Episode 23: Sunday November 22

Drs. Sam Jejurikar, Salvatore Pacella, and Sam Rhee discuss a case and review different minimally invasive ways to narrow and contour the face and neck. From Botox and Dysport, to Kybella, buccal fat excision, liposuction and more, the plastic surgeons review how to narrow and shape the face with options that offer little downtime and scarring.

The 3 plastic surgeons talk about the many factors should be taken into consideration when choosing which techniques are best. If you are interested in the latest and greatest in face and neck contouring, this episode is a MUST WATCH!

Full transcript (download PDF here)

S01E23 - Face and Neck Minimally Invasive Contouring
Dr. Sam Jejurikar: [00:00:00] Good morning, everyone. And welcome to our next edition of three plastic surgeons and a microphone. I'm dr. Sam Jujurikar of Dallas Teax whose Instagram handle is @samjejurikar. And as always, I am joined by my two esteemed colleagues, Dr. Salvatore Pacella from LA Jolla, California. who's @SanDiegoplastic surgeon on Instagram and dr. Sam Rhee, Paramus, New Jersey who's instagram handles @Bergencosmetic. Before we get into any sort of meat to talk about our show today, I am going to throw out our disclaimer, which is this show is not a substitute for professional medical advice, diagnosis or treatment. This show is for informational purposes only.
Treatment the results may vary based upon the circumstances, situation and medical judgment after appropriate discussion, always seek the advice of your surgeon or other qualified health provider. With any questions you may have regarding medical care, never disregard professional medical advice, or delay seeking advice because of something in the show.
So I'm excited about today's topic. This topic idea was brought to us today by Dr. Sam Rhee. And we're going to be talking about facial and jawline contouring, which I know is something we all see a lot of in our practice. Dr. Rhee, please guide us. 
Dr. Sam Rhee: [00:01:13] Thanks. I'm just going to go ahead and throw out my patient's pick, and then we can start talking about it and, different, treatment options and things that, we could consider for a patient.
So this is a young woman who let's see here is interested in narrowing her face. She feels like her lower face is too big and fat, and she came to me looking for treatment options. 
Dr. Sam Jejurikar: [00:01:43] Okay. And 
how 
Dr. Salvatore Pacella: [00:01:44] old are you? 
Dr. Sam Rhee: [00:01:46] she's young. She's under 30, like 20 something, 20 like young twenties. 
Dr. Salvatore Pacella: [00:01:51] Okay. 
Dr. Sam Jejurikar: [00:01:52] And she'd like to have you said a smaller, lower face a more sculpted lower face.
Is that what she was going for? 
Dr. Sam Rhee: [00:01:57] Yeah, she thought her face was too broad and big. 
Dr. Sam Jejurikar: [00:02:01] Okay. 
Dr. Salvatore Pacella: [00:02:04] sure. the first question I have for you is what is her weight? Is she, an appropriate weight or thin skinny? 
Dr. Sam Rhee: [00:02:11] her weight's appropriate. She's she has a pretty normal BMI. She's not obese in any way 
Dr. Salvatore Pacella: [00:02:17] whatsoever.
I think when I look at, when we look at facial proportion, we want a nice. Oval shape to the face. We don't necessarily want a rectangular shape to the face. That's an, that's a, usually a very masculine attribute, and I could easily see how this gal would be concerned about this appearance.
If you just look at her, her, straight on view here, she's got a very wide base of her job. and one thing I would say as a young person in your twenties, surgery is clearly something that is a huge commitment at a young age. so I would really tend to lean towards non-surgical treatments for someone like her, specifically, what really works very well in young women and young men who have a very thick.
corner of the jaw here. This is what's called the gonial angle and the gonial angle is created by the job bone, but it's also created by big muscle, responsible for chewing called the masseter muscle. And that can be a very  in many people. And in fact, many of us are our teeth grinders in the middle of the night.
We have a little bit of sleep apnea here and there, myself in particular and this area of your job own, if you really grind your teeth at night can be. Can be very thick. So sometimes a little strategic Botox or Dysport or other neuromodulator along the angle of the along the gonial angle will help over a couple months, six months to a year to reduce the overall profile.
Dr. Sam Jejurikar: [00:03:53] Yeah, I, very much echo what dr. Pacella has to say. I think, Botox to the masseter muscles has really been something that's been popular in Southeast Asia for years. it's been something that for 10, 15 years, has been one of the major areas. RIAs they'll actually use Botox and there's a little bit different to what our approach in the U S had been for a long time in the U S we had used Botox predominantly in the upper one third of the face to try to deal with wrinkles.
But, if you think about it, Botox works specifically at the neuromuscular junction. And if you apply Botox selectively into large muscle groups, like they have, for years with patients, they'll put like cerebral palsy or whatever, you can get selective muscle atrophy. So for. The gonial angle or for the jawline area using Botox every three to four months.
I find that I have to use a substantial volume of Botox to actually achieve the effects. I probably would use 20 to 25 units per side Botox every four months. And it would help tremendously with getting, facial slimming, other things that I look at when I see this patient. and I will say that.
In the era in the last four or five years, when the, program face tune and Instagram filters have become so much more common, I've seen so much more patients coming in who want to have a more angular and refined look to them. they'll talk a lot about how the bottom of their chin, really bothers them.
And there's a variety of ways to actually handle the extra fat that she has below her chin. Just dr. Pacella was saying there are noninvasive treatments, which I think are quite good. but. You have to make some concessions to use them Kybella, which was an injection, was something that was used a lot in my practice up until about two or three years ago, Kybella is an injection that you'll actually have to repeat two or three times.
and it dissolves the fat almost instantaneously. However, it takes two to four months for the fat. to go away. I've actually treated myself with Kybella a couple of times. The second time was, quite memorable because I did it. And then I got an international flight a few days later. And when I landed in Paris, for what would have been my 40th birthday celebration, my neck was all swollen up.
to the point where I really didn't feel comfortable putting any pictures on there, unless I used substantial filters on my phone to actually make 
mine better, 
the whole purpose behind doing Kybella. But the point is noninvasive treatments. Not that they're, they cause more swollen than surgery, for sure they do not.
but they do cause substantial swelling. And in our practice, we then gone through an evolution where we were first using. we were using, After Kybella CoolSculpting was a really popular thing. We would use to try to melt fat in this area. And now in the last six months, we switched more to radio-frequency.
If we've seen really exciting things with the book and evolve, which can, which can cause both a degree of skin tightening. That removal as well, but there's a variety of non-surgical things that you can do for the jawline area to help, to help fix it. Obviously, liposuction is still the gold standard by which everything else would be measured and given her age and given how young she is, if she were interested in amenable to liposuction, just run of the mill regular life should do very well.
And she should get skin tightening with that. you know that, I don't know if you want to talk about it, but Pacella or if you want me to talk about it, The buccal fat pads. that's an interesting area. And I'm curious philosophically, what you guys think about that. I think removal of the buccal fat pads, which can be done under anesthesia or in the office.
I prefer doing an under anesthesia. Was, it was a treatment that was really popular in the eighties and nineties, usually in conjunction with a facelift to try to make people look, more useful, or to give them a more angular look, as we understood more and more about what creates a youthful appearance.
We went away from taking it out a lot because, she may not like the fact that her face looks full, but she looks young. And 20 years down the road, she's going to want to look really young. So then for awhile, buccal fat pad removal kind of went away from my practice and now it's coming back because people really want it.
And they want that more angular sculpture look and people will actually say when I bring up to them, we need to be careful about taking out buccal fat pads. Cause you'll look older down the road. We'll see that they literally just say, I'll get filler if I need it. And they're. Totally. Okay. With that. 
Dr. Salvatore Pacella: [00:08:01] The buccal fat pad resection, gives that filter look of the kissy face.
Dr. Sam Jejurikar: [00:08:06] Exactly. 
Dr. Salvatore Pacella: [00:08:08] now one thing, going back to this gal here that I do notice here is, let's look at the middle of the face for a second here. So although the. The lower third, her face is very wide and very thick. W what I do notice is that the middle of her face is it is actually a little bit underdeveloped.
If you look at, the position of her eyes compared to where her cheekbones are, you could see that her eyes are quite prominent. And her cheekbone is very recessed. So I think what you can use that as a little bit of a optical illusion. If you added a little bit of augmentation to the mid-face and reduce a bit of the volume of the lower face that can achieve synergistically much more.
So am I going in and out? I feel like I'm going in and out. 
Dr. Sam Rhee: [00:08:57] Yeah. We can hear you. 
Dr. Salvatore Pacella: [00:08:59] Okay. Okay. what I was saying is if you add a little bit of volume to the bid face, reduce a bit of volume to the lower face that just adds a little bit more synergy accordingly. 
Dr. Sam Jejurikar: [00:09:10] Great point. Yes. And how would you add that volume to the mid-face?
Dr. Salvatore Pacella: [00:09:14] pretty simple fat transfer procedure, I think, so we can take a little fat from her abdomen or wherever, and just add a little bit of a volume to, to the cheek. And mid-face area here through a couple of little tiny incisions, something easily could be done in the office or you could use some soft tissue filler, anything out there.
Dr. Sam Jejurikar: [00:09:32] Yeah. And I liked that sort of theme that you were, You were talking about non-surgical things. if you did both Botox to her masseter muscles, cut Bella or CoolSculpting to the chin. so filler injection to the cheeks, these are all things that you could do without surgery. would you, if you did a fat transfer, would you do that in the office or what'd you do that with the anesthesia?
How would you do that? 
Dr. Salvatore Pacella: [00:09:53] I'd probably do it in the office. She's I'm young enough. There's minimal. minimal, local anesthesia. That's used, particularly if I'm doing it in the cheek. So I think it's pretty reasonable. Okay. 
Dr. Sam Jejurikar: [00:10:05] so I'm to ask you a few more questions, dr. Ray. So yeah. I assume you had this whole conversation with her about surgical versus non-surgical approaches.
What are her expectations? Like what is it that are the things that she must have, and she must achieve to get the results that she's looking for. 
Dr. Sam Rhee: [00:10:22] Really? I love listening to you guys discuss everything because it's pretty comprehensive. I think, she was a patient who was pretty, well-informed I think a lot of the younger patients that we see.
Have done a lot of research or I don't know, social media, what have you, like you said, there are certain trends that come up. and so her, I have found that some of the younger patients have very specific procedures that they are interested in and, and they come to you looking for those procedures.
So in her case, when we talked about non-invasive, which. she thought about, but some of the issues with, younger patients, especially something like a Botox to the master, which was one of the first things discussed is an ongoing cost. I think that, that was something that as a young professional, she wasn't sure she wanted to do.
She was looking for more of a definitive treatment, which, some of our patients, go straight for, which was not unreasonable. and, And then obviously something that was extremely invasive, gonial angle reduction, which, I had done before at UCLA, and earlier, was not something she wanted to consider.
So she came to me with a list of procedures that she was interested in. the main one was some sort of liposuction of her neck because she felt that she was very heavy under her jaw. and then, and then, like you said, there's this increasing trend for buccal fat, excision or a treatment. and when she presented those options that she really wanted to me, I thought they were reasonable.
we did talk about all the other ones that we just went through. Yeah. 
Dr. Salvatore Pacella: [00:11:55] Dr. Rhee, just one question. so let's say, she was interested in, injection of Dysport or from that modulator to the masseter. and she said to you, is that going to affect how I chew? That's a big muscle for chewing, isn't it?
Dr. Sam Rhee: [00:12:13] Absolutely. I do a fair amount of, neuroma, neuro blockers, neuromuscular blockers for a masseter treatment. And they don't seem to have any issues in terms of showing it all that I've seen. at least in the doses that I'm using, Not a problem. 
Dr. Salvatore Pacella: [00:12:26] Yeah. There are. And if you remember from your time with Henry, at UCLA, there's a couple of different muscles that are responsible for chewing and what we call mastication so that, I tell patients, there are actually, one, two, three, four, five, six more muscles that are in the face that are responsible for chewing.
it's actually quite interesting that we have so much. th that there's a volume of muscle. That's responsible for something that's so small. And it just tells us how we used to be derived or evolved from creatures that used to tear meat out of our jail. Think about it is one of the biggest muscles in the face.
The masters is one of the biggest motions in that phase. 
Dr. Sam Jejurikar: [00:13:10] I'm only laughing because you referred to tearing meat with your jaws in the past tense where we all know that's still an active part of your life. But the other thing which is interesting was how dr. Pacella and I both immediately went to the fact that we.
Kind of stereotyped a young patient is not wanting to have surgery where we thought, okay, she's young, she's going to want to avoid surgery. And we thought that recurring injectable treatments would be preferable, but it's, but that's why it's so important to talk to our patients and find out what it is they're wanting.
So we're, where we were looking, which was, we'll try to avoid going to the operating room instead. She was going directly to that. and so leads you to a very different way to treat the same issues. 
Dr. Sam Rhee: [00:13:50] Very true. I just had PTSD by the way, just when you talked about mastication about that's an in-service exam question, and then you have to admit name all the different cranial nerves for each of those muscles.
And, and so I just, was like panicking for a second. I thought you were going to ask me that one too. 
Dr. Salvatore Pacella: [00:14:06] Okay. 
Dr. Sam Rhee: [00:14:07] All right. so yeah, so it's interesting because patients will often come to us as surgeons because they want surgery. And then if they're looking for something else, they don't necessarily come to us for.
There's something else. All right. So let's, move on. So let's talk just, so this was from the Mayo clinic. I just pulled, a diagram, about neck liposuction. And, I usually make three incisions when I do liposuction of the neck. I'll make one segmental and then I'll make one behind each ear.
Is there anything that you guys consider in particular when you're doing something like neck liposuction specifically? 
Dr. Salvatore Pacella: [00:14:40] Yeah. I used to do it exactly the way you did. it making three incisions and I've found that I wasn't getting a ton of value from the ones on the corners. And I just shifted to just one simple incision.
And I think with the right cannular, I use a thin two millimeter Candela. I use. power assisted liposuction. I think it breaks at the tissue really nicely. I'm able to get a lot out just from one little tiny incision. 
Dr. Sam Jejurikar: [00:15:07] I'm, I've evolved more to dr. His way of doing it as well as in the patient that you just demonstrated.
I would do standard liposuction with a 1.8 and a 2.4 millimeter cannular, just in the area below the neck, in an older patient who I'm concerned about laxity of the scan, and maybe a little bit of jowls, I would add. Radio-frequency I would use face tight or AcuTight and those patients I'll add. I'll now add the incisions behind the ear that you were referring to mainly.
So I can use radio frequency to get a component of skin tightening. at the same time in this patient who's useful and it seems to have perfect skin elasticity. I would just use the one incision as demonstrated, in this diagram. 
Dr. Sam Rhee: [00:15:48] Sounds good. and then for the buccal fat, it's funny because when I was doing my crane officials fellowship, we do, and in my early part of my career, we do affords.
And that was exactly what you tried not to get because the buccal fat would always come out of the incision. It was always in the way you had to push it away. And now I always found it ironic that we're deliberately making an incision to get to the buccal fat. It was always the thing we wanted to avoid.
and, I have done it both, in office and, under, anesthesia. And it's a 
Dr. Salvatore Pacella: [00:16:18] pretty 
Dr. Sam Rhee: [00:16:19] straightforward procedure, I think, for, for most surgeons. Is there anything that you guys do specifically with your buckle fat excisions? 
Dr. Salvatore Pacella: [00:16:27] Yeah, I think, this is a popular procedure that you see on in Bram being done to many.
Non-core providers in the office. and I think it's really important to understand for our listeners out here, you want a surgeon that feels very comfortable in this area. That is a certified facial plastic surgeon feel comfortable are, facial plastic surgeon or plastic surgeon doing this procedure.
There are critical. Nerves and ducts in this area that if damaged are near impossible to fix. So this little hole you're seeing right here, if I recall correctly, dr. Rhee, that is called Stensen's duct, correct? Yeah. And if you not watching for that hole, you can easily blast through that.
And the consequences scarring of the biggest. salivary gland in the entire face and, chronic swelling of the face. I've actually seen this multiple times, come into my office after patients have buccal fat excision from somewhere else where the Stensens duct had been scarred down or lacerated for some reason.
And the patient comes out with a massive, thickness on the side of the face and tissue that needs to be drained. It's just an absolute disaster. So although it's very easy to perform, if it's done incorrectly, it can be a disaster. 
Dr. Sam Jejurikar: [00:17:58] Yeah. Just to follow up on what dr. Pacella was saying. Another very important, critical structure, which travels in the midst of the bug that, or our branches of the facial nerve, the buccal branches of the facial nerve, which are responsible for a lot of just the voluntary motions of facial expression, over the cheek.
And, we talk about buccal fat pad excision. But you're not removing the entire buccal fat pad. And I'm not sure if there are non-core providers and people that aren't plastic surgeons or facial plastic surgeons. So we're doing the procedure who don't realize that because. The way that you do this operation, it's very straightforward.
You make an incision through the cheek, you dissect through the muscles, you see the, the buccal fat pad. you let it spill out, but you're only removing about 20 to 25% of the gland when you're doing it, which on this diagram, a dr. Rehabs is called a TeraGo mandibular extension of the buccal fat pad.
You're just removing that bottom tail to create a chisel, a chiseled look. And if you do that and you just let it spill out, you can take out. What's there without damaging the branches of the facial nerve. But I have a feeling, there are people that are out there that are just trying to take out too much and they're digging in the cheek.
They're getting, they're actually interfering with nerve branches and the extension of the product land that dr. Patella was referring to. And that's how we run into problems. this should be a very straightforward operation to deal with through a minimal incision, but at there, your provider does not know what they're doing.
There are serious problems that can happen. 
Dr. Salvatore Pacella: [00:19:24] and then, to raise the level of degree of difficulty here, a couple of years ago, I shifted my facelift practice into doing our, deep plane, extended facelift. so I'm going fairly close to this area on the other side.
So making a decision here, we're going deep into the face. We're pulling the deeper structures of the face. Many times we can encounter the buccal fat pad. Through a facelift incision, and it's fairly straightforward to remove it from a facelift on the opposite side, without going into the mouth, as long as you're careful and you'd know what you're doing and, the correct plane, gentle spreading of the tissue, not counting, not using electric cautery, et cetera.
Dr. Sam Rhee: [00:20:06] it's funny. I, I'm glad you guys both mentioned those things because I always assume it's so straightforward, but that's because we have experience in these things. And, I know not to mess with the product I know not to, over resect. and I just assume everyone. Who's a provider does that, but you're absolutely right.
There are people out there that do not know these things. And, I guess no one should really assume soon that it's really, the training that makes the difference. and I think that is one of the things to know is how much to resect. also I think when we talk about that overly gaunt appearance, there's, there is, the thought of really removing the right amount.
but not over removing both for, Functional issues like the buccal branches, as well as, aesthetically 
Dr. Salvatore Pacella: [00:20:49] one other one other point here. I think, this kinda goes back to our training at Michigan and how, as we started off as REIT plastic and reconstructive surgeons, and most of us have shifted towards cosmetic surgery, but just to go back to our training and our comfort level with these areas of anatomy, the absolute first time.
That I saw these structures and alive patient was in the middle of the night in an ER in Ann Arbor. I, a gentleman got involved with a bar fight and, had a bottle slashed across a space with a big Y shaped . In the middle of the face. And I saw buccal nerve branches. I saw this entire buccal fat pad coming out of the wound.
I saw two ends of Stenson's duck that I had to put a little tube in and carry it out through the mouth. So this was the best lesson in anatomy that I ever 
Dr. Sam Jejurikar: [00:21:41] had. So 
Dr. Sam Rhee: [00:21:44] yeah, that's exactly the same thing that happened to me. Big trauma had to saw over the duct over a, a conduit, it was just.
Yeah. if you've done that, then this doesn't seem 
Dr. Sam Jejurikar: [00:21:55] so scary. 
Dr. Salvatore Pacella: [00:21:59] learning the buccal fat pad removal and a weekend course just isn't cutting 
Dr. Sam Rhee: [00:22:02] it. So that is true. 
Dr. Salvatore Pacella: [00:22:04] So this is
Dr. Sam Jejurikar: [00:22:06] stick it, cause they had actually might be cutting it accurate. 
Dr. Salvatore Pacella: [00:22:11] You don't want to be cutting. 
Dr. Sam Rhee: [00:22:13] This was her, after doing, both the neck liposuction and the buccal fat pad excision from the front. And as you can see, and this is, the discussion about older appearance is something that is of interest to me because.
obviously she does look older, but in a way that she loves, she thinks that, this is something that, she wanted to look, she did not want to look so baby like, and have such a round face. and that was exactly the look that she was going for. But you're right in 20 years or 30 years, is that something that will be, of issue to her?
That's not something I actually thought of at the time. Of, working with her on this. 
Dr. Sam Jejurikar: [00:22:51] Still though. It's a very, it's a very nice transformation. the shape of her face has changed from being, from being so round. Now she has a heart shaped face to her. her cheekbone definition looks more pronounced, even though you didn't even add any filler to her cheek bones.
It looks as though just that the facial proportions and the projection of the mid face has changed. profoundly and it really shows what can be achieved with relatively straightforward procedures. yeah, I think 20 years from now, she'll look older as a result from it. And maybe you have signs of, advanced aging that she doesn't have now, but most patients aren't really thinking that way.
And they'll deal with that down the road and with injectable fillers, which we can do in the office, you can easily overcome that. So very nice results. I think she's probably very pleased. 
Dr. Salvatore Pacella: [00:23:35] Yeah, really good here. I think, what I really notice here is you've, you've a subtle change.
That is noticeable. Okay. And you can't quite put your finger on it. It doesn't really look like she had surgery. It didn't look like she really did much. but you've really recreated the gonial angle very nicely. I think that liposuction on the sides has worked tremendously. And then, the excision of the buccal fat pad really created a situation where the mailer.
Mailer tissue looks much more prominent now because you've taken out the tissue down below. You really didn't add anything to the mailer region. You didn't know any additional fat, but you've reduced fat. So it's that synergy of the mid-face that's very important. 
Dr. Sam Rhee: [00:24:20] Thank you. I appreciate that.
I think that this also shows there are different ways to address each different patient based on what they want. I think Capella would have been an option instead of neck liposuction. I have leaned, I do Kybella, but I've leaned away from it just because of what Sam said about the next swelling and the multiple treatments.
and I think, the skin tightening in an older patient is going to be important. I think for sure. and so there are a lot of different options here that were raised and discussed that I think, can be customized to every patient based on what they're looking for. 
Dr. Salvatore Pacella: [00:24:52] and the other nice thing here, dr.
Ray, it you'll see this in New Jersey, San Diego, Dallas, et cetera. You've now, had this patient in your practice. In your twenties and you've done an excellent job with her. This is somebody that's going to reap the rewards of this throughout our lifetime. And that's somebody, she's now has a level of trust in you, that this is somebody you can help throughout her entire lifetime if she has there ever has any other concerns.
So that's the nice thing about our discipline and plastic surgery is the longevity of our patients. If we do a great 
Dr. Sam Jejurikar: [00:25:23] job with them, Yeah, I have one last question for you, dr. Ray, for viewers that are considering these procedures, what's the post-operative recovery course, is this an, is this a hard thing for people to recover from?
Can they exercise right afterwards? You have more compression garments? what can a patient who's considering neck liposuction and buccal fat pad removal. What do you tell them? The recovery is going to be like 
Dr. Sam Rhee: [00:25:45] the buccal fat pad is a pretty quick recovery. I think the key to that is to just. counsel patients to wait for results.
There can be some swelling in that area and it is a relatively subtle, but significant result, but it can take a couple of weeks. They don't really have to do much, which other than some, oral rinse, just to protect the incision a little bit, nothing fancy. And then I do have them wear a neck wrap for, a couple of weeks.
sometimes they, It's hard. It's hard for patients at work to wear it all the time. So sometimes, they'll wear, they'll get rid of it sooner rather than later. but usually patients are up and running after a three, four weeks without too much, too much of an issue. 
Dr. Sam Jejurikar: [00:26:23] The neck rapid is for the buccal fat pad or for the liposuction 
Dr. Sam Rhee: [00:26:25] for the neck.
Liposuction. Yeah. I'm pretty adamant about that for the first week or two. and then, I know, no matter what I say, they're going to do what they want to do pretty much after that. 
Dr. Sam Jejurikar: [00:26:37] they've, they've learned to trust what they read on the internet more than they trust what we tell them to do.
But, exactly what I actually did for my patients for exactly the reasons that you've said is I now try to negotiate myself into a week without wrapper on the head. and then I tell them to wear it when socially convenient for about six weeks thereafter. So when they're at home, 
Dr. Sam Rhee: [00:26:55] thank you very much, guys. I really appreciate it. so we wrap up another show. That's fantastic. I really appreciate your guys' input and thoughts about everything and hope you guys have a great 
Dr. Sam Jejurikar: [00:27:04] day. You as well take care.