Treatment Goals

After rigorous evaluation of patient photographs over the arc of their youth, middle age, and senescence, I have noticed little gravitational effect on the upper and midfacial regions that would warrant a browlift and midface facelift. In my opinion a browlift offers little advantage to most patients who would benefit from fat transfer. When I lifted their brows with my fingers during an initial consultation, many patients exclaimed that they did not look like that in their youth. When I attended a speech given by my colleague, Mark Glasgold, who showed young and old photographs of the same individual, I realized that deflation was the major issue with the aging process. That realization began my journey to understand aging more precisely, and the more I looked the more I came to appreciate the principal role that volume has in the aging process. Although during my fellowship training I was exposed to a large series of midface facelifts, I have come to realize that the midface facelift has even less effect when volume can be an easy, more reliable, and more aesthetically beneficial way to rejuvenate the midface.

Do I perform surgical procedures anymore? Yes, facelifts for the lower jawline and neck and the occasional blepharoplasty, but both of these procedures are commonly undertaken in conjunction with fat grafting, which remains the centerpiece of my surgical methodology. I have come to understand that fat grafting as a stand-alone procedure can work well to enhance a face in the right patient without the need for other surgeries. Selecting the appropriate patient is mandatory.

Fat Grafting and Blepharoplasty

I almost always perform fat grafting in conjunction with blepharoplasty. I perform a conservative, skin-only upper blepharoplasty in about 15% of my fat grafting cases and only do so when I see that the upper eyelid skin hangs at or below the ciliary margin or when the edge of the skin has a crêpelike appearance ( Fig. 1 ). In almost all other cases, fat grafting is sufficient to improve the situation ( Fig. 2 ). I use the analogy of a deflated balloon to describe the upper eyelid/brow complex. During aging, the principal phenomenon of the upper eyelid is loss of fat, so it is more analogous to a balloon deflating than a curtain falling. Although it is counterintuitive to a patient who believes that there is an excessive amount of tissue there rather than a paucity, I show them before-and-after photographs that justify my analogy of inflating a deflated brow rather than needing a browlift or isolated upper blepharoplasty to address the problem. I am always cognizant that other surgeons can achieve excellent, natural results with only a browlift and upper blepharoplasty but, in my view, fat grafting makes more sense and it has yielded me more consistent results. As far as the lower eyelid is concerned, I perform this procedure in less than 5% of my fat grafting cases and almost never as a stand-alone procedure ( Fig. 3 ). I believe that almost every individual suffers from some degree of lower eyelid hollowness, and a small percentage of those individuals have a steatoblepharon that is so substantial as to justify excision along with additional fat placed along the orbital rim for optimal results. I perform a selective lower eyelid blepharoplasty using a transconjunctival approach to remove any excessive fat from the lower eyelid before I inject fat into the orbital rim hollowness. As mentioned earlier, in most cases fat grafting is sufficient to cover the exposed eyebag that represents an exposed fat pad circumscribed and exacerbated by a hollow orbital rim below.

This patient underwent a conservative right upper eyelid blepharoplasty along with facial fat transfer to achieve the desired results.

This patient underwent only a fat transfer to the face, because no traditional blepharoplasty was required to remove redundant tissue.

This patient underwent a fat transfer in conjunction with a conservative skin-only upper blepharoplasty, transconjunctival lower blepharoplasty, and plasma skin resurfacing.

Fat Grafting and Facelift

The term facelift is a broadly encompassing and confusing term. When I refer to a facelift I am specifically referring to a lower face (jawline) and neck lift using whatever technique appeals to the reader. I personally perform my facelifts through an superficial muscolu-aponeurotic system technique and do so only in patients who would benefit from it. A small jowl can be easily camouflaged with fat grafting and/or fillers. However, when the jowl becomes noticeably dependent below the jawline and/or platysmal changes are visible in the neck, then no amount of fat or filler can correct the situation. Further, aesthetically, a lower facelift helps to make a fat-transfer result look better. However, many facelift cases are performed prematurely. Although volume restoration of some kind can be beneficial even to someone starting in their mid to late 30s, a facelift procedure typically is not necessary until at least the 50s in most cases (with the exception of individuals with fair skin, advanced aging, and sun damage who may require intervention in their 40s). Because those who would benefit from facelifts are in a smaller group within the fat grafting group (think of a Venn diagram), most of my facelifts have fat transfer, and a smaller percentage of my patients having fat transfers have facelifts. The exception to this rule is 2-fold:

• 1.
  

  Patients who previously had a fat transfer and have now matured to the point that a facelift would be beneficial.

  
  
• 2.
  

  An isolated facelift can be performed in someone who has a very aged neck and in whom the primary focus is on the neck only. In this case, a facelift could be performed without a fat transfer.

Facial fillers can also be used as a substitute for fat transfer, as discussed later. Fat should not be grafted into areas where planned undermining for a facelift will occur. However, most fat grafting is done in the central face and undermining for a facelift occurs in the outer lower face. In the individual who would benefit from fat grafted in the outer face (eg, in the far lateral buccal expanse or mandible), and would benefit from a facelift and would like both performed simultaneously, I typically would favor performing an optimal facelift in this area rather than worry about not being able to put fat grafting there then in the future plan on adding some fillers to augment this deficient area.

Combined Procedures

To sequence all of these procedures, I perform the lower blepharoplasty first so that I do not encounter and accidentally remove any transplanted fat in the lower orbital rim. Then I perform the fat grafting, which I find to be the most artistically important procedure and one that requires less tissue distortion than would arise after a facelift, which may impair judgment as to how to place the fat. After fat transfer, I then perform an upper blepharoplasty. At the conclusion of the procedure, I perform the facelift, and I may apply the circumferential pressure bandage immediately following the facelift portion of the procedure.

Alloplastic Implants

In general, I am opposed to alloplastic implants as a principal method for facial rejuvenation, especially cheek implants, because of how aging occurs. Both soft tissue and bone are lost as people age. However, in the current era of improved dentition, most aging involves a greater loss of the overlying soft tissue envelope in relation to the underlying bony tissue. Therefore, more bone prominences are exposed, as people age. If this is the case (consider almost anyone more than 40 years of age who has not gained significant weight since their 20s or adolescence), there will be a predominance of bony shadows that develop and dominate the face. Adding hard implants under the skin exacerbates these bony prominences, which can exaggerate the bony exposure and also worsen the surrounding shadows.

The only way the midface can be properly restored with alloplasts is if a greater number of alloplasts are placed to fill in all of these shadows and to simulate soft tissue coverage, namely in the nasojugal region, tear trough, central and lateral malar area, and extended buccal zone. All these implants could be replaced with careful sculpting of fat into these depressed zones.

The chin is another area that I think has been overaugmented with alloplasts. For the younger patient with microgenia, a chin implant is the preferred method to correct the deficiency because like replaces like (ie, a weak bony chin is replaced by a hard implant). As people age, the fat loss around the chin, especially, the area above where an implant could safely reside, namely the mental sulcus region, becomes more pronounced and requires fat or, alternatively, a filler in most cases. Just like a malar implant, a chin implant can exacerbate the depth of surrounding soft tissue loss and in this case it can make the mental sulcus look deeper and the whole region bonier, which is another indication of aging.

Fat Grafting: Patient Selection

Fat grafting is not necessarily safe for all comers. The 2 groups of individuals whom I counsel against fat grafting are the very young (less than age 35 years) and those with weight instability. The reason is the same as for not performing fat transfer in both of these groups. Young people do not know how they will age over time in terms of weight gain. If someone gains significant weight (on the order of more than 10 kg), the fat that is transplanted is liable to grow and to distort the face because it is not a bioinert substance like injectable hyaluronic acid, but behaves like grafted fat.

Because fat is traditionally harvested from the lower abdomen and thighs, it is a tenacious kind of fat (ie, it stays well), but it also is subject to the nature of abdominal and thigh fat (ie, it is the first area to gain size with weight fluctuations). This caution is particularly applicable when a patient has lost significant weight and is ready to undergo a fat transfer. I think that it is almost always safer to graft a patient who either has a long history of weight stability or is undergoing a fat transfer before significant weight loss. I like to undertake a fat transfer in someone losing weight about one-third of the way toward an ideal but realistically targeted body weight.

During my studies for my hair-transplant board certification, I realized that fat grafting in many ways reflected how hair grows after a hair-transplantation procedure. Like grafted hairs, parcels of fat that are transplanted behave like free grafts. After an early period of so-called primary and secondary inosculation that may last a few months, the grafted fat attains a long-term, durable blood supply, or neovascularization. For this reason, transplanted hairs begin to flourish and grow after 6 months but continue to do so up until 18 months. I have witnessed the same changes in grafted fat, in which they start to improve in many cases 6 to 18 months later. The difference with grafted hairs is that, early on, a volume of fat is present that may be confused with a final result. As the fat cells shrink slightly over a period of a few months, the patient begins to fear that the result is dissipating. The patient should be reassured that, in most cases, the fat begins to show slight then ongoing improvement for a year or more after this aesthetic valley, which I refer to as the dip. It does not always return. Just like grafted hairs, there is some variability as to total take of fat. However, if fat is used to rebuild multiple facial areas (eg, temples, brows, upper eyelids, lower eyelid, anterior and lateral cheeks, extended buccal regions, anterior chin, and prejowl sulcus), even if the take is not perfect in any one area, the overall result should be favorable. Small touch-ups can be performed with injectable fillers, a point that is discussed more thoroughly later.