Ilya Reyter, MD

The key to understanding why a face appears "older" or tired is to look at what happens to facial volume over time. By studying MRI images of the aging face, we have learned that fat and bone are reabsorbed by the body slowly over the years. In time, this leads to sunken, hollow looking cheeks, especially the upper cheeks. This can often lead to a deep valley, right underneath the lower eyelid, causing the lower eyelid to look like it is bulging out.

Previously, almost all lower eyelid bulging was treated by surgically removing the lower eyelid fat. This eliminated the bulging, but somehow caused the face to appear even older as the person aged. Young faces look full. Older faces look skeletonized an hollow. So, by further hollowing out the face, the patient looked even older. Quite the opposite of what many patients were trying to accomplish.

Having understood the connection between fat loss and the aging face, many doctors are using new techniques for treatment of this condition.

One such technique is fat transfer. Having taught fat transfer for years at the University of Southern California Keck School of Medicine, I know this to be an incredibly powerful procedure. It can be performed using just local anesthesia in a doctor's office. The fat is harvested almost painlessly from the thigh or abdomen, and injected into the face using a tiny needle or cannula. The fat fills the valley in the upper cheek, and feels soft and natural. Sure, some fat may be absorbed by the body, and a touch up fat transfer may be necessary, but a touch up is easy to do, and takes very little time.

Another good option is using a hyaluronic acid filler such as Restylane. This works just like fat transfer, by filling the valley where the lower eyelid meets the upper cheek. The advantage, however, is that Restylane is very quick and easy to do, and eliminates the need for fat harvesting. I do this quite often, and have developed a technique that leads to very little pain or bruising. It is quite remarkable how often patients can avoid surgery just by doing this procedure.

In regard to your question about where Restylane can be placed, it depends on technique. With proper experience, it is possible to place Restylane almost anywhere along the lower eyelid. There is always the risk of injecting Restylane directly into a blood vessel, and this can lead to retinal artery occlusion and blindness. However, this is such a rare occurrence, that only very few instances were ever reported, despite the popularity of these types of injections. I feel quite comfortable performing these types of injections, and would also feel comfortable having this performed on me or my family members (and in fact, I have performed this on many of my family members!)

Should the lower eyelid bulging be severe enough to warrant surgical correction, again, the key is volume preservation. There is a trend developing toward preservation and repositioning of lower eyelid fat as opposed to removal of the fat. By repositioning the fat, the surgeon can avoid the hollow, skeletonized appearance that can result as a person ages after having lower eyelid surgery done. I almost always use this technique for lower eyelid surgery.

There is a great art to performing skin closures after Mohs surgery. Regardless of who performs the closure, it does take some time for the skin to heal, and the swelling to go down. Immediately after surgical closure of the wound, it is not unusual for significant swelling to occur, distorting tissues, and sometimes causing a temporary pulling and tightness of the skin.

Fortunately, these changes dissipate over 1-2 weeks after surgery. Occasionally, however, it may take longer for the post-surgical changes to go away, sometimes as long as several months.

With that said, I always make it a point to see my patients a few days after surgery and I continue seeing them regularly as the healing progresses. At these visits, I discuss the surgical closure and ask the patient if they have any concerns about the cosmetic or functional outcome of the surgery.

Although a revision surgery may be performed to correct an unexpected surgical outcome, this is very rarely necessary, especially when the procedure is performed by someone accustomed to performing Mohs surgery closures.

I would encourage you to bring up your concerns to the surgeon at your post-operative visit. If none was scheduled, call the surgeon's office and ask to see the doctor to discuss this soon.

Accutane is a wonderful medication, but it can be pretty hard on the liver. In fact, one of the main side effects seen in many people who take the medication is alteration of liver function enzymes. We check these regularly when someone is taking Accutane.

The safest way to perform liposuction is to use the tumescent technique, or injection of large amounts of dilute local anesthetic solution. Lidocaine is the anesthetic used. Lidocaine can be toxic if high amounts are in the body. The liver has the job of clearing lidocaine from the bloodstream.

If the liver is irritated, damaged, or not working properly as a result of a medication such as Accutane, toxic amounts of lidocaine can build up in the body and lead to very serious complications.

I would advise any patient to wait until they were off Accutane, even if the liver appears to be working properly on the medication. It is simply not worth the risk.

The laser that your dermatologist is using is likely very different than the Med Spa laser. Typically, only a physician will perform intense facial resurfacing. At a med spa, typically nurses perform the treatment, which limits the power of the treatment that can be used.

My favorite laser for facial resurfacing, after having tested them all, is the Active Fx. It has the power to deliver real, visible results after one treatment. The downside is that it usually takes 4-7 days to recover from the treatment. I generally avoid "minimally invasive" lasers for resurfacing, since they typically produce minimal results. In my practice, I have many patients who have done multiple Fraxel treatments elsewhere that come in to see me regarding more intense facial resurfacing. Quite simply, no laser matches the improvement that a carbon dioxide laser can achieve on skin tone, texture, and wrinkles.

I have been using Active Fx since the machine came out on the market several years ago. I remain very impressed by the results that this laser delivers. After having tested most of the competing devices, I know that the Active Fx is able to produce real, visible improvements after just one treatment.

The main indications for performing an Active Fx treatment are: fine lines/wrinkles, acne scars, sun spots and skin laxity caused by years of sun exposure, and uneven skin tone/pebbly skin texture.

The Active Fx laser is much more powerful than many of its competitors, and has the capacity to deliver a true, non-fractional carbon dioxide laser treatment, should that be necessary. For a younger person, I usually use the Active Fx, fractional settings, which generally deliver impressive results after just one session. The healing time after a standard Active Fx treatment is generally 4-7 days, depending on the settings used.

Occasionally, it is necessary to repeat an Active Fx treatment to enhance the results, but it is the expectation, not the rule.

Some people try to avoid the healing time by choosing to do a less intense treatment with an alternate laser. Unfortunately, minimally invasive laser resurfacing generally produces minimal results.

In my experience, almost every lipoma can be easily removed using only local anesthesia right here in the office.

Even large lipomas can be removed in the office. Sometimes I employ a liposuction cannula to remove lipomas, as this technique can remove even quite large lipomas while leaving tiny scars (1-3 millimeters in length). I have never had a patient require an overnight stay for lipoma treatment.

Although having a lipoma on the lip is possible, it is quite uncommon. If this nodule is in fact a collection of fat cells, or a lipoma, then there are 2 main ways to remove it: cut it out or remove it with suction (liposuction).

Sometimes it is possible to remove such nodules by going from the inside of the mouth, thereby avoiding a visible scar on the face. Removing it with liposuction is sometimes also a great option, because small cannulas can be used, some no bigger than 1-2 millimeters, thereby leaving no big scars on the face.

Viafill is a branded kit for fat transfer sold by a company to physicians. I guess the point of the kit is to make fat transfer easier for physicians by standardizing the process. I have heard some claims that the Viafill procedure may produce better results than traditional fat transfer. However, I have never seen these claims substantiated by independent scientific evidence, which makes me question their validity.

Having taught liposuction and fat transfer for years at the University of Southern California Keck School of Medicine, I know that the most important component of fat transfer is the surgeons technique in removing and placing the fat. When I teach doctors to perform fat transfer I always spend the most time showing them the importance of proper fat placement and the volume of fat that must be placed to help insure fat survival and good cosmetic results.

Fat transfer can create an incredible improvement in the appearance of an aging face, often eliminating the need for more invasive surgical procedures, such as facelift, while producing natural looking results. When selecting the physician to perform this amazing technique, the main focus should be on the skill and experience of the surgeon. I am not sure that this particular Viafill system offers any substantial improvement to the established method of fat transfer that experienced doctors are already using today.

This is a great question.

A scar, by definition, is not normal skin. A scar occurs when skin cells make excess collagen and other skin proteins in response to injury or trauma. Essentially, normal skin is replaced by these newly produced skin proteins, forming a visible scar.

Once the scar forms, there is really no way to remove it without causing some sort of new injury or trauma to the skin, which can then lead to another scar.

It becomes a vicious circle. The goal is to try to do the least amount of damage to the skin while treating the scar, to help diminish the appearance of the scar while not causing enough injury to make the skin react and form a new, bigger scar.

This is most evident when trying to cut out an unattractive scar. Often times, a new scar forms, which can be just as bad or worse than the original scar.

This is not to say that I advocate no therapy for scars. Quite to the contrary, I perform many procedures aimed at reduction of scar size and appearance, with many of them producing quite successful results. From lasers, to injections with steroids, to dermabrasion, and even surgical scar revision, there are many things that can be done to improve the cosmetic appearance of a scar.

But making it vanish forever - not possible (yet).

The wrinkles you are seeing are most likely just temporary effects from the dryness that Retin-A can cause when you first start using it.

Retin-A is actually the most powerful wrinkle fighter available. It is a member of the retinoid family, and retinoids have been shown, scientifically, to reduce wrinkles. No other cream, lotion, or potion has as much rigorous science behind it to support claims of wrinkle reduction.

The downside to Retin-A use is dryness of the skin when you first start using the cream, much like soreness that occurs when a person first starts exercising. Eventually, the dryness goes away as the skin adjusts to the cream, but that process can take weeks if not months in some people. The key is to go slowly, don't use it everyday at first. Listen to your skin, and use less if your skin is showing signs of irritation.

To relieve dryness from Retin-A I usually recommend a mild, non-soap cleanser to wash your face (such as Cetaphil) and a light moisturizer, again like Cetaphil, to help decrease some of the light irritation and flaking that Retin-A can cause. Also, I tell people to use the Retin-A 2-3 times a week at first, and gradually increase frequency of use, as your face can tolerate.

Over time, use of Retin-A will definitely make wrinkles on the face appear softer and less apparent.