Dr. Timothy R. Miller, in an interview featured on Modern Aesthetics, discusses how his practice's sophisticated 3-D imaging system enabled him to study the results of fat repositioning, a technique used for lower blepharoplasty patients. Using 3-D imaging, Dr. Miller observes patients over time and notes the enhanced volume in the tear trough and areas of the upper cheeks.

Dr. Timothy R. Miller, M.D., presented two lectures at the annual Vegas Cosmetic Surgery Meeting in June 2016. An annual speaker at the meeting, Dr. Miller presented his latest research and techniques on lower blepharoplasty (eyelid) surgery, and also gave a lecture and video demonstration on temple augmentation.


Dr. Miller Recipient of Physician of Excellence Award

Dr. Miller was named a 2016 Physician of Excellence by the Orange County Medical Association. This prestigious award recognizes local doctors who routinely go "above and beyond" for patients and their communities.

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Dr. Miller Recipient of Physician of Excellence Award

We are pleased to announce that Dr. Timothy R. Miller, M.D. is a recipient of the 2016 Orange County Medical Association Physician of Excellence award!

The OCMA's "Physicians of Excellence program has become recognized as a fair and unbiased selection process identifying those physicians in the community who have exhibited the skills, training and commitment to their patients and the community to stand out above their peers as physicians of excellence."

Read more about the OCMA award in the Orange County Register's Coast magazine here.

Physician of Excellence Award to Dr. Miller

JAMA Facial Plastic Surgery: Long-Term 3-Dimensional Volume Assessment After Fat Repositioning Lower Blepharoplasty

Dr. Timothy R. Miller published this article in JAMA Facial Plastic Surgery after researching patients who underwent blepharoplasty designed to reposition fat below the eyes. Learn the conclusions of his study into this specialized technique.

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JAMA Facial Plastic Surgery: Long-Term 3-Dimensional Volume Assessment After Fat Repositioning Lower Blepharoplasty

Dr. Timothy R. Miller is a specialist in eyelid surgery and other facial plastic surgery procedures at his Orange County practice in Aliso Viejo. Clickarticle on the PDF below to read blepharoplasty research he published in the March/April 2016 edition of JAMA Facial Plastic Surgery.

JAMA Facial Plastic Surgery article

To schedule your personal consultation with Dr. Miller, please call us at 949-482-1752. You can also request your consultation online.

On His Own: Facial Plastic Surgeon Timothy R. Miller, MD, Starts Over Again

On His Own: Facial Plastic Surgeon Timothy R. Miller, MD, Starts Over Again, featuring Dr. Miller in the August 2015 issue of Plastic Surgery Practice, covers facial plastic surgeon Dr. Timothy R. Miller's journey to open his private practice.

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On His Own: Facial Plastic Surgeon Timothy R. Miller, MD, Starts Over Again

Dr. Miller standing on balcony

Dr. Miller Featured in Plastic Surgery Practice

Facial plastic surgeon Timothy R. Miller, MD, is meticulous. This serves his patients well, and it also is one of the reasons that it took him some time to open his new private practice — Refreshed Aesthetic Surgery in Aliso Viejo, Calif.

Dr Miller sweats the small stuff. Whether repositioning the last bit of fat during a lower bleph, submitting a manuscript to a peer-reviewed journal, or choosing the marble panels for his new office, he won't sign off until it's perfect.

This attention to detail is why many former patients sought Miller out when his doors first opened on December 30, 2013, and also why he has developed a new following in a relatively short time — not an easy feat in such an oversaturated market as Orange County. While he did have a foothold and some name recognition in the area because of time spent at another local practice, it wasn't easy to start fresh, but he knew he had to try.

"There is never a moment when you say, 'This is the perfect time' to open your own practice, but if it is something you want, you need to take a leap of faith," Miller says. "You gather more and more confidence in yourself and your ability, and eventually you just have to do it or you will have regrets."

Self-doubt and fear did seep in along the way, and he would reach out to colleagues, friends, and a former fellowship advisor and his parents for counsel and moral support during those times. Of course, there were some hiccups, too, but today, Miller looks at them like growing pains. "It feels like home," he says.

It has never been easy for plastic surgeons to strike out on their own, but changes in the healthcare landscape — including reimbursement restrictions — have made it even more trying today. In fact, rising numbers of plastic surgeons are actually leaving private practice for group practice or other employed positions. About 50% of all American Society of Plastic Surgeons are still private-practice surgeons, which is different from days past when the overwhelming majority of plastic surgeons were in private practice.

Location, Location, Location

For Miller, magic didn't really strike until he found the ideal location. "There were a lot of things out there that didn't fit my style, and then a new medical building was built with easy freeway access from Newport Beach, San Diego, and Riverside," he says.

The new location had pretty much everything on Miller's rather extensive checklist — including amazing views. "I held out for the best possible spot within the building for my office, one which would allow my main exam room where I do Botox and fillers and my consult room to provide sweeping views of Orange County," he says. "I really wanted my patients to have a different and very memorable aesthetic impression and experience, and I wanted those impressions to begin as soon as they parked their car until the time they left the office."

Dr. Miller working with a woman at a table

He contracted with a design firm in Austin, Texas. (Yes, there were many closer to home in Southern California, but he liked what saw in Austin.) Among the first orders of business was the build-out of an American Association for Accreditation of Ambulatory Surgery Facilities-accredited center and a "very luxurious and comfortable" overnight suite. Another must-have was a dedicated photography room, as he is a stickler for technical precision and measuring outcomes in an evidence-based fashion.

Once it was built to perfection, Miller had to fill the office — with both staff and patients. There was a lot of trial and a fair share of error at the beginning, he says. Outsourcing to third-party vendors to help with hiring and other business matters didn't help set the tone he wanted for his practice.

Ultimately, he opted to create and cultivate his own online footprint, and do all of his own hiring and new patient outreach. "I answer RealSelf questions, and we do a lot of social media to get and keep my practice name out there," he says. He does work with an Internet firm for search engine marketing, he writes most of his own web content, and he heavily edits all that is supplied for him. He also donates services to local charities. It all seems to be working, as he was just named one of the best cosmetic surgeons by the Orange County Register in its annual "Best of OC" issue for the second year in a row.

"You need to be true to your own style," he says. "That was the biggest lesson that I have learned."

Drilling Down

Like most plastic surgeons, he doesn't look his age (he's 50), but if he had wrinkles, they would tell a story — that is likely very different from other plastic surgeons.

Before going to college, Miller took a job drilling for natural gas and oil in Northern California. "I wasn't ready, and I wanted to work and earn a nice living," he says. "And being a roughneck sounded like a cool job that was physically demanding with an element of danger." It involved operating heavy machinery and drilling down holes that are 3 miles deep. Eventually, he had his own crew — and yes, they did strike natural gas and oil on several occasions.

But after a few years, "You just realize it's a young man's game, and with the constant fluctuation of the price of oil and natural gas, you want a more stable life."

So he started over. Miller went to college and on to earn his MD at the University of California, Davis School of Medicine. He then completed a 5-year surgical residency in otolaryngology-head and neck surgery, followed by an American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) facial plastic surgery fellowship, and practiced for 9 years before opening his opus Refreshed Aesthetic Surgery.

The Perils of Private Practice

By and large, private practice is the dream of most plastic surgeons, but it isn't easy. Edwin F. Williams III, MD, a facial plastic surgeon at Williams Plastic Surgery Specialists in Latham, NY, and the president-elect of the AAFPRS, did the same thing years ago, and he is often sought out by young facial plastic surgeons for advice.

Dr. Miller wearing scrubs working with a machine

There is no secret sauce, he says.

"Get out there and be known as a good doctor, and then people will follow," he says. Adding to the pressure today is the fact competition is coming from all ends and angles. It's not just plastic surgeons who want in on elective, cosmetic cash-pay procedures; it's dentists, obstetricians, internists, and aestheticians.

There have been other changes to the landscape since Williams opened his practice as well. "We didn't have injectables until April 2003, so what we would do is work our rear ends off in the emergency room doing lacerations to get patients in for facial plastic surgery procedures down the road," he says.

Today, facial plastic surgeons work hard to get nonsurgical cases into their office. "They are making a pretty good income, but just 10% is from that, so their level of comfort and confidence in performing the good stuff starts to fade," he says.

Not Miller. His ratio of surgery to minimally invasive procedures is 60:40. "It is a great mix for me and my practice, but my goal is 80:20, which I think I'm a year or so away from," he says.

Another issue facing young facial plastic surgeons today is medical school debt, Williams says.

"This raises the glass ceiling even higher," he says. "The ones who hit their number will do well, but not everyone does."

Knowing how to run a successful business is a skill set that even the best surgeons may not possess. It's important to be able to work as part of a team — even if your name is the only one on the shingle. "Your staff are your customers, too, and if you don't know how to work with a team, you will have turnover," he says. "Good staff will make or break you."

There are other trade-offs as well, Williams adds. With autonomy comes risk — and this takes a certain personality. "You have more control over your life, but with that you accept more risk."

No stranger to risk after time spent drilling in Northern California and starting over when most of his colleagues were starting out, Miller is certainly up to task.

To schedule your personal consultation with Dr. Miller, please call 949-482-1752. You can also request your consultation online.

Can You Relate?

Editor Denise Mann shares her personal experience and back story with facial plastic surgeon Dr. Timothy R. Miller, MD in the August 2015 issue of Plastic Surgery Practice.

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Can You Relate?

Dr. Miller Featured in Plastic Surgery Practice

I first met facial plastic surgeon Timothy R. Miller, MD (aka, this month's cover subject) several years ago. At the time, Plastic Surgery Practice was in another editor's capable hands.

Miller sought me out to discuss some of the content on a facial plastic surgery website I was helping to develop and launch. We talked about the copy. He had some suggestions and constructive criticism. I listened, tried not to get defensive, took copious notes, and eventually reworked some of the articles in question to address his concerns. He served as the medical reviewer of the revised pieces.

Miller went on to other things, as did I, but we always checked in with each other. He would tell me if he had something being published or made a particularly astute new clinical observation. I would call on him when I needed expert insight for this article or that one.

When I was appointed PSP editor, Miller submitted some articles and contributed to others. He told me that he was opening his own practice. I wished him luck and said when the time was right, we would do a cover on his new venture. He never asked, implied, or assumed.

There is a similar backstory concerning this month's "10 Things" subjects. I met the Shinhars through my youngest son. They have a son who is the same age, and our kids played together after school. Around the same time, I was hearing whisperings about an unassuming ear, nose, and throat doctor on the Upper East Side who is a magician with Botox and fillers and peddles his services at a very fair price, and that his wife, an aesthetician, had a cult-like following of her own.

I eventually realized my new friends and the toasts of the Upper East Side were one and the same. Like Miller, the Shinhars never tried to woo, sell, or pitch me as an editor. They were more concerned with when our sons could play. Our relationship — both the professional one and the social one — developed organically.

This is how relationship building should work, and it's also how plastic surgeons can also build a loyal patient base and grow their practice (which happens to be the overarching theme of this month's cover story). Relationship building is about connecting without want, developing a rapport, building trust, and seeing where things lead.

You never know what the future holds or who will become a loyal patient, friend, or colleague. And remember, if you ever want to know who people really are, watch to see how they treat people who they don't think they need.

To schedule your personal consultation with Dr. Miller, please call 949-482-1752. You can also request your consultation online.

Dr. Miller Featured in Physicians of Excellence

In April 2014, Dr. Miller was featured in the annual Physicians of Excellence publication from the Orange County Medical Association. The selection denotes "physicians in the community who have exhibited the skills, training, and commitment to their patients and the community to stand out above their peers."

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Dr. Miller Featured in Physicians of Excellence

Dr. Miller smiling

As its name suggests, Refreshed Aesthetic Surgery's goal is to help you look and feel "Refreshed!"

Refreshed Aesthetic Surgery is devoted to aesthetic treatments and cosmetic surgery of the face and neck. The Aliso Viejo office is home to Timothy R. Miller, M.D., a double board- certified facial plastic surgeon who has offered Orange County residents facial cosmetic surgery since 2005.

Dr. Miller has dedicated his education, training, and practice exclusively to facial cosmetic surgery. A dedicated physician with "old school" values toward education and the practice of medicine, he is well known to his patients for delivering honest and thorough evaluations with exceptional results.

Dr. Miller designed and opened his state-of-the-art cosmetic surgery office and accredited surgery center to provide patients seeking aesthetic services with a more personalized and unique experience, combined with a boutique-like feel and charm. At his practice, Orange County women and men of all ages turn to him for his honest assessments and for results that consistently enhance and beautify their appearance.

"Our mission," Dr. Miller said, "is to educate and honestly assess each patient, offering the finest aesthetic treatments available so you will look and feel refreshed."

The practice was named "Refreshed" to emphasize Dr. Miller's guiding aesthetic philosophy and mission to prospective and current patients. That mission is to recommend and perform only those procedures that will enhance a person's features and provide results that Dr. Miller said "will have you looking natural, refreshed, and beautiful — not pulled, altered, or resembling someone unlike yourself."

Highly trained in all aspects of aesthetic facial surgery, Dr. Miller offers a complete range of facial procedures using only the latest advanced techniques. These include facelift, mini–facelift, brow lift, eyelid surgery, neck lift, rhinoplasty, ear surgery, facial implants, and Mohs reconstructive skin cancer surgery.

Although the practice's focus is aesthetic surgery of the face, a variety of non-surgical and esthetician services are also offered. These include non-surgical facelifts, HydraFacials®, Botox®, dermal fillers, fat augmentation, laser skin rejuvenation, facials and chemical peels.

To schedule your personal consultation with Dr. Miller, please call 949-482-1752. You can also request your consultation online.

10 Things: It's Miller Time

10 Things: It's Miller Time, featuring Dr. Miller in the August 2014 issue of Plastic Surgery Practice, covers facial plastic surgeon Dr. Timothy R. Miller's journey to open his private practice.

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10 Things: It's Miller Time

Dr. Miller Featured in Plastic Surgery Practice

After some serious soul searching several years back, Timothy R. Miller, MD, decided the time was right to strike out on his own. And Miller, a double board-certified facial plastic surgeon, officially opened his private practice, Refreshed Aesthetic Surgery, in Aliso Viejo, Calif, on December 30, 2013. He is fastidious and exacting when it comes to detail, and the state-of-the-art facility reflects Miller's aesthetic vision and creates a harmonious ambiance for all who enter. He even incorporated some of the principles of feng shui into the décor.

Miller spoke to PSP about the challenges of going it solo, why he would never do a reality show, and how he chose the name Refreshed Aesthetic Surgery for his new practice.

Here's what he had to say:

1. What has been the most challenging aspect of starting your own practice?

Designing and building the office, while getting all the contractors and subcontractors to see your vision, and then completing the construction with my attention to detail. But, I'm happy to say that it all worked out well, and all the struggles with the build-out and starting my own practice were definitely worth it.

2. What is your signature procedure?

I have two signature procedures, but I do not believe giving them "catchy" names is really ethical. I have always felt that the result rather than name is most important, so the "signature" comes from your execution of the technique and the end result. I use the high superficial muscular aponeurotic system technique for my facelifts and the fat repositioning technique for my lower blepharoplasties, and both are best when combined with fat augmentation.

3. What is the biggest trend you are seeing in your practice?

The emphasis is on natural results and looking refreshed, not different. This is why I intentionally named my practice Refreshed Aesthetic Surgery.

4. What technology would you not want to practice without?

Fractional CO2 laser (Lumenis) and 3D imaging (Canfield M3).

5. Are you an innovator, early adopter, early or late majority, or a laggard?

I've been all at some point in time, but mostly an early adopter of technology or philosophies that have not hit the mainstream.

6. What is your professional mantra?

Education and honest assessments and recommendations.

7. Would you ever do a plastic surgery reality TV show?

No. First, I'm not photogenic, and my personality is too low-key. Additionally, my patient population is typically professional people who would not want cameras around the office.

8. Tell us something about you that is really surprising.

Before attending medical school, I worked in the oil/natural gas fields as a roughneck (then driller) for 10 years.

9. Last great read?

The last great read was the book In Your Face by Dr Bryan Mendelsen because it addressed, albeit for right or wrong, the appearance of the face and how it is so important and pivotal in nearly all aspects of life.

10. Where do you get your industry news?

Plastic Surgery Practice (seriously, I do!) and attending meetings.

To schedule your personal consultation with Dr. Miller, please call 949-482-1752. You can also request your consultation online.

THE EYES: When One Plus One Equals Three

Facial plastic surgeon Timothy R. Miller, MD was featured in the July 2013 issue of Plastic Surgery Practice, which covers rejuvenation of the peri-orbital area.

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THE EYES: When One Plus One Equals Three

Dr. Miller Featured in Plastic Surgery Practice

Many aesthetic patients are seeking rejuvenation of the peri-orbital area. The request is understandable considering the influence the peri-orbital area has on an individual's outward appearance. Common complaints include eyes looking tired, sad, or simply old. Indeed, the peri-orbital area has the extraordinary capacity to either accurately express one's emotional status, energy level, health, and age, or inadvertently communicate undesirable impressions when volume loss, excess skin, or pseudo-fat herniations are present.

Before and after of eyelid surgery for the lower eyelid with fat repositioning only
One-year result after lower blepharoplasty with fat repositioning only. Above/Middle: Before. Bottom: After. Note effacement of tear trough and elimination of cantho-lid-cheek distance. Improved, yet peri-orbital area volume augmentation would provide superior result. *, tear trough; L/C, lower eyelid/cheek junction.

These "mistaken impressions" have real consequences. Several studies have demonstrated that tired, sad, and older-appearing eyes can have a negative effect on upward mobility in the workplace and place a damper on social life.

Combining simultaneous autologous fat grafting with fat-repositioning lower blepharoplasty can dramatically improve the look of the peri-orbital area. Unfortunately, patients are usually offered techniques that center on the removal of skin and intra-orbital fat, thereby creating "a more aged and skeletonized appearance rather than a youthful appearance."2 The continued prevalence of surgeons offering "subtractive" blepharoplasty techniques is surprising, given improvements seen with fat-preservation techniques. Indeed, the paradigm shift toward fat-preservation blepharoplasty began in the early 1980s and has achieved wider recognition with increased but not widespread use in the last decade.

At about the same time fat-preservation techniques for blepharoplasty were becoming more recognized, surgeons using autologous fat augmentation began to publish their own positive results regarding peri-orbital rejuvenation. The concept had a similar slow, but steady evolution in acceptance.6 The presence of ample soft-tissue volume in the peri-orbital area has become acknowledged as an essential ingredient in true aesthetic peri-orbital rejuvenation. This can be accomplished by replenishing, by use of autologous fat augmentation, or retaining, by way of fat-preservation lower blepharoplasty.

It remains uncommon to combine the two techniques during the same surgery. Indeed, most surgeons who perform fat-preservation lower blepharoplasty do not use fat augmentation, and those surgeons who routinely perform autologous fat augmentation continue to use fat-subtractive over fat-preservation techniques for their lower blepharoplasties, typically through a transconjunctival approach.

The simultaneous use of the two techniques, however, can offer improved results over either procedure alone.

Sweet Spots

Thorough anatomical studies of the face during the past decade have demonstrated well-defined, superficial, and deep compartments of fat.7 These discrete compartments play a significant role in defining the topography of our facial features, especially in the peri-orbital area. The deep compartments central to the peri-orbital area are the deep medial cheek fat, the medial and lateral suborbicularis oculi fat (SOOF), infra brow fat, and temple (fossa) fat. Loss of volume in any of these areas through age, health, or surgery will have a profound impact on peri-orbital appearance.

Consequently, knowledge of the existence and location of these four compartments provides the astute aesthetic surgeon a road map to accurately diagnose and restore youthful peri-orbital contours. (Figure 2) For instance, when injecting autologous fat, having a focused target of these discrete compartments will ensure that all compartments affecting the peri-orbital area are treated. Simply placing fat or filler in the tear trough or randomly injecting around the eyes provides only a partial or incomplete correction at best.

Before and after of woman who had autologous fat augmentation
Autologous fat augmentation only. A) Before. B) Illustration of deep peri-orbital fat compartments. DMF, Deep medial fat; M, Medial SOOF; L, Lateral SOOF; T, temporal fat compartments. C) 6 months. D) 5 years, no Botox or fillers.

Fat-Repositioning Lower Blepharoplasty

Fat repositioning is one of three lower-blepharoplasty techniques described to preserve pseudo-herniated intra-orbital fat. The technique has evolved since its introduction in 1981, but the tenet of fashioning vascularized pedicles of fat, from the nasal and middle intra-orbital fat pads, and overlaying these pedicles over and inferior to the orbital rim, remains the same. The technique of fat repositioning was developed because subtractive lower blepharoplasties often created hollowing and failed to adequately efface the tear trough deformity or the lower eyelid-cheek junction (palpebromalar groove).

One-year result by another surgeon using subtractive blepharoplasty techniques
One-year result by another surgeon using subtractive blepharoplasty techniques. Note lack of rejuvenation from continued tear trough deformity and hollowed, skeletonized appearance. A) Before. B) After.

A modification of the fat-repositioning technique was developed by Robert Alan Goldberg, MD, who described a trans-conjunctival approach as an alternative to development of a skin-muscle flap.8 The new approach placed more emphasis on technical surgical skill, as exposure for developing the fat pedicles was more limited. In addition, preserving the integrity of the orbicularis oculi muscle, and lateral portion of the orbital retaining ligament, was advantageous for limiting the issues reported with skin-muscle flaps.

The trans-conjunctival approach allows for fat grafting without exposing the grafted fat. A skin-muscle flap would disrupt the soft-tissue cover, potentially affecting fat graft survival. Most surgeons who perform fat-augmentation procedures use the trans-conjunctival approach, but for fat removal only. Not only does this approach subtract vital fat from the peri-orbital area, it omits the release of the tear trough ligament and adjacent orbicularis retaining ligament, which compromises the effacement of the tear trough and lower eyelid-cheek junction. Although more edema and fullness after fat augmentation further reduces the operative exposure while performing subsequent fat-repositioning lower blepharoplasty, the combination clearly enhances the results as more causes of peri-orbital aging are being addressed and corrected.

10-month result. Upper and lower blepharoplasty with fat repositioning and augmentation
10-month result. Upper and lower blepharoplasty with fat repositioning and augmentation. A and C) Before. B and D) After.

The improvement of the tear trough and lower lid/cheek grooves after fat repositioning was initially thought to be the result from the elevation of the lower eyelid soft-tissue inferior to the orbital rim with the subsequent positioning of pedicled fat underneath these grooves. However, a recent anatomical study has produced a more thorough explanation.9 The study showed the existence of true osteo-cutaneous ligaments residing in the tear trough area and lower eyelid area.

Upper and lower blepharoplasty with fat repositioning and augmentation
Upper and lower blepharoplasty with fat repositioning and augmentation. A to D) Note more robust projection and smoother contours from targeted peri-orbital fat compartment augmentation.
Tear trough ligament diagram
Reproduced with permission, LWW. Wong CH, et al. The tear trough ligament: Anatomical basis for the tear trough deformity. Plast Reconstr Surg. 2012;129:1392-1402. TTL, tear trough ligament; ORL, orbital retaining ligament.

The tear trough ligament, for example, attaches to and tethers the skin in the medial portion of the lower eyelid, forming the tear trough groove. This ligament is one of the main causes of the tear trough groove. The ligament is quite short, yet strong and adherent. Without complete release of this "robust" ligament, the tear trough groove will persist. Understanding the true anatomical nature of this ligament has clinical relevance and may explain the inconsistency in effacing the tear trough using fillers or fat augmentation alone; that is, the ligament and tethering still persists to some degree.

Careful preoperative facial analysis will reveal which fat compartments around the peri-orbital area require augmentation. Fat is harvested and treated using the techniques described by Sydney Coleman, MD. Fat cells are then meticulously placed into in all four areas. The plane of augmentation in all areas, except the temple, is submuscular down to periosteum. However, minute amounts of fat are commonly placed in the subcutaneous plane. For the temple, the plane is subcutaneous but extends down to but not under the deep temporalis fascia.

The lower blepharoplasty is performed next after placing lubricated eye shields. A transconjunctival incision is made with development of a plane between the orbicularis oculi muscle and orbital septum. Care is taken not to prematurely open the septum. The orbital rim is identified through blunt dissection. The arcus marginalis is identified and is often found inside the orbital rim, especially in older individuals. The release of the orbicularis retaining ligament (not the arcus marginalis) is performed. The medial dissection releases the adherent tear trough ligament and extends laterally to the fascial extension that exists between the arcuate expanse and the orbicularis retaining ligament.

Blunt dissection exposes the inferior oblique muscle, which facilitates the safe release of the fat pads for transposing over the orbital rim in a tension-free manner. Fat pedicles are developed by incising a thin, short strip of septum overlying the particular fat pad. No fat is removed. A larger fat pad is simply released and spread further down the malar face to augment the deep medial cheek fat compartment. The release is much like unrolling a camping bed roll. Lateral fat is more fibrous and is either repositioned or conservatively excised. Any excised lateral fat is placed between the transposed medial and middle fat pedicles as a free graft.

The pedicled fat grafts are secured with a transcutaneous #4-0 Monocryl suture on a RB-1 needle times three. The sutures are easily removed in 3 or 4 days and do not leave scars. The transconjunctival incision is always closed with three buried gut sutures. A pinch technique, upper blepharoplasty with fat preservation, skin resurfacing, and other procedures are then performed as indicated.

Lower blepharoplasty with fat repositioning, surgical photos
Lower blepharoplasty with fat repositioning, right side. A) Exposure and release of orbicularis retaining ligament. B) Release of tear trough ligament. C) Medial and middle fat pads. D) Identification of inferior oblique muscle. E) Pedicle development. F) Tension-free release. G) Repositioning into sub-periosteal pocket. H) Trans-cutaneous secured pedicles and pinch technique.

Peri-orbital rejuvenation requires a thoughtful and thorough approach. The pitfalls of relying on "subtractive" techniques for peri-orbital rejuvenation were described more than 30 years ago, yet their use still continues today. Clearly, fat-preservation blepharoplasty or rejuvenation by volume augmentation alone, by filler or fat augmentation, enhances the results over subtractive methods. For aesthetic surgeons who are seeking more robust and refreshed peri-orbital results, the combination of simultaneous autologous fat grafting and fat-repositioning lower blepharoplasty offers an approach, with the potential of improved results over performing either of these procedures alone.

To schedule your personal consultation with Dr. Miller, please call 949-482-1752. You can also request your consultation online.

The Forgotten Temples

Facial plastic surgeon Timothy R. Miller, MD was featured in the April 2012 issue of Plastic Surgery Practice, which covers volume augmentation for facial rejuvenation.

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The Forgotten Temples

Dr. Miller Featured in Plastic Surgery Practice

Fat augmentation: 5-year postoperative result
Fat augmentation: 5-year postoperative result. No temple augmentation.

The role of volume augmentation for facial rejuvenation will continue to progress as our knowledge and insight into facial anatomy, aging, beauty, and aesthetic harmony continue to mature. Soft-tissue augmentation has been used with positive results for some time, but the focus within the facial aesthetic community, as a whole, of where to place volume has certainly changed and expanded. With experience, practitioners recognize that filling just a wrinkle or nasolabial fold, for example, can help or, better yet, appease a patient's concern, but true facial rejuvenation, with harmony, requires a more thoughtful scope of evaluation and an expanded treatment philosophy.

Treating the Hallow Temples

The hollow temple is an area often overlooked by patients and practitioners alike. Once pointed out, the expression is one of surprise for not recognizing this obvious "problem" before. Or if previously known, hairstyles have commonly been changed or altered to conceal the area. The lack of fullness within the temple area can be due to a relatively deep temporal fossa, a hypoplastic temporalis muscle, or an atrophied adipose tissue layer.

Most temples do have a slight concavity, but too much concavity (or convexity) disrupts the frame or silhouette of the face. The hollowness also exposes the superior-lateral orbital ridge and zygomatic arch, which are features deemed less attractive and associated with aging and/or poor health. Consequently, the aim in treating the hollow temple is to provide a better overall shape to the face and a smooth transition from the peri-orbital area to the temporal hairline.

Figure 1 is a 5-year follow-up photograph of a patient with fat augmentation to the peri-orbital area (tear trough and infra-brow) and cheeks. The improvement and longevity from her fat-augmentation procedure is evident, but if you now evaluate and consider the temple area, the results become less impressive. No fat was placed in her temples, and the resulting hollowness, over time, accentuated her superior-lateral orbital rims and provided a less than ideal appearance and facial shape.

Another example of the importance of temple augmentation is illustrated in Figure 2. This 63-year-old female underwent a high-superficial musculoaponeurotic system (SMAS) facelift, fractional CO2 laser resurfacing, and fat augmentation. From her preoperative photograph to postoperative year 1, her temples are satisfactorily filled from her fat-augmentation procedure despite being on a significant weight loss program. A 25-plus-pound weight loss during year 2 recreates the hollowness once corrected by fat augmentation. Notice the improvement in her facial shape and overall peri-orbital aesthetics when her temples are revolumized or "rescued" with hyaluronic acid (HA) fillers.

Temple hollowing pre and post operative
Temple hollowing. A. Preoperative. B. One year postoperative. C. 2.5 years postoperative with 25-pound weight loss. D. Appearance after temple filling with HA filler: Note restoration of facial shape and improved position of lateral portion of eyebrows.

For the hollow temples, the most common treatment methods are fat augmentation, poly-l-lactic acid (PLLA), and syringe-based fillers such as HA fillers. The benefits, longevity, and techniques of fat augmentation to the temples and other facial areas are well established. Fat augmentation is often combined with other facial aesthetic surgery procedures, including brow lifting, but the procedure may have limitations for some patients. Commonly, patients with very deep hollowed temples, who are seeking aesthetic improvements, are patients with very limited fat stores.

Correction of hollow temples and facial features - before and after photos
Correction of hollow temples and facial features with PLLA, nine vials total over four treatment sessions. A. Pretreatment. Appearance with significant temple hollowing. B. Seven months. C. 2 years, 4 months.

In these circumstances, the fat stores may be either too limited for any fat-augmentation procedure or only enough fat exists for transfer to more aesthetically "vital" areas, such as the peri-orbital or cheek areas. Additionally, fluctuating weight, which significantly impacts transplanted adipose cells, as illustrated above in Figure 2C, and downtime can be significant deterrents for some patients.

For these reasons, PLLA and HA fillers are excellent alternatives. PLLA's safety profile and its effects on temple (and overall facial) augmentation are well established.2 The volumizing from PLLA comes from the induction of fibroplasia (collagen growth), which in reality takes multiple treatments and months for the results to present themselves fully. This can be seen as an advantage because many patients like the idea of temple filling with their own "collagen," and the slow progression to end result provides privacy. Friends, family, and co-workers will not see a dramatic overnight change in their appearance. The results begin to diminish by 2 years, but much longer outcomes are not uncommon.

Fat Augmentation Versus PLLA for Temple Augmentation

The technical aspects between fat augmentation and PLLA are significant. For instance, fat is typically placed throughout the subcutaneous and temporoparietal fascia layers where the facial nerve resides, and down to but superficial to the deep temporal fascia layer. In contrast, the needle or cannula delivering PLLA is placed through the deep temporal fascia and then deep to the temporalis muscle onto the temporal fossa bone(s), where a small depot of PLLA is deposited. It is noteworthy to mention that the temporal fossa is, indeed, covered with a thin, adherent periosteum (pericranium). The point is significant for two reasons.

Many physicians recall that the periosteal layer of the scalp transitions to become the deep temporal fascia layer, which covers the temporalis muscle, without recognizing that a portion does extend on the undersurface of the temporalis muscle to cover the temporal fossa.3,4 Without periosteum, there would be a limited supply of fibroblasts to manufacture collagen. The fibroplasia in this plane acts like a shim elevating the temporal contents.

Demonstration of injecting a hyaluronic acid filler into a woman's temple
Demonstration of entrance sites creation using a 20-gauge needle (top row pictures) and hollow temple filling with hyaluronic acid filler using a 25-gauge, 1.5-inch cannula.

However, despite the deep placement, some amount of fibroplasia can be seen (during brow lifts) and felt (with needle resistance in subsequent PLLA treatments) in the more superficial layers. The basis is presumably from the permeability of the deep temporal fascia as well as PLLA seeping through the penetration sites made in the deep temporal fascia upon injection, and facilitated further by the massage regimen encouraged after the procedure. The reasons for the deep placement were from complications with nodules and papules reported in the temporal area when more concentrated and superficial placements of PLLA were reported.5,6

Treating Hollow Temples with HA-BASED Fillers

The "latest" treatment for temple filling is with HAs such as Restylane or Juvéderm. In contrast to placement in lips or nasolabial folds, these fillers are hydrated with saline and/or lidocaine.7 The reasons for this are at least twofold. Hydration allows more volume of product (albeit at lower density and tonicity), and promotes smoother placement of product. The hydration also decreases the risk of the Tyndall effect (bluish discoloration). The placement is in the more "elastic" subcutaneous layer and approximates the temporoparietal fascia layers. Thus, the volume expansion is often more substantial than what is seen with PLLA. One reason for this is anatomical. The deep temporal fascia is a relatively thick, durable fascia layer attached firmly at its edges on bone (temporal line of fusion, processes of the lateral orbital rim, zygomatic arch).

Like a moderately tight drum, volume augmentation underneath the fascia has a limited capacity to distend or elevate, especially more superior in the temple where the deep temporal fascia is a single layer.8 Consequently, hyaluronic fillers are an ideal treatment for hollow temples because of their more superficial placement and can be offered to patients as a stand-alone procedure or as a supplement to fat augmentation or PLLA treatments.

The technique of hollow temple filling with HA is straightforward. Typically, patients will require a minimum of 2 cubic centimeters (cc) of HA filler per side. Hydration volumes vary, but adding 3 cc of bacteriostatic saline (0.9%) and 1 cc of 1% or 2% lidocaine (with or without epinephrine) is sufficient. This provides 6 cc of volume and will fit in most 5-cc syringes.

I use a disposable 25-gauge 1.5-inch cannula (DermaSculpt, CosmoFrance Inc, Miami, or a 0.7 Tulip infiltrating cannula (Tulip Medical Products Inc, San Diego) for placement. Initial entrance sites (usually two to three) are made using a small needle (20 to 23 gauges). The product is then delivered in a threading fashion using a slow, controlled fanning motion.

Before-and-after result with diluted hyaluronic acid in woman's face
Before-and-after result with diluted hyaluronic acid (HA) filler, 2.0 cc of HA per side.

Cross hatching over areas ensures a smooth and consistent result (Figure 4). Much of the edema will dissipate in minutes to hours as the saline and local anesthesia is absorbed. Follow-up in 3 to 4 weeks is standard, allowing more filler placement if required (Figure 5).

The risks associated with any temple-augmentation procedure should not be minimized. Injury to the facial nerve is possible and is one of the reasons that cannulas are used in fat grafting and during HA filler placement. Other risks include hematoma, vessel occlusion or emboli, numbness, infection, and the occasional superficial vessel in the temple becoming more prominent after filler placement. The vessel usually returns back to its normal size in hours but can persist for 2 to 3 weeks.

The hollow temple is an additional area that should be examined for patients seeking facial rejuvenation. The hollow temple often goes unrecognized and untreated, but several safe and effective treatment options are available.

To schedule your personal consultation with Dr. Miller, please call 949-482-1752. You can also request your consultation online.

Press Releases

3-D Imaging Helps Orange County Eyelid Surgery Specialist in Research

Dr. Timothy R. Miller, a leading facial plastic surgeon in Orange County, used 3-D imaging for lower eyelid surgery research published in a prestigious journal.

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3-D Imaging Helps Orange County Eyelid Surgery Specialist in Research

Dr. Timothy R. Miller, a leading facial plastic surgeon in Orange County, used 3-D imaging for lower eyelid surgery research published in a prestigious journal.

Aliso Viejo, California (February 2016) — Dr. Timothy R. Miller, a board-certified facial plastic surgeon in Orange County, says using advanced 3-D imaging technology in recent research helped him to draw some important conclusions about a certain fat repositioning technique in lower eyelid surgery.

"Prior to 3-dimensional imaging, evaluation of the effectiveness of the fat repositioning lower blepharoplasty technique was difficult to quantify," Dr. Miller wrote in a study published this month by JAMA Facial Plastic Surgery. "Specifically, standard photography relied on shadows and tight camera angles to illustrate qualitative results."

Lower blepharoplasty is perennially one of the most popular procedures among Dr. Miller's Orange County patients, he says.

"The popularity is understandable considering just how much this small area of the face can influence a person's entire appearance," Dr. Miller says. "Common complaints include eyes looking tired, sad, or simply old. Lost volume, excess skin, and bags under the eyes may all contribute to this appearance."

Dr. Miller recently researched the effectiveness of repositioning fat below the eyes to rejuvenate their appearance, rather than performing fat grafting or combining the 2 techniques, which are other common approaches. He used 3-D imaging to measure how effectively the fat repositioning technique improved the tear trough and the lower eyelid-upper cheek area, and he found strong results.

Dr. Miller, who also specializes in facelift and rhinoplasty surgeries, among other facial treatments, at Refreshed Aesthetic Surgery in Orange County, says another study of using fillers to augment the lower eyelid area also demonstrated the effectiveness of 3-D imaging.

"It enables surgeons to quantify the results we achieve in a much more measurable way," he says, "which is especially helpful for research purposes. In addition, on the practical side, we can show our patients their results in a way that is not possible using standard 2-D photography."

An earlier study that appeared in a journal published by the American Society of Plastic Surgeons® also noted that 3-D imaging can help improve the results of facial plastic surgery.

"Three-dimensional dynamic imaging techniques may help researchers to better understand 'the multidimensional attributes of the aging face,'" the ASPS study said.

Dr. Miller agrees: "As a specialist whose practice is exclusively focused on aesthetic surgery and treatments for the face and neck, I want to provide my patients access to proven, advanced techniques. Using 3-D imaging helps my patients, it helps me as a surgeon and a researcher, and it's simply an excellent technique that helps the field in many ways."

Learn more about eyelid surgery and Dr. Miller's approach by requesting a consultation online or calling Refreshed Aesthetic Surgery at 949-482-1752.

Surgeon: Twin Study Shows Premature Facial Aging Worse for Smokers

Dr. Timothy R. Miller, a facial cosmetic surgery specialist in Aliso Viejo, says a recent study established that twins who smoke have significantly more premature facial aging than their non-smoking twin counterparts. Read More

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Surgeon: Twin Study Shows Premature Facial Aging Worse for Smokers

Dr. Timothy R. Miller, a facial cosmetic surgery specialist in Aliso Viejo, says a recent study established that twins who smoke have significantly more premature facial aging than their non-smoking twin counterparts.

Aliso Viejo, California (November 2013) — Dr. Timothy R. Miller (www.lookrefreshed.com) says a study showing twins who smoke display more signs of early aging than their non-smoking identical twins reflects the effects he's seen as a cosmetic surgery specialist in Aliso Viejo.

"Most of the smoking-related differences affected specific areas of the face, such as the premature development of eyelid bags, with similar aging related changes to the middle and lower thirds of the face," Dr. Miller says of the results of the study, which appeared in the November issue of Plastic and Reconstructive Surgery®.

"Smokers' faces featured more wrinkles, creases, eyelid bags, and jowls," Miller says. "Surprisingly, there were fewer differences in aging seen in the upper face, such as forehead lines or 'crow's feet' around the eyes."

Although earlier research has confirmed smoking's relationship to premature facial aging, this study is among the first to include facial analysis of smokers to determine what parts are affected the most.

It is becoming clearer why smoking causes premature aging, says Dr. Miller, who regularly performs procedures such as eyelid surgery and facelift surgery at his Orange County practice and who has years of experience studying the structures of the face. He said this research suggests tobacco use might cause wrinkles, eyelid bags, and even jowls because smoking damages and degrades the supportive connective fibers of the skin, such as collagen and elastin.

"It's widely known that the toxins in tobacco disrupt the flow of oxygen through the blood vessels," Dr. Miller says. "This can really affect a person's complexion and cause a dull, sallow appearance — and premature skin laxity and wrinkles."

One of the study's interesting findings, he says, is that when both twins were smoking, the twin who smoked just 5 years less than their identical counterpart showed significantly less signs of early aging.

"This should provide hope and some measure of inspiration to quit smoking," he says. "It's amazing how much cosmetic damage can be prevented by reducing your life-time tobacco use by 5 years."

Dr. Miller says there are several options available to reduce the appearance of this damage, from surgery to less-invasive treatments such as injectable dermal fillers. These non-surgical options, along with BOTOX® Cosmetic, are popular in Aliso Viejo as smokers and non-smokers look to reduce the signs of aging without the cost or downtime required for surgery.

Despite the effectiveness of the treatment options, Dr. Miller says he still encourages his patients to avoid smoking.

"This new study is yet another reason to quit smoking," he says. "People have long known about the health risks, but maybe now that it's clear their looks can be dramatically affected for the worse, they'll be more likely to never start or seek help to stop altogether."

To schedule your personal consultation with Dr. Miller, please call us at 949-482-1752 or request your consultation online.