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A Note From Dr. Karam

I decided very early in my medical education that I wanted to pursue the Facial Plastic Surgery as my specialty. The field offered an opportunity to truly touch lives, make a difference, and required the highest level of surgical execution and techniques. I also loved how creative it was and how it allowed innovation to improve outcomes. These were all the reasons I loved it and choose to become a Board Certified Facial Plastic and Reconstructive Surgeon.

I didn’t take long for me to realize that the subspecialty of Facial Rejuvenation was really far from optimized when I was training 15 years ago. People who were noticing their faces aging or had aged would get a facelift, neck left and brow lift and all of them would look strange, different and unnatural. They would lose their identities and the essence of their natural spirit. You could tell these people from across a room in a matter of seconds. This was what it meant to get a facelift. To me this was unacceptable. I made it my mission to learn and develop new ways of doing things that resulted in a more natural look and a truly restored appearance.

This has been a 10 year journey that led to the culmination of techniques we now call Vertical Restore™.

Vertical  Restore Dr. Amir Karam

Vertical Restore Explained

Facial aging happens to all of us and when it does, in a relatively short period of time, our faces start to look different than how we see ourselves. Put differently, we feel as young and vibrant as we always have yet our faces start to show our true age. When this happens, we no longer look as young as we feel and this is feels bad. It bothers us. It makes us self aware when it comes to photos or even close interpersonal and even professional situations. This transition toward facial aging, robs us of our youth and beauty but even more troubling, our identities.

This discordance between the way you look (older) and the way you feel (younger) is the main reason people come to see Dr. Karam for help. What everyone wants is to simply look as young as they feel and what this means is to erase the recent changes affecting our faces and to restore them back to a period before aging started to make them look different. This usually relates to early 40s and mid 30s. This was Dr. Karam’s inspiration to develop the perfect approach to address this. When it is addressed, the biggest impact is emotional. Feeling comfortable in your own skin is essential for overall happiness. This is what gives Dr. Karam’s work so much meaning.

The Facial Aging Changes

The most simple way to summarize the aging changes is as you age your face goes from an upside down triangle to a rectangle. What happens is the fascia in the face (the SMAS) starts to elongate (droop) and descend. This leaves the face looking different than it did during youth and this is why we look different to ourselves and to others when it occurs. This change in shape is the core problem and addressing it is the most important and impactful way to solve the problem.

The key to understanding the solution, which is the Vertical Restore, is to understand the problem. Think of fascia as cooking dough. If you hold up dough and let it hang, it will elongate with the help of gravity. The same thing is happening to the face. The fascia (dough in this analogy) is getting longer. But the key to understand is that this is happening from the top down. It’s not just a part of the face. It is the entire face! So, it is important to address the whole thing at the same time so it looks fully and naturally restored not like a partially remodeled kitchen.

  1. The upper face starts to sag around the outer eyes. Leaving the eyes looking heavy and crowded in the corner.
  2. The midface starts to go down and toward the nose. This leaves the check deflated, as the cheek fat pad no longer sits on the cheek bone, instead is pushed down toward the nose, which make the nasolabial fold heavier.
  3. As the cheeks sag, jowls are formed. This is often the most noticed change that makes the face look different with age. Jowls along the jawline, leaves the jawline looking square and heavy instead of oval and lean. This is from the cheeks falling and hanging over the jawline.
  4. Sagging and heaviness in the neck. The neck is attached to the cheeks. Most people don’t know this. When the face sags, the neck sags too. The upper support of the neck is the cheek so these change in tandem. Further, under the chin, fat accumulates and the neck gets heavy. This fat is a combination of some above the muscle and a lot below the muscle. The fat below the muscle is not accessible to liposuction or any non-surgical approaches.

Skin

The body’s largest and most sensitive organ changes significantly with age: elasticity, thinning, discoloration, lines and wrinkles.

Volume

As we age, facial fat begins to diminish throughout the face, leaving one looking tired, deflated and hollow.

Sagging

This is what everyone thinks of when they think of aging. The loose skin around the upper and lower eyelids, the bags under the eyes, the sagging of the outer corner of the eyebrows, jawline and neck.

Comparison of the Vertical Restore with a Facelift

  1. A big difference between Vertical Restore and a facelift is how balanced and comprehensive Vertical Restore is. It addresses everything from the top of the temple down to the neck. This includes the outer eyebrows, the midface, the jawline, and the neck. A facelift address the jawline only. Treatment of the jawline only leaves the overall face looking only partially treated which ultimately leaves the face looking odd. No one wants to look odd! To avoid you have to bring everything back to where it came from so that it all looks like it belongs together. This comprehensiveness is a key to a natural outcome.
  2. Facelift generally speaking “pull” the face sideways or towards the ear. This flattens the face and makes it look tight and stretched. This is another tell-tell sign that someone has had a facelift and that is never a good thing. If you can tell, that means it’s not a good or even acceptable facelift.

    The Vertical Restore doesn’t do that. It lifts the soft tissues of the face back to their original positions, not new ones. By lifting vertically, not only is the results more power and lasting but the outcome leaves you looking more restored and not pulled. It’s about looking like you use to and looking refreshed not like you are walking through a wind tunnel permanently!

    This is something you can do to yourself if you haven’t already (my guess is you have if you are reading this). Take your fingers and lift your cheeks toward the top of your ears. Watch your neck, jawline and neck improve. When you do this, you will notice the skin around your temple bunch up. This is why we need to keep going and not stop there. With vertical lifts, the temple would be a roadblock and needs to be included in order to smooth things out and ultimately look right. Next, lift your outer brow and temple straight up by placing your fingers along your temple hair line and observe how lifting your outer brows opens the hooding around your eyes and when combined it will get rid of that bunching.
  3. The neck should always be included in these aging situations. Not only is the it always involved, it is one of the aging changes that bothers people the most and it’s the one area that ages most rapidly. A typical horizontal lift won’t address the neck because it pulls the face sideways. The neck (muscle) is attached to the cheeks so when the cheeks start to come down the neck comes down with it. What needs to happen at the very least is to vertically reposition and anchor the neck back up. Vertical Restore does this.

    The other important aspect is, as we age the deep fat pad under the muscles of the neck start to grow. This is called submental fat hypertrophy. When this occurs we looks that smooth shelf under our chins and instead get a bulge or heaviness. This looks like a double chin or in more advanced cases like a turkey waddle. Necks come in all shapes and sizes but they all have some of these above changes occurring.

    Vertical restore doesn’t just remove some fat under the skin and tighten the neck muscle (platysma), it goes under the muscle where, that suborn and ever-expanding fat pad lives, and removes that along with any other bulky structures that could make the neck look heavy and full. Going into this space is an advanced approach and to do it well and safely is even more uncommon. However, it is essential for a beautiful and youthful neck.

    Once the tissue under the muscle has been addressed, the platysma muscle is addressed. The excess is muscle (that has gotten longer with age) is reduced by trimming it and then suturing/folding it together at the midline. This creates a durable and stable neck and it is further improved by the vertical lifting from above. The loose excess skin is removed both behind the ear and from above, leaving the neck significantly smoother.

    To test the power of this, place your fingers at the jawline near the ear and lift upward. See how this lifts the neck and improves the angle.
  4. To address the jawline and midface, Dr. Karam employs a deep plane approach. This releases the various facial ligaments that are holding the face in its aged position. This release is key, because without it, you are limited by how much repositioning that can be achieved as well as the durability of the outcome. The other benefit is, healing happens much faster because it is not disrupting the relationship between the skin and the fascia. This is another one of those very advanced and difficult to master approaches, but after 10 years, this has been a hugely beneficial addition. It not only lasts longer, but it restores the position of the midface, helps the nasolabial folds, smoothens the jawline, and lifts the neck.
  5. The outer brow is addressed simultaneously as discussed above. The approach that I have been using is not a brow lift. I don’t believe people need browlifts because, with the exception of the other one third of the brow, the rest of the brow doesn’t sag. So, knowing this is the case, why lift the entire brow? The answer is you shouldn’t because when you do you end up looking surprised or entirely different. This is never the goal. Looking restored and refreshed is the goal. So, Dr. Karam employs a very minimally invasive approach to reposition the tail of brow back to its original spot. In woman, this is just above the orbital rim and in men it is at the orbital rim. This procedure never looks extreme and always looks natural.

Dr. Karam, who is board certified by the American Board of Facial Plastic and Reconstructive Surgery and American Board of Otolaryngology, offers services in San Diego County including San Diego, Del Mar, Carlsbad, Carmel Valley, Encinitas, Rancho Bernardo and La Jolla in Southern California.

If you are ready to schedule an appointment with Dr. Karam, contact us today.

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