In recent years, nonsurgical techniques and devices for rejuvenating the aging face have taken the profession by storm.

It is my firm conviction that most of the more dramatic, meaningful, natural, favorable—and in the long run, economical—examples of facial rejuvenation are accomplished through the expert application of time-honored surgical techniques. In my experience the use of fascia or scar harvested from the patient’s own body has proven to be the most economical and long-lasting method of filling thinning lips and deep facial grooves. Fat is less predictable, and the vast majority of commercial fillers provide only temporary improvement.

Neuromodulators, fat, and fillers can be used in some patients who wish to lessen lines and wrinkles created by facial expression. Many younger adults choose to use neuromodulators in an attempt to slow the development of the undesirable signs of aging. It is my opinion that all options should be discussed with patients, even if the patient requests a certain product. Doing so fulfills the physician’s requirement for “informed consent.”

Neuromodulators have gained popularity and can be used for a variety of facial issues. These injections can lessen expression wrinkles about the forehead and crow’s-feet area. I have reservations about using neuromodulators in the peri-oral region of the face, except when extreme puckering of the mentalis muscle occurs with facial expression. The temporary paralysis with neuromodulators is different than what is accomplished with skin resurfacing. In some cases a combination of neuromodulators and resurfacing is recommended.

Neuromodulators may also be injected to improve some of the spasms and asymmetry that patients with facial paralysis and Bell’s palsy experience. It should be noted that results obtained with neuromodulators are not permanent, so their use will have to be repeated. And undesirable lagophthalmos (ptosis) of the upper eyelid has been reported, as well as drooping of the upper lip and drooling at the corners of the mouth.

Soft tissue grafts have long been used in plastic surgery. The first breast augmentations were en bloc fat grafts, but because hard lumps (healed areas of fat necrosis) made it difficult to distinguish scar from cancer, the practice was abandoned.

Fat harvested from other parts of the body has been injected into various regions of the body. It appears that the skill of the surgeon in harvesting the graft and preparing it for reinjection and the skill with which the fat cells are injected are the keys to success. Still, many surgeons are beginning to reveal that varying degrees of injected fat remains and retreatment is usually necessary. A rule of thumb is this: fat injected into muscle tends to survive more often than fat cells injected into fat or subcutaneous tissues.

I recommend that anyone who plans to incorporate fat grafting into their practice spend an appropriate amount of time with an experienced surgeon who has performed hundreds—if not thousands—of fat grafts, and learn the finer details of the procedure.