plasma
which is a concentration of the healing factors from your blood which stimulate
collagen and blood supply resulting in better skin I use PRP for all skin types
and have found benefit for darker skin types who are not candidates for laser
as mentioned earlier the presence of fat prolapse resulting in under-eye bags is
often accompanied with a deficiency in cheek volume and projection associated
with genetics and aging bone structure determines the facial appearance more
significantly than anything else this means that addressing bone volume
can help you improve your appearance more effectively than any thermal energy
device or the latest innovations with threads the concept is called structural
volumizing where I use my experience performing facial implant surgery such
as the placement of cheek and chin implants to place long lasting
hyaluronic acid fillers I often enhance the cheeks at the same time I perform
surgery for under-eye bags the cheeks can be thought of as framing the eyes
and the balance of the cheeks with the eyes makes the whole face look better I
perform this placement without bruising and without any effect on the recovery
time after surgery I hope you found this information helpful thank you for your
question

What’s the best procedure for mid-face rejuvenation?
People dealing with facial aging particularly in the mid-face area will often assume that
they need a mid-face lift.
However, what is seen as sagging, or skin or tissue laxity may actually be more a loss
of projection and definition due to age-related volume loss.
I’ll discuss my experience, and my approach to mid-face rejuvenation.
I’m Dr. Amiya Prasad, I’m a Board-certified cosmetic surgeon, and a Fellowship-trained
oculofacial plastic and reconstructive surgeon.
I’ve been in practice in New York, and Long Island for over 25 years.
As a cosmetic surgeon focused on treating facial aging, I perform all types of facelift
surgeries, including mid-face lifts.
The experience and knowledge of facial anatomy as a surgeon has guided my approach to the
precise placement of cosmetic fillers at the deeper bone level to restore age related bone
volume loss.
I recall how in the late 90s, facial aging in the mid-face was seen as a problem caused
by laxity and vertical descent of the soft tissue in the mid face.
Different types of mid face lift procedures were being developed using new endoscopic
technologies.
Mid-facelifts are not the same as facelifts, which include SMAS facelifts, deep plane facelifts,
or short-scar mini facelifts.
Full facelifts are meant to address sagging skin, tissue, and as well as tighten the underlying
facial muscle foundation called the SMAS, short for the superficial musculo aponeurotic
system.
These different facelifts, which range with the extent of surgery appropriate for different
age brackets usually start with an incision along the front of the ear, and can extend
behind the ear, so skin be trimmed and lifted, the underlying muscle tightened, and soft
tissue repositioned.
The skin is then redraped, and the incision is closed along the front of the ear.
With mid-facelifts, only lifting the mid face is addressed, so the incision is made in the
temple for surgical lifting of this area only.
In my opinion, these midface lifting strategies addressed a small part of the more significant
cause for a deflated and sagging appearance in this area: Volume loss.
This doesn’t mean that there was no recognition of volume loss, as surgeons often advocated
combining midface lift and fat grafting to add volume.
It’s important to understand that as we age, bone, muscle, fat, and soft tissue decrease,
with bone loss being the most significant.
For example, cheek bone volume loss can make the skin over the cheeks appear to sag, as
the volume that once gave the cheek skin its structure and support is now lost.
Having performed mid-facelifts in the past, as well as surgical placement of cheek implants
to restore volume, I’ve changed my approach to the mid face by focusing on the bone loss
and using new techniques to approach this problem.
For most of my patients, I restore mid-face volume using a specialized method to place
long lasting hyaluronic acid fillers at the bone level in a way comparable to the placement
of facial implants.
Traditional filler placement at the mid-face is usually done at a more superficial level
of the soft tissue.
At this level the skin is unable to support any substantial filler volume.
The filler material will oftentimes migrate, so you can look soft, doughy, and even bloated.
With an understanding of the deeper anatomy of the face from performing facelift and other
facial surgeries, I’m able to precisely place filler at the deeper bone level, and
avoid migration that is seen when filler is placed in the soft tissue.
Placing filler at the foundational bone level actually improves the definition your facial
bone structure.
This method is called Structural Volumizing.
At this time, my filler preference are thicker hyaluronic acid fillers such as Juvederm Ultra
Plus and Juvederm Voluma.
Hyaluronic acid is found naturally in the body, so these fillers are quite biocompatible
and are safely metabolized with time.
We perform structural volumizing for the midface routinely in our office.
Many of our patients come in during their lunchtime and return to work right after.
Your results can be seen immediately after the procedure, however we allow for 2 weeks
to let the material settle into the space it was placed into.
I see my patients in 2 weeks and see if any enhancement would be of benefit.
Generally speaking, one of the first noticeable effect of aging in the mid-face is characterized
by volume loss, leading to you having less projection and definition.
As opposed to surgery and fat grafting, the strategic placement of filler at the bone
level can add structure, definition, as well a subtle lifting effect, without surgery.
I hope you found this information from my experience helpful.
If you’re interested in recommendations for your individual situation, you may contact
us through our websites or call our offices to schedule a consultation.
Thank you.

Defined and youthful cheekbones are often underappreciated until they
diminish with facial aging well-intended injectors place fillers under the skin
hoping the shape they molded under the skin during the procedure would remain stable
unfortunately the filler doesn’t hold its shape so results are either minimally noticeable
from underfilling or the person ends up looking doughy and bloated from overfilling
I find that many people are influenced by marketing and assume that the brand
of the filler is the basis for the quality of results in reality the brands of fillers such as
Restylane and Juvederm have a lot of comparable filler characteristics within their subcategories
these subcategories of fillers have different levels of viscosity which a practitioner can
easily select from so in actuality it’s the technique that defines the quality of the results
not the specific brand by applying a more advanced technique and deeper level of filler placement we
can achieve natural looking defined results which remain stable for typically one year or even more
this is called structural volumizing as the placement of material is at the bone structure
level in addition this placement technique allows for flexibility and convenience for our patients
as they don’t have to worry about having conspicuous swelling bruising or
very visible marks which are more of characteristic of typical conventional injection
methods many of our patients have their cheekbones enhanced over their lunch hour and they return
to work immediately afterwards I routinely see my patients after two weeks to see how they look and
review their before and after pictures so they can see the benefits of the improvement for themselves