Origins

What is plastic surgery? According to the first English dictionary of science (Lexicon Technicum: Or an Universal English Dictionary of Arts and Sciences, published by John Harris in 1710), it is “the Art of making Figures of Men, Birds, Beasts, Fishes, Plants, et cetera, in clay, et cetera… It differs from Carving, because here the figures are made by Addition usually, but in Carving always by Subtraction of what is superfluous.” Thus plastic was originally described as the art of building up figures to create new structures rather than cutting away. Dorland’s Illustrated Medical Dictionary gives a surprisingly similar meaning. The first definition of plastic is “tending to build up tissues or to restore a lost part.”

Plastic surgeons of 100 years ago, who viewed their role as sculptors and augmenters, were in practice much closer to that definition than are modern aesthetic surgeons. The literature of the early twentieth century abounds with reports on efforts to augment tissues with a wide variety of injectable fillers, such as rubber latex, gutta percha, celluloid, gold, silver, ivory, cow horn, and other materials. Frederick Strange Kolle, author of the first book on cosmetic surgery, Plastic and Cosmetic Surgery, which was published in 1911, devoted more than one fourth of the text to the use of hydrocarbon filler injections (paraffin and petrolatum jelly) for facial augmentation. He described an extensive classification system for using hydrocarbons in the face, including eight indications in the forehead, seven in the orbit, fourteen in the nose, four in the cheek, four in the ear, ten in the mouth, six in the breast, two in the neck, and eleven miscellaneous indications in the body. Kolle and other authors reported on the natural feel and acceptance of the body to injected hydrocarbons, noting that they did not remain as solid when injected. Instead, they would break up into microparticles: when entering the body, each particle would be separated from other particles by the host tissues so that they were more easily integrated, and the host tissue remained the predominant palpable tissue.

Thus at the beginning of the twentieth century subcutaneous filling was used extensively for altering facial proportions. This practice continued during the first two decades of the twentieth century. However, during that time, complications resulting from injected paraffin and other substances became obvious, and aesthetic surgeons, disillusioned with available fillers, abandoned this approach to rejuvenation after 1920—failing to recognize that it was the product, not the process, that needed to be improved.

As an alternative to injectable fillers, they developed simple surgical procedures to remove the signs of aging. This emphasis on excising and removing has persisted as new and more elaborate procedures have been devised for cutting away and suspending skin, fat, and muscle to obliterate the wrinkles, folds, and troughs associated with aging. The result has been the often-cited “stigmata of plastic surgery”—the hollow eyes and tight-pulled faces that patients today are so anxious to avoid. Although reconstructive plastic surgeons have remained builders and restorers, working primarily to restore humans to a more normal, whole condition, aesthetic surgeons moved away from building and restoring to become “carvers.” For them, excision and suspension became the indisputable gospel.

Personal Evolution

As a student of history, schooled in atmospheres that encouraged independent thinking, I have taken a different approach to aesthetic rejuvenation and recontouring. Augmenting and filling always seemed the way to approach this problem—all that was needed was a filler that was natural, stable, and without the complications of earlier fillers. For me, fat has proved to be that medium. In 1988 I first spoke on fat grafting at the annual ASAPS meeting, showing a year’s longevity of the fat. Since 1990, when I began submitting abstracts to ASAPS and ASPRS with titles such as “Maintenance of Facial Fullness: A Primary Approach to Aging,” I have attempted to get the message out that fat grafting, when done appropriately, can provide an excellent natural means for facial rejuvenation and recontouring, with natural results and long-term stability. As a part of that message, I have continued to stress the importance of rethinking how we approach facial rejuvenation, rejecting the theory that sagging is the primary problem with aging. Rather, I see aging as a process in which there is an absolute decrease in subcutaneous facial volume leading to secondary facial changes: sagging, texture changes of the skin, and exposure of underlying structures. Over time this message is gaining acceptance. Over the past 30 years, this way of thinking has dramatically advanced aesthetic plastic surgery so that surgeons now are now able to deliver much more natural rejuvenation and enhancement of faces and bodies.

Current Practice

The plastic surgery community over the past 30 years has at times embraced my concepts and at other times ignored them. Regardless, the world of aesthetic surgery has changed. The focus in aesthetic surgery is once again on augmentation: words such as volume, fullness, and structure have been added to the title and content of almost every surgical rejuvenation lecture.

The reasons for the modern plastic surgery community’s reservations about restructuring with fat are perfectly understandable. Plastic surgeons have been extensively trained on the many nuances of removing the signs of aging with blepharoplasties, facelifts, and forehead lifts. We have been reliant on procedures that excise and suspend for so long that it is difficult to totally alter our vision and our practice.

There are technical barriers as well. Successful fat grafting is technically demanding and requires the same attention to detail that one would devote to any surgical procedure. In addition, correct fat grafting technique requires a much higher quality of photography than other types of aesthetic surgery to document the millimeters of change. Plastic surgeons in training are selected for their technical skills; however, there is no guarantee that a plastic surgeon will have the ability to visualize in three dimensions, let alone create a free-form, three-dimensional structure on the face or body. Even if surgeons can obtain good survival of the transplanted fat, they may not be able to sculpt in three dimensions, creating a pouty lip, a sharp jawline, a smooth lower eyelid, or an appropriately sloping forehead.

And as important as a facility in sculpting, a surgeon must have the ability to observe and document the dramatic enhancement in the quality of overlying skin that occurs over time after fat grafting. Many surgeons simply do not have the interest or ability to photograph changes in the texture of skin, especially that which occurs over not just months, but also years and decades. Yet this is a phenomenal change, which should be encouraged.

Possibly the biggest stumbling block to acceptance of the concepts of filling has, until recently, been economic. If experienced surgeons have trained for years in the principles of excision and suspension and now have successful practices based on traditional surgical techniques, it is difficult for them to abandon these procedures for structural fat grafting. It is much easier for younger physicians to make the shift. However, with the modern patient demanding a much broader range of services and treatments that are less invasive and that produce more natural results, surgeons are incorporating Coleman structural fat grafting along with fillers into his or her practice, both as a primary procedure and as an adjunctive one.

Aesthetic surgery is moving rapidly away from excision and suspension procedures to augmentation procedures for rejuvenation in particular. The reason? The primary event of facial aging is atrophy or loss of fullness. The obvious solution for atrophy is the restoration of volume or fullness. To fully understand why this makes sense, we have rethought our traditional concept of aging. I propose the following model to help us really see the aging changes that we are dealing with so that we can develop the best strategies for addressing them.