Treat signs of aging using under eye dermal fillers
A couple of things happen as we age. The fat compartments under the eyes above the cheeks shrink (atrophy is the scientific term). Thus reducing support for the skin and muscles around the eyes. The bones around the eye sockets also remodel (change shape) which causes even greater loss of support for the overlying soft tissues. This sagging in the under eye area gives rise to the signs of aging. And dermal fillers are a great way to reduce the signs of under eye aging.
Under-eye area showing signs of aging
5 signs of under-eye-aging:
Hollowness or sunken under-eye area is the direct effect of the fat atrophy.
The lengthening of the lid cheek junction (above red line) which is due to the lack of support.
The tear-trough deformity, which is a groove under the eyebags. This is also due to the lack of support.
The Eyebags. These may be psuedo-eyebags caused by skin laxity rather than actual eyebags, which are caused by fat pad herniation.
Dark eye circles. Thin skin draping over muscle gives rise to the darker color. Only very rarely are dark eye circles the result of actual pigmentation on the skin.
The Treatment For Under-eye Aging
The treatment however is relatively simple. Dermal fillers when skillfully injected into the fat compartments in the under-eye area provides support and resolves most of the above problem features. The dermal filler is carefully placed using a cannula (a needle with a rounded tip) to minimize trauma. The dermal filler spreads evenly over the areas treated. Lumpiness is rare with the cannula technique of injection. Bruising can sometime occur even with a cannula but are usually quite minimal.
As for the crepey skin in the under eye area, the dermal fillers can help somewhat, but usually a bit of laser to tighten up the skin, and reduce the fine lines, and that’s all it takes to brighten up the look. The fractional CO2 laser is good, but has a bit of downtime. Otherwise, Sylfirm or Thermage eyes are not too bad too.
Watch Dr Davin Lim from Australia being treated by Dr David Loh while he was in Singapore. Under eye dermal filler injections.
A medical case report by David Loh Surgery has been awarded the PRS Global Open 2019 ‘Best Case Report’ (Gold) by international medical journal Plastic & Reconstructive Surgery.
With facial fillers being a widely available aesthetic procedure to temporarily reduce the appearance of wrinkles, or contour faces, there have been some cases where patients have developed features of “impending skin necrosis”: discolouration of the skin due to the premature death of skin cells, in reaction to soft tissue augmentation resulting from the injection. While rare, this complication may occur even under the care of experienced injectors.
David Loh Surgery’s founder Dr David Loh and partner Dr Phoon Yi Shan, who is in charge of the branch clinic at Novena Medical Centre, together with two other doctors jointly authored a case report on such an incident which was successfully managed with prompt diagnosis and treatment.
Entitled Successfully Managing Impending Skin Necrosis following Hyaluronic Acid Filler Injection, using High-Dose Pulsed Hyaluronidase, the paper was first published by PRS Global Open in its February 2018 issue. Using data collected on the article’s view count and sharing activity, among others, David Loh Surgery’s case report was then scored and selected by the journal’s editorial and publishing staff for the award.
“We are very honoured to represent Singapore in contributing to the global body of medical knowledge with our recent case report on successfully managing hyaluronic acid filler-induced impending filler necrosis,” says Dr David Loh, founder and medical director of David Loh Surgery.
“This accolade from PRS Global Open, as an open-access and peer-reviewed international journal, bears testament to our commitment to furthering safety and standards in aesthetic medicine. The culture of knowledge sharing and continuous learning is very much in line with our philosophy at David Loh Surgery,” he adds.
Plastic and Reconstructive Surgery is the official publication of the American Society of Plastic Surgeons. The title launched Plastic and Reconstructive Surgery – Global Open, in April 2013 as a companion journal with an intention to globalise plastic surgery research, collaboration, and best practice sharing through its open access platform.
PRS Global Open holds its annual Best Paper Awards event with the aim of recognising the best new papers by both US and international authors across multiple categories including that of Best Case Report under which Gold, Silver and Bronze Awards are presented.
David Loh Surgery’s award-winning case report can viewed in full here:
The Liquid Facelift is a popular procedure in aesthetic clinics across Singapore. It is termed ‘liquid” because it involves using only B*tox (a liquid) and hyaluronic acid fillers (a gel) to create a lifting effect on the lower parts of the face. It is a non-surgical and involves very little recovery time. In fact, as a “facelift” achieved through injections only, it has also been popularly called a “non-surgical facelift” or “lunchtime makeover”.
Over the years, many experts have also described other variations of the Liquid Facelift, and they are all very good.
The are 3 important factors to consider when performing The Liquid Facelift.
The first is where to inject. Great masters of filler injections have proposed various depths of injection. Some for reasons of safety (deeply just above the periosteum), while others have target the “retaining ligaments” to build “struts”and “supports” for the sagging. Dr David Loh proposes that fillers be placed into fat compartments to mimic the state they were in before they underwent atrophy with age.
The second is when to inject. Understanding that fat pads will sequentially atrophy in the process of aging, might one not be able to pre-emptively inflate the fat pads to prevent sagging altogether? Hence the question about when to inject becomes quite important as we can prevent, rather than chase, signs of aging.
And the last consideration is how to inject. This is a cannula vs needle question that many expert injectors of dermal fillers have weighed in on. And the aesthetic medicine community is actually quite divided on which technique is better. Dr David Loh’s technique uses a cannula to accurately deliver fillers into the fat pads.
With there 3 considerations in mind, Dr David Loh popularized and has been teaching a particular form of the Liquid Facelift since 2015, and the technique has been named The DL Lift by many in his industry; DL being the initials for Dr David Loh who described it.
What is the underlying philosophy of The DL Lift?
In 2018, Dr David Loh and Dr Phoon Yi Shan, the partners the David Loh Surgery, described and published The DL Lift in The Prime International Journal of Aesthetic and Anti-Ageing Medicine, a medical industry journal, detailing the technique for other doctors.
One of the fundamental reasons why we sag when we age is because of sequential and progressive fat compartment shrinkage. Yes, fats in the face are compartmentalized and they are adjacent to each other. When one compartment shrinks, the tension in the whole structure we call the SMAS is weakened, and sagging happens.
However, the fat compartments shrink sequentially, some like the under-eye fat pads shrink as early as when we are in our late twenties. Hence hollowness and tired looking eyes can be seen in commonly in the thirties. Then the temple fat compartments shrink in the thirties, and the lateral cheek fat compartments shrink in the forties. This leads to the formation of the jowls in the fifties. This is a well-documented phenomenon that has been published in medical literature.
Doctors at David Loh Surgery have shown that by selectively restoring volume in certain fat compartments that have begun to atrophy, we can restore tension in that layer under the skin that supports the face.
“More importantly, if we already know when which fat compartment will atrophy in each stage of our lives, we can preemptively add volume to that compartment, so that facial sagging can be slowed down or even prevented altogether.”
This preventive anti-sagging proposition is a novel concept, because in real life most people would not approach a doctor to reverse aging until aging has occurred.
The DL Lift technique involves using cannulas to accurately deliver fillers (or autologous fat) into the specific fat pads that have either atrophied or are predicted to atrophy. This restores the tension within the SMAS and gives a mild facelift type effect. The whole procedure takes less than an hour and the results are instant.
There is usually little recovery time, only the occasional bruises and some swelling that might take a week to subside. The procedure can be used in conjunction with other treatment like Ultherapy, Thermage and Thread Lifts.
Dr David Loh founded David Loh Surgery in 2002 with the aim of helping his patients improve their appearance and self-image, and in the process enhance their confidence. The clinic only uses treatments that are scientifically proven to be safe and effective. The medical jargon for this is “evidence based”, and has remained a cornerstone of all treatments provided at David Loh Surgery.
Furthermore, these treatments usually involve little or no recovery-time. Treatments like b*tox and fillers, fat transfers and ultherapy are what Dr David Loh is better known for.
Dr David Loh and Dr Phoon Yi Shan have left their mark in the medical aesthetics industry through publications like the one above in The Prime Journal, as well as on matters relating to filler complications management. One of their papers was awarded a Best Paper (Gold) by the Plastic and Reconstructive Surgery journal in September 2019.
Dr David Loh is the President of The Society of Aesthetic Medicine in Singapore, which actively promotes safety, efficacy and standards of care among its members through regular teaching sessions, workshops and conferences.
What causes gynecomastia (male breasts or Man Boobs)? How can we treat it? Also, what is pseudo-gynecomastia?
The first: Exercise?
One thing is for sure, “push ups” are not one of the treatments.
The glandular tissues in the breasts are by nature sensitive to hormonal changes. They grow and swell when there is a surge in sex hormones. And shrink when hormone levels are low. Which is why females develop breasts at puberty.
Though uncommon, some boys also develop swelling in the breasts usually around puberty, but which then spontaneously resolves. It may affect one or both sided of their chests. The name for the condition is gynecomastia, and it is probably the result of a temporary hormonal imbalance causing the breast tissue to be sensitized. No treatment is needed for this group of boys.
Second: Investigate and Treat hormonal disorders, if any.
A small percentage of these cases of pubertal gynecomastia continue to have a small amount of breast swelling into adulthood. In the great majority of these persistent cases, there is no underlying cause to be found. However, a small percentage of these cases are associated with a more serious underlying conditions where excessive female hormones are produced – including certain cancers. But these are extremely rare.
Quite commonly these days, gynecomastia is also associated with the abuse of anabolic steroids for body building purposes. In fact, they constitute the large majority of the cases we treat.
And then there is “pseudo-gynecomastia”. Whereas in gynecomastia, the breast’s glandular tissues are enlarged, in psedo-gynecosmastia only the surrounding fat tissue is excessive, which then gives rise to the appearance of breasts on a man’s chest.
“Pseudo” or “real” are quite easily distinguishable. When squeezed between your fingers, fat feels different from glandular tissue. Fat being softer to touch than glandular tissue. An ultrasound scan may also be useful to distinguish between the two.
Distinguishing between “pseudo” and “real” gynecosmastia is important because while pseudo-gynacomastia is mainly a body contouring issue and there are methods including liposuction which can help reduce it; “real-gynecomastia” may be a sign of a more serious underlying pathology. And it calls for clinical investigation into whether there are underlying medical conditions.
A series of tests (lab and X rays) should be able to rule out the more serious stuff. And the tests are not expensive. Referrals can be made if serious underlying conditions are detected.
Third: Liposuction or Excision for Men Boobs
In most of the cases, there will be nothing wrong elsewhere and then the gynecomastia becomes a purely cosmetic issue. The breast tissues can be surgically excised in a minor surgical procedure.
The commonest group of patients that present with male breasts are nowadays those whom had at some point in their lives abused anabolic steroids.
The signs are very tell-tale. Firstly, these patients are bulkier in terms of muscle mass than an average male, they have rougher and more leathery skin than usual, and they have “bitched nipples” (this is body-building terminology for permanently erected nipples).
Treatment for this group of patients may involve combining a liposuctionwith a surgical excision, as they would have both swollen glands and accumulated fat after they abandoned the body building circuits.
There are of course medications that can help block the oestrogen sensitivity. Drugs like Clomiphene and Tamoxifen are inexpensive ones. They may not always work. So cosmetically speaking liposuction and or surgical excision is still the surer bet.
About our Doctors
Dr David Loh is the founder of David Loh Surgery located in Wheelock Place and Novena Medical Center. He is assisted by Dr Phoon Yi Shan, who is a senior partner in the aesthetic practice. Dr David Loh is accredited by MOH to perform liposuction. Dr David Loh is the President of the Society of Aesthetic Medicine.
Our doctors use a combination of liposuction and surgical excision to help our male patients achieve a better-looking chest. We will investigate for any underlying medical condition that may be causing the hormonal imbalance.
Fat grafting is a long established technique in cosmetic surgery; probably for as long as liposuction has been available. And that’s since the later part of the 1980s.
What’s new is that we can now select the smallest particles of fat cells (Nanofat), and use them to erase lines and wrinkles, as well as to improve skin quality. Some researchers have referred to them as stem-cell-like fractions called Stromal Vascular Fraction (SVF) or Mesenchymal Stem Cells (MSCs).
1. WHAT IS NANOFAT GRAFTING?
Nanofat injection is a method to reduce fine lines and wrinkles, or generally to improve skin quality in the face.
Nanofat is delivered like a filler injection except in this case the material used is autologous fat (one’s own fat cells).
Fat grafting (or fat transfers) are not exactly a new procedure. The procedure where grafted fat is used to volumize and lift the face, has been around for a long time. Of course, techniques and methods have improved over time. However, the advent of Nanofat represents a quantum leap in Fat Grafting methods. We are now able to treat even the fine lines under the eyes and around the mouth using Nanofat delivered with a very fine cannula.
Nanofats are actually the smallest particles of fat cells, which will survive best in a transplant scenario. The skin benefits are believed to be at least partially due to the stem-cells and growth factors in the Nanofat.
The ability to micronize fat cells down to very fine spheres has opened up many new possibilities, and as such the field of fat grafting has re-gained in popularity in the last few years.
2. WHAT IS NANOFAT USED FOR?
Nanofat can deliver skin quality improvements like the reduction of fine lines and wrinkles.
Recent studies have also shown that nanofat can improve the appearance of old scars(reference article – click here). (Updated in 2021 in The Plastic Reconstructive Journal: Adipose-derived stromal vascular fraction, or more commonly referred to as Nanofat, can improve skin quality via increased collagen production, and resist UV induced skin damage when injected into the dermis of the skin.
Used together with MilliFat and MicroFat, which provide structural support for the sagging face, we can reverse a host of the signs related to ageing. The only thing it does not treat is pigmentation. But it can even reverse skin damage due to sun (or UV) exposure.
Fat grafting is often used to enhance the effects of a threadlift or some non-surgical facelift like Ultherapy and Thermage.
3. WHAT IS THE FAT GRAFTING PROCEDURE LIKE?
The procedure involves harvesting fat from the abdomen or the inner thighs under local anaesthetic – essentially a mini-liposuction.
The fat is then cleaned, filtered and separated into different size cells – MilliFat, MicroFat or NanoFat. The larger fat cells are used to revolumize and lift the face, a kind of structural support, using a technique that Dr David Loh published. The technique has been commonly called the DL Lift.
The smallest of the fat cells are the Nanofat. They are used for the reduction of lines and wrinkles. Or for general skin quality improvements.
During the whole process from extraction, filtration to re-injection, the fat cells are completely free from environmental contamination (scientific jargon: closed system). We have a patented closed system for nanofat injections.
Post procedure, there will be some bruising and discomfort in the donor area (the area where fat was harvested in a mini-liposuction). This may take a few days to a week to recover. The overall discomfort is generally mild.
The face where the fat has been grafted will also be slighted swollen (about 20% bigger, I would say), and be slightly tender (sore to touch). Some bruising is to be expected, but again the overall recovery process is quite comfortable.
4. HOW LONG CAN THE GRAFTED FAT LAST?
A certain percentage of the transplanted fat will not take in the new environment and undergo apoptosis. Usually for the face, because of the rich blood supply, graft survival rates are quite high. You can expect somewhere in the region of 40%-60% grafted fat survival rates. So, we only need to over transplant by a little to achieve the desired outcomes.
After about one-month, whatever fat cells that remain will last forever. They will have been incorporated into the face and will last forever barring the ravages of time. In fact, they will expand and contract with extremes of weight fluctuations.
5. HOW DOES FAT GRAFTING PRICE COMPARE WITH DERMAL FILLERS?
When we do a fat grafting procedure, it is always a full face procedure. Meaning we treat the forehead, temples, cheeks and even the chin. And we harvest nanofat to treat the undereye and perioral areas too. The reason being that we want to maximize the areas treated because a mini-liposuction is involved each time. Multiple syringes of dermal fillers would be needed in order to treat similar areas. Maybe of the order of 8-12 syringes. At $1000 per syringe, you can imagine the cost even if we give discounts when multiple syringes are used. See your price list
Fat grafting (structural augmentation and nanofat grafting) costs $4,000 before GST. That’s it. And a proportion of the fat will stay for the long term.
The only “shortcoming” with fat grafting is that certain areas that need stronger structural support like the chin and the nose, harder HA fillers like Volux might still be better. In order to achieve the kind of projection needed for such areas.
The kinds of aesthetic treatments that men have done on themselves are not very different from the ladies.
The main difference being that men prefer those treatments with almost no recovery time. Treatments like Skin Tightening Treatments, B*tox and Dermal fillers. What gave rise to the era of male aesthetics was really the invention of aesthetic treatments that involved so called “no downtime”.
What really broke down the barrier to men fully embracing aesthetic treatments were the skin tightening treatments that started becoming popular around 2009-2010. Treatments like Ultherapy and Thermage mean “no-downtime”, and totally non-invasive skin tightening treatments. This went down very well with men.
In the past, cosmetic surgery used to be associated with bruises and bandages; extended healing time and exaggerated features post-surgery. Men absolutely hate having such procedures done. For one they cannot apply makeup to conceal any bruises, and secondly men hate taking time off work for such vanity-associated reasons.
With the newer methods and technologies, doctors are now getting reasonably good results with no recovery time at all. Hence more men are keener to do such procedures. Not only are they keener to do such procedures, they are also more keen to talk about their experiences with they spouses or their male buddies. This really re-defines aesthetic treatments for men, aka males aesthetics.
In fact, we have found that the “power of control” over one’s appearance that aesthetic treatments offer, goes down very well with the highly-driven male-corporate climbers’ psyche. Looking sharp is as much a prized commodity as being sharp-witted and sharp-minded.
You have to to admit it. Not only do they embrace aesthetic treatments, they will often travel the world looking for the latest technologies and the most skillful doctors.
And these highly driven, very successful individuals, usually have no qualms talking about “having work done” so long as the aesthetic treatments do not leave them with any recovery time. And as long as they do not have to put on makeup to conceal bruises, they would be most happy to share their experience about how they keep young and competitive.
That is in essence what male aesthetics has become – the “power of control” in our ever changing and highly competitive world.
Something new and exciting that i have to share about melasma treatment. A laser that effectively treats the most difficult kind of pigmentation, melasma. I know this might sound cliche, but it is a breakthrough as far a melasma treatment is concerned. Introducing the Dual Yellow Laser. It is not some new fangled toy. It has been in the market for a number of years, and it has clinical papers to prove its efficacy and safety.
Where lasers failed in the past was that that they were designed to fragment pigments under the skin. In doing so, we sometimes injure that skin, which leaves a mark (PIH) itself. Even if we don’t cause any injury, there is another underlying reason for melasma, the aggregation of tiny blood vessels, that is not treated. So along comes this Dual Yellow Laser that can address both these problems. Hence we have seen a dramatic improvement of outcomes in the treatment of melasma.
But of course that is not the whole story. Effective treatment of melasma should really start with sun-protection. One should also review underlying hormonal causes that can be modified. Like the use of oral contraceptive. Chemical peels like glycolic acid peels and retinoids, and de-pigmentation agents like hydroquinone, arbutin etc can also be used.
Laser should be used as a laser resort, after all the above have failed or the benefits have plateaued, to clear the more superficial pigments.
Blotchy pigmentation and telangiectasia are characteristics of melasma.
B*tox, and the various other brands of botulinum toxin are complex molecules that are derived from nature but synthesized in a laboratory. They work by blocking nerve receptors in muscles, sweat and oil glands. When skilfully administered to the target muscles, B*tox can be used to decrease wrinkles, reduce sweating and decrease oiliness in the skin.
What are the uses for B*tox?
Classically, B*tox is injected to erase lines on the forehead, between the eyes (the glabellar frown lines) and the crow’s feet. Less lines means less shadows across the face which looks neater and fresher. Or younger.
A novel use for B*tox would be to reduce the size of the jaw muscles. B*tox is injected into the biting muscles at the back of the jaw to cause the muscle to weaken and shrink. This then gives a slimmer and more triangularly shaped face.
B*tox can also be used to define a jawline and also to lift the skin of the neck.
And then there is Intradermal B*tox (previous also called Microb*tox or Mesob*tox). Multiple tiny injections of b*tox are placed within the skin to decrease the “opened-pores”. And btw, the intradermal b*tox also reduces sweating and oil secretions, which gives another level of refinement to the skin. Conditions like mild acne and rosacea responds well to this treatment.
B*tox is also quite often used in the treatment of hyperhidrosis. Injected into the skin of the armpit or the palms, it will reduce sweating for 6 months of more.
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Ok, how to get the best results?
The best results depend mostly on the aesthetic doctor’s skill and experience. Hence prices also differ greatly among doctors. This is a situation where you really get what you are willing to pay for.
For those who have only bad experiences with B*tox, you have only yourselves to blame. Because among all the available aesthetic treatments in the world, B*tox gives the most predictable results in trained and experienced hands. If the intention is to erase a line, and if it is technically feasible, it will be successful in more than 90% of the time. No laser treatment comes close to this kind of results.
So why is it that sometimes there are no results? The results and duration of action (longevity) are dose-dependant. If an area needs 20 units of the product, but you are only willing to fork out money for 10 units (“just to try”, many patients will often say), then of course the results will be sub-optimal and it will not last.
Also, it is not wise to dictate that your doctor treats one set of muscles only. Adjacent muscles compensate and may give rise to unfavourable results – like the “Spock sign”. Always treat anatomical zones in totality.
The take home message, if you want the best results from your B*tox treatment, is to go to a trusted doctor and listen to her/him. Otherwise ask Dr Google to inject for you.
Should you go to unlicensed beauticians? As you would expect, skill and experience differ already among trained aesthetic doctors. What more with people who have not had medical training on hygiene and facial anatomy. We cannot stress more about this point.
Cellulite is caused by “bulging” fat-pockets tethered down by fibrous bands under the skin. Excess fat and water-retention aggravates the “bulging.” Dimpling and uneven skin, which is characteristic of cellulite, has also been likened to an orange peel – peau d’ orange.
Cellulite, which affects over 90% of post-pubescent women to varying degrees, is commonly found on the thighs, buttocks and legs. The older one gets, the more likely that there is cellulite. This can be explained by an increase of hard fibrous bands accumulating in the thighs over the years.
HISTORICAL PERSPECTIVE
On the point about poor circulation, it is very interesting to note that doctors in the early days of Medicine (19th century) classified Cellulite as a disease of poor circulation and possibly an “infection”. You find the term “Cellulitis” used in older textbooks. Cellulitis nowadays denote an infection of the skin and its subcutaneous tissues. Which Cellulite is absolutely not. It however shares the characteristic of infection, like swelling and poor circulation.
ANATOMICAL PREDISPOSITION
Cellulite is caused by bulging fat pockets squeezed by fibrous bands in certain parts of the body. The fibrous septae in men are diagonal whereas in women where they are perpendicular to skin. This and the difference in fat distribution between the sexes, make cellulite more common in women.
COMMON MYTHS
The actual problem is not the result of being overweight, contrary to common beliefs. Cellulite can sometimes be found on non-obese girls in their 20’s.
However, weight reduction often causes it to appear less visible. Exercise decreases the appearance of cellulite mainly be improving tissue circulation. And to a certain extent, it reduces fat deposits.
CURRENT TREATMENTS
Treatments that improve local tissue circulation will be useful. Medical grade RF, Mechanical RF, Shockwave, and even manual massage will he useful. The heat generated by some of these methods destroys a little of the fats, contracts the fibrous septae and improves tissue circulation.
We have both mechanical and non-mechanical RF, shockwave and 2 kinds of cryolipolysis for the above purpose. However, these are only useful for mild degrees of cellulite. And regular maintenance is needed, as you would imagine for a condition where the underlying problem is “poor circulation”.
Subcision in the hands of an experienced liposuction doctor is a more permanent solution. The harder and thicker fibrous bands can be severed in subcision, which is a minor surgical procedure. Like below.
EXPECTATIONS
Cellulite-free legs like in fashion models can only happen in print media because of photoshop. In reality, very few women can escape having some cellulite. It’s all a matter of degree.
However, with a scientific approach to understanding and treating the underlying causes, we can treat cellulite to a reasonably good degree.
