There is currently a major paradigm shift from excision-based surgery to strictly volume enhancement. Because there is still no perfect facial filler, development of synthetic facial injectables continue to advance at a remarkable pace. Each type of filler carries a specific characteristic that makes it more suitable for a certain clinical application. The continuing change in facial fillers offers the possibility for volume augmentation procedures with less downtime and without the need for harvesting fat. We predict that volume enhancement will continue to play an increasing role as both a complementary and as a stand-alone procedure in facial rejuvenation.
Key points
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There is currently a major paradigm shift from purely excision-based surgery to combined surgical and volume enhancement.
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Because there is still no perfect facial filler, development of synthetic facial injectables continue to advance at a remarkable pace.
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Each type of filler carries a specific characteristic that makes it more suitable for a certain clinical application.
- •
The continuing change in facial fillers offers the possibility for volume augmentation procedures with less downtime and without the need for harvesting fat.
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We predict that volume enhancement will continue to play an increasing role as both a complementary procedure and as a stand-alone procedure in facial rejuvenation.
Introduction
Over the past several years, the role of volume restoration with autologous fat has become an increasingly recognized entity as a primary mechanism by which to overcome the aging process. Facial fat grafting has assumed a renewed interest among aesthetic surgeons owing to technical advances that have been shown to be beneficial both in achieving consistently excellent cosmetic results and in limiting morbidity.
The aging process can be understood with a simple analogy of the aging face: in youth, the face is like a grape, and as people age, volume depletion causes the face to become like a raisin. When performing age-related surgeries, the redundant skin is lifted, pulled, and cut away so that the remainder no longer resembles the grape of youth but is more like a truncated pea. This approach does not restore all the highlights, contours, and convexities of youth. Filling the depressed facial zones helps restore a youthful appearance more effectively. Note that this reductionist philosophy does not reflect the authors’ opinion entirely, because we recognize the complexity of the aging process that can comprise volume loss, volume gain, gravitational descent, and dermatologic changes. In the past, the aging face was perceived as a change caused by gravity and skin redundancy and it is now interpreted as arising from tissue deflation, which can be corrected with facial fat grafting.
The best approach for prospective patients with aging faces seeking to restore a youthful countenance is to view old photographs from the patient’s youth. Old photographs provide a framework for our goals and help the patient understand what combination of procedures will provide a natural and rejuvenated appearance. During the consultation and evaluation, it is important to maintain a global approach for optimal rejuvenation. The myriad of procedures may include fat grafting, face-lifting, microliposuction/liposuction, blepharoplasty, and or skin therapies. The combination approach toward fat grafting is not necessarily a stand-alone procedure in every case but an adjuvant to traditional procedures ( Fig. 1 ). This integrated strategy allows the surgeon to select the right combination of individually tailored procedures based on how that person looked previously.
The advent of disposable microcannulas for use with office-based facial fillers, and the continued development of filler products intended for facial volumization, has challenged fat grafting as the sole method for facial volumization. Fillers are now a suitable alternative in patients who desire fat transfer or as an adjunct to fat transfer because microcannulas can be used for advanced facial sculpting, which fat grafting alone was only able to achieve a few years ago.
This article proposes a systematic approach to facial fat enhancement of the midface emphasizing simplicity, consistency, and safety, which is the result of a decade of clinical experience with ongoing refinements in technique. Autologous fat transfer plays a critical role in facial rejuvenation of the midface as a stand-alone procedure or in combination with traditional age-related surgeries. Preoperative education and counseling are emphasized.
Introduction
Over the past several years, the role of volume restoration with autologous fat has become an increasingly recognized entity as a primary mechanism by which to overcome the aging process. Facial fat grafting has assumed a renewed interest among aesthetic surgeons owing to technical advances that have been shown to be beneficial both in achieving consistently excellent cosmetic results and in limiting morbidity.
The aging process can be understood with a simple analogy of the aging face: in youth, the face is like a grape, and as people age, volume depletion causes the face to become like a raisin. When performing age-related surgeries, the redundant skin is lifted, pulled, and cut away so that the remainder no longer resembles the grape of youth but is more like a truncated pea. This approach does not restore all the highlights, contours, and convexities of youth. Filling the depressed facial zones helps restore a youthful appearance more effectively. Note that this reductionist philosophy does not reflect the authors’ opinion entirely, because we recognize the complexity of the aging process that can comprise volume loss, volume gain, gravitational descent, and dermatologic changes. In the past, the aging face was perceived as a change caused by gravity and skin redundancy and it is now interpreted as arising from tissue deflation, which can be corrected with facial fat grafting.
The best approach for prospective patients with aging faces seeking to restore a youthful countenance is to view old photographs from the patient’s youth. Old photographs provide a framework for our goals and help the patient understand what combination of procedures will provide a natural and rejuvenated appearance. During the consultation and evaluation, it is important to maintain a global approach for optimal rejuvenation. The myriad of procedures may include fat grafting, face-lifting, microliposuction/liposuction, blepharoplasty, and or skin therapies. The combination approach toward fat grafting is not necessarily a stand-alone procedure in every case but an adjuvant to traditional procedures ( Fig. 1 ). This integrated strategy allows the surgeon to select the right combination of individually tailored procedures based on how that person looked previously.
The advent of disposable microcannulas for use with office-based facial fillers, and the continued development of filler products intended for facial volumization, has challenged fat grafting as the sole method for facial volumization. Fillers are now a suitable alternative in patients who desire fat transfer or as an adjunct to fat transfer because microcannulas can be used for advanced facial sculpting, which fat grafting alone was only able to achieve a few years ago.
This article proposes a systematic approach to facial fat enhancement of the midface emphasizing simplicity, consistency, and safety, which is the result of a decade of clinical experience with ongoing refinements in technique. Autologous fat transfer plays a critical role in facial rejuvenation of the midface as a stand-alone procedure or in combination with traditional age-related surgeries. Preoperative education and counseling are emphasized.
Treatment goals and planned outcomes
There are several goals of facial fat grafting. These goals include the achievement of a natural rejuvenation and restoration of youth, the avoidance of complications, and the attainment of long-lasting aesthetic benefit. In the modern era of facial fat grafting, learning about autologous fat grafting requires completely rethinking of the approach to the aging face. Clinicians must use a novel aesthetic appreciation of the aging process. Clinicians also must use new operative techniques, including body harvesting and infiltration, and must manage unique complications. The details of approach and technique are described later.
Facial aesthetic surgeons must think about autologous fat transfer in a different manner than a typical operative procedure. Specifically, typically they strive for the ideal result; however, for autologous fat transfer, a more conservative approach is advocated. Surgeons must taper their expectations. In particular, as the limit of fat transfer is pushed by increasing volumes transferred to obtain an ideal result, the associated increased recovery time and potential for complications increase dramatically. If the surgeon or patient thinks that they is undercorrected, reharvest and transfer of additional fat is an easy task compared with the difficulty of correcting a complication such as a visible contour irregularity or reduction of an overcorrected face. Thus, conservatism should be the rule, especially for surgeons inexperienced with facial fat grafting.
The aesthetic of volume enhancement embodied by facial fat grafting mandates a different approach to patients. The goal of facial fat transfer is to return patients back to their own youthful appearances. Many aesthetic surgeons now evaluate a patient during consultation and attempt to define what areas of the face require improvement without reference to how the patient looked when younger. Patients are encouraged to bring in young photographs, which help the surgeon evaluate the patient’s youthful appearance and help the patient understand the importance of volume loss in the aging process and the need to replace it. The patient must help guide the desired aesthetic outcome. Regardless, patients’ past photographs are reviewed to help the patients understand the role of fat grafting. Past photographs also help surgeons to conceptualize the optimal fat grafting plan.
Our vision for facial rejuvenation does not insist that autologous fat transfer is the only possible method by which facial enhancement is achieved. Fat grafting is a complementary role in our clinical practice. We think that a patient’s aesthetic result can be greatly enhanced by the use of a combination of approaches; for example, fat grafting, face-lifting, and blepharoplasty ( Fig. 2 ). Patients are considerably more pleased when each procedure adds to the tally of aesthetic improvement. Traditional procedures and fat transfer need not be exclusive of one another. Two ideologies can be embraced: volume enhancement for volume depletion and lifting procedures for gravitational descent. Judicious use of fat grafting with select lifting procedures can constitute a potent mixture for correcting specific flaws of aging. Combining procedures can also diminish the risk of morbidity. With ongoing clinical experience, surgeons will begin to perceive the role that volume enhancement can play in the armamentarium of facial rejuvenation.
Anatomy
As the face matures, soft tissue loss is accentuated by the presence of facial retaining ligaments that create unfavorable shadows. The anatomy for fat grafting does not relate so much to an intimate knowledge of specific underlying anatomic structures but rather to understanding the hills and valleys across the surface of the face that can be transformed into a more uniformly convexity free of unwanted depressions.
The easiest way to categorize the face for anatomic understanding is into thirds: the upper third comprises the brow and temple area; the middle third comprises the cheek and midface; and the lower third comprises the prejowl, jowl, and lateral mandible. This systematic approach provides a formula for specific volume enhancement based on each individual anatomic territory. Rather than delve into the esoteric minutiae related to each anatomic zone, the clinical significance of each area is emphasized with attention to the clinically relevant pearls to guide the optimal surgical strategy.
The middle third of the face is perhaps the most important area for facial rejuvenation with autologous fat and is anatomically the most complex in terms of fully understanding each subunit. By our definition, the middle facial third includes the lower eyelid, malar, and submalar area. A youthful face is characterized by a confluence of the lower eyelid and cheek regions, which become separated into visually distinct regions with the aging process. With aging, the orbital rim becomes a separate entity from the cheek because of orbital fat bulging superiorly and the cheek fat receding, which reveals the bony orbital rim. The voluminous lateral cheek mound of youth dissipates to uncover a smaller, flatter contour of the malar bony eminence that lacks any notable soft tissue coverage. The anterior cheek begins to separate, often with a linear depression that courses from the nasojugal depression down inferolaterally to the buccal recess, which corresponds with the ligamentous attachment known as the malar septum ( Fig. 3 ). The buccal region can show marked atrophy and should be reconstituted along with the discussed anterior and lateral malar regions to achieve better confluence and to avoid exaggeration of buccal hollowing following malar augmentation. As an extension of the midface, the nasolabial fold should be deemed part of midfacial volume enhancement.
