Had consultation with Raffaini and Ramieri

[facebadbetter]

Ramieri:
* bimax, 4 mm with CCW rotation and backwards genioplasty.
* says any more advancement would = chimp lip
* infraorbital rim implants for midface hypoplasia

Raffaini:
* 8 mm linear advancement
* says no need for rotation and no danger of chimp lip
* doesn't do implants, says they age badly, so wants to do zygo osteotomy and fat transfer

Qs:
1. Are there any examples of Raffaini over advancing / giving chimp lip?
2. Is zygo osteotomy with Raffaini a decent alternative to orbital rim / zygo implants?
3. Who has better examples of tightening / lifting sagging/excess soft tissue in the midface and under jaws?

 

[Jonas2k7]

bump

 

[chrishell]

Ramieri:
* bimax, 4 mm with CCW rotation and backwards genioplasty.
* says any more advancement would = chimp lip
* infraorbital rim implants for midface hypoplasia

Raffaini:
* 8 mm linear advancement
* says no need for rotation and no danger of chimp lip
* doesn't do implants, says they age badly, so wants to do zygo osteotomy and fat transfer

Qs:
1. Are there any examples of Raffaini over advancing / giving chimp lip?
2. Is zygo osteotomy with Raffaini a decent alternative to orbital rim / zygo implants?
3. Who has better examples of tightening / lifting sagging/excess soft tissue in the midface and under jaws?

Why did Raffaini say implants age badly?

What kind of zygo osteotomy did he recommend? Do you need lateral or anterior projection or both?

 

[chrishell]

Pascali is a good surgeon for midface lifts and he has experience working on people with malar implants.

You read on here sometimes that implants "pull your skin up" but this effect is overstated. You also often read you need stronger bones in order for something like a midface lift to stick. This is all true to some degree but it is just that: a matter of degree. Boneless 60 year old grandmas get good facelifts. I suspect in more cases than we realize the bottleneck on your ogee curve is the sagging midface rather than weak zygos. Yes, in general men should lead towards bone surgeries and women soft tissue surgeries but this binary shouldn't be so overblown. In any case, a substantial portion of patients getting zygo implants need a midface lift anyway.

 

[greycel]

Why did Raffaini say implants age badly?

What kind of zygo osteotomy did he recommend? Do you need lateral or anterior projection or both?

Bump, what did he mean they age you badly?
Also I'd steer away from zygo osteotomy. Knew a guy who did it, and he didn't do it with bone grafts so it ended up looking uncanny
But risky surgery to get right, very risky

Would advise you to stay away from zygo osteotomy. It often increases laterally that has a less desirable effect, as men benefit more from anterior projection (for harmony)

1. Are there any examples of Raffaini over advancing / giving chimp lip?

Yeah I have heard Raffaini have undesirable outcomes
He is better if you are considerably recessed, and stand to benefit a lot.. and you don't get unlucky.
Also he is harder to work with, he wants to be in charge, and do everything his way.. so take that how you will

Rameiri is more consistent, but the results are often very conservative

Pascali is a good surgeon for midface lifts and he has experience working on people with malar implants.

You read on here sometimes that implants "pull your skin up" but this effect is overstated. You also often read you need stronger bones in order for something like a midface lift to stick. This is all true to some degree but it is just that: a matter of degree. Boneless 60 year old grandmas get good facelifts. I suspect in more cases than we realize the bottleneck on your ogee curve is the sagging midface than weak zygos. Yes, in general men should lead towards bone surgeries and women soft tissue surgeries but this binary shouldn't be so overblown. In any case, a substantial portion of patients getting zygo implants need a midface lift anyway.

If you were not recessed, then there would be no periorbital and malar sagging, at a young age..
So if there was sufficient support we would've been fine

To address an issue that has already occured, will implants for support, LipoLab for removing sagged fat pads, and facial fat transfer back to undereyes/zygos (for youthful appearance).. be a viable solution?
Opposed to a midface lift, that doesn't reposition the malar fat pad to where it originally was, just tightens the skin..

 

[chrishell]

Bump, what did he mean they age you badly?
Also I'd steer away from zygo osteotomy. Knew a guy who did it, and he didn't do it with bone grafts so it ended up looking uncanny
But risky surgery to get right, very risky

Would advise you to stay away from zygo osteotomy. It often increases laterally that has a less desirable effect, as men benefit more from anterior projection (for harmony)


Yeah I have heard Raffaini have undesirable outcomes
He is better if you are considerably recessed, and stand to benefit a lot.. and you don't get unlucky.
Also he is harder to work with, he wants to be in charge, and do everything his way.. so take that how you will

Rameiri is more consistent, but the results are often very conservative


If you were not recessed, then there would be no periorbital and malar sagging, at a young age..
So if there was sufficient support we would've been fine

To address an issue that has already occured, will implants for support, LipoLab for removing sagged fat pads, and facial fat transfer back to undereyes/zygos (for youthful appearance).. be a viable solution?
Opposed to a midface lift, that doesn't reposition the malar fat pad to where it originally was, just tightens the skin..

It's not either/or, it's always a matter of degree. Degrees of recession, degrees of sagging. The more recessed you are, the quicker the skin sags, yes. If your zygos are shit and your skin sags like shit, then get the zygo implant. If your zygos are slightly below average and your skin sags like shit, MAYBE you might consider, and perhaps nothing more than consider, the lift instead of an implant. Ok and then maybe, suppose the midface lift lasts 6 years instead of 5 if you had gotten the implant because the less recessed face causes it to sag slightly slower. And imaginably it also depends on your particular brand of shit zygo. Or slightly below average zygo. Maybe midface lift would be better for some and not for others. The aesthetics goals of midface lifts are much more clear and they work out well more often than implants do IMO and in the hands of a good surgeon, are tailored in the moment. Whereas implants are very hard to get right on first try. Which is why I bring up the possibility.

It's really futile to go into detail right now. All I was saying with that point is: people here often accept as a matter of principle that you always have to solve the bone issue first. This does not have the be the rule 100% of the time. Maybe it can be more like 80% or something. Or 60%.

It depends on the midface lift technique. There are methods that reposition the fat pad and/or remove skin.

 

[longjohnmong]

PI suspect in more cases than we realize the bottleneck on your ogee curve is the sagging midface rather than weak zygos.

A perfect example of this is this Yaremchuk patient. He had infra and zygo implants (separate implants) between pics 1 and 2, and midface lift between 2 and 3:

 

[chrishell]

A perfect example of this is this Yaremchuk patient. He had infra and zygo implants (separate implants) between pics 1 and 2, and midface lift between 2 and 3:

View attachment 3111086

Yes this is a great example. And Yaremchuk (as I think we talked before) did midface lifts with ALL cheek implants. With THAT alone he was miles ahead of others regardless if his designs were mediocre sometimes.

 

[longjohnmong]

Ramieri:
* bimax, 4 mm with CCW rotation and backwards genioplasty.
* says any more advancement would = chimp lip
* infraorbital rim implants for midface hypoplasia

Raffaini:
* 8 mm linear advancement
* says no need for rotation and no danger of chimp lip
* doesn't do implants, says they age badly, so wants to do zygo osteotomy and fat transfer

Qs:
1. Are there any examples of Raffaini over advancing / giving chimp lip?
2. Is zygo osteotomy with Raffaini a decent alternative to orbital rim / zygo implants?
3. Who has better examples of tightening / lifting sagging/excess soft tissue in the midface and under jaws?

Having had 3mm linear advancement on top of CCW rotation myself, 8mm just sounds like so much. But also Raffaini is Raffaini. Why would someone from this forum know more than him?

 

[greycel]

Yes this is a great example. And Yaremchuk (as I think we talked before) did midface lifts with ALL cheek implants. With THAT alone he was miles ahead of others regardless if his designs were mediocre sometimes.

It's not the best example
The guy benefited the most from getting rid off his sclera show that he had because of his bad infra shape
Not recession

 

[chrishell]

It's not the best example
The guy benefited the most from getting rid off his sclera show that he had because of his bad infra shape
Not recession

He had a recessed midface. And he had the scleral show in large part because of his recessed infras.

The infra implant alone did not solve the scleral show.

Hence he got a lift and all was resolved.

It is a good example of why implants are often not enough and lifting procedures are necessary.

All the issues you brought up are deeply related and cannot be compartmentalized like that.

 

[k99]

It's not the best example
The guy benefited the most from getting rid off his sclera show that he had because of his bad infra shape
Not recession

nah he benefited the most from that lift it fixed his negative tilt and hallow eyes

 

[longjohnmong]

It's not the best example
The guy benefited the most from getting rid off his sclera show that he had because of his bad infra shape
Not recession

We were talking about the ogee curve. You can see that it was the midface lift either alone or in combination with the implants that created it, not the implants alone.

Here's everything he got:

A 24-year-old male patient who requested several changes in his facial contour. Two operations were performed, 18 months apart. In the First operation, malar and infraorbital rim implants were placed and a rhinoplasty was performed, through bicoronal, intraoral, and intranasal incisions. In the second operation, paranasal and mandibular body implants were placed, the rhinoplasty was revised, and a midface lilt and lateral canlhopexies were performed. Frontal, lateral, and oblique views (left) before the operation, (center) after the first operation, and (right) after the second operation. Left, frontal and lateral views and center frontal and lateral views reprinted from Yaremchuk, M. J. Infraorbital rim augmentation. Plast. Reconstr.

 

[greycel]

nah he benefited the most from that lift it fixed his negative tilt and hallow eyes

Why are u saying nah
We are agreeing

He had a recessed midface. And he had the scleral show in large part because of his recessed infras.

Not true I have extremely recessed top 0.1% recession infras and no sclera show, because downturned medial canthus and no sclera show from Infra shape
The infra shape is the only thing that affects sclera show

 

[chrishell]

Why are u saying nah
We are agreeing


Not true I have extremely recessed top 0.1% recession infras and no sclera show, because downturned medial canthus and no sclera show from Infra shape
The infra shape is the only thing that affects sclera show

His infras were clearly recessed. Getting the infras did not solve the scleral show. Hence, the infra shape cannot be the only thing that affects scleral show. If you disagree with that statement, which is all I was saying, that is a comically radical and weirdly myopic claim. There are plenty of people with good infras but otherwise droopy eyelids. Such people get cantho if they want it gone.

He likely did not have a saddled design which could or maybe wouldn't help.

 

[greycel]

His infras were clearly recessed. Getting the infras did not solve the scleral show. Hence, the infra shape cannot be the only thing that affects scleral show.

The infra shape is purely genetic and is different from recession
This won't be better if you were less recessed

The recession of the infras are anterior that cause the negative orbital vector. It doesn't change the shape of the infra itself though

You could change your infra shape with infras with saddle perhaps, not sure about this

But you just said getting infras did not solve sclera show.. that's true because they solve the recession which is anterior
They won't change the shape of the infra itself, as there are blood vessels so they can't be directly placed on top of it, which is why a saddle is placed on top inside of the eyelid.. which if shaped appropriately might get rid of sclera show.

 

[chrishell]

The infra shape is purely genetic and is different from recession
This won't be better if you were less recessed

The recession of the infras are anterior that cause the negative orbital vector. It doesn't change the shape of the infra itself though

You could change your infra shape with infras with saddle perhaps, not sure about this

But you just said getting infras did not solve sclera show.. that's true because they solve the recession which is anterior
They won't change the shape of the infra itself, as there are blood vessels so they can't be directly placed on top of it, which is why a saddle is placed on top inside of the eyelid.. which if shaped appropriately might get rid of sclera show.

By changing the anterior projection of the infra, i.e. ameliorating the recession, you are by extension changing the shape. Trivially.
This is a category mistake.

 

[greycel]

By changing the anterior projection of the infra, i.e. ameliorating the recession, you are by extension changing the shape. Trivially.
This is a category mistake.

You are barely if it all achieving any effect
You are not changing the shape of the eye, that is genetic

The only change in eye shape from environment is that our lateral canthus gets less sharp as we age, but I'm talking many decades not by 30s or 24 as the guy was

Everything has an effect on everything. It's whether it is significant enough to be classed as a factor that contributed to it
Not only does it not contribute at all, but what you are arguing for has a very marginal effect

Fixing recession by increasing sagittal projection of the infras will not have a significant change to eye shape
And certainly not anywhere close to what OP would've benefitted from

His after has the greatest change, because the midface lift helped his eye area specifically
His eye area benefitted because he has an unideal infra shape, not because of how recessed his infras were

 

[haus33]

That's quite a difference between Ramieri and Raffaini's plans. Ramieri is known to be conservative but never botches.

I understand that fillers, implants and fat transfer are considered alternatives of each other. They all seem to have drawbacks and with fat transfer the reasoning is it is unpredictable and can lump or disappear quickly. Implants some say age badly, with bone resorption.

 

[greycel]

That's quite a difference between Ramieri and Raffaini's plans. Ramieri is known to be conservative but never botches.

I understand that fillers, implants and fat transfer are considered alternatives of each other. They all seem to have drawbacks and with fat transfer the reasoning is it is unpredictable and can lump or disappear quickly. Implants some say age badly, with bone resorption.

Can you expand on fat grafting?
Especially for the undereyes, heard less risk of complications

 

[kingofkings]

* doesn't do implants, says they age badly, so wants to do zygo osteotomy and fat transfer

Most zygo osteotomies I've ever seen have a femininizing affect on the face.

Pretty interesting that two of the "top guys" have such different contrasting opinions on what surgery you require.

 

[haus33]

Can you expand on fat grafting?
Especially for the undereyes, heard less risk of complications

I've seen conflicting stuff on it, the problem is when doctors come out against a certain treatment they are usually advertising a different kind i.e. saying fat transfer is bad when they're selling fillers. But here's one who is doing that and lays out some of the potential issues:



Here's a real self post where a woman asks whether implants or fillers are better, and both doctors replying obviously promote the one they are selling and are anti the alternative:

https://www.realself.com/question/n...25-infraorbital-implants-cheek-lift-permanent

So it's hard to tell.

 

[greycel]

I've seen conflicting stuff on it, the problem is when doctors come out against a certain treatment they are usually advertising a different kind i.e. saying fat transfer is bad when they're selling fillers. But here's one who is doing that and lays out some of the potential issues:



Here's a real self post where a woman asks whether implants or fillers are better, and both doctors replying obviously promote the one they are selling and are anti the alternative:

https://www.realself.com/question/n...25-infraorbital-implants-cheek-lift-permanent

So it's hard to tell.

Looking at statistics, I saw risks for complications are low
And ppl I've talked to on this site who have got it have said it helped them a lot

So I think those who shill fillers, want constant fuel of income, are going to promote it

 

[bigseal]

What were the prices quoted?

 

[mistywoods]

Ramieri all day, but I would listen to your gut feeling as well, which surgery plan makes more sense to you

 

[haus33]

4 mm with ccw vs 8 mm no ccw is crazy

Does Raffaini do ccw in other cases ? From his instagram a lot of the faces he does have short faces so maybe he does cw mostly rather than ccw.

I'm thinking these surgeons might be really good for one type of face and not good for another.