Lifting and skin treatments are often insufficient to rejuvenate the face unless volume is restored as well

I have found that a simple and effective way of thinking about facial aging is to divide it into three main parts:

• superficial skin changes;

• laxity of skin and underlying muscle (subcutaneous muscle–aponeurotic system, or SMAS); and

• loss of volume.

The superficial skin changes, such as fine lines and age spots, are treated with good skin care, chemical peels, and facial lasers. Laxity of the skin and muscle, and loss of volume, are normally addressed by facelifts. The spectrum of facelift techniques used by plastic surgeons ranges from the less surgically invasive, such as the thread lift and S-lift, to the more invasive, such as the deep-plane and extended SMAS-type facelifts.

Whereas all of these facelift techniques focus on tightening loose skin and resuspending structures that have descended, the vast majority do not fully address the loss of volume that can occur with facial aging. For some patients, volume loss can be the most evident sign of aging.

Richard Ellenbogen, MD, FACS, developed the volumetric facelift, a technique that focuses on treating both skin laxity and volume loss.1 I was pleased to contribute to this development. The technique involves replacing fat in areas where it has been lost, removing fat below the mandible, and conservative skin tightening and redraping to effectively reverse the signs of aging and produce a natural, younger appearance. We believe that this approach provides a simpler surgical technique that gives durable, natural results, as well as a smoother, less painful, and more rapid recovery.

In this article, I will explain the volumetric facelift technique, as well as some additional features of the procedure that I perform in my practice.

Preoperative Considerations

Patients are encouraged to bring photos of themselves when they were younger to the initial consultation; this helps the surgeon determine how the face has aged over the years. Although they are somewhat controversial, computer-based “morphing” programs or manual graphic manipulation of current photos can also give the patient an indication of desirable (but not guaranteed) results.

Some patients present with a heavier face. They will often resist the added volume from the volumetric facelift, because they think that their face is already too “fat.” For these patients, I will consider a more traditional SMAS-tightening facelift without fat grafting. Most patients would still benefit from fat grafting, at least to the lips and infraorbital regions, but I let them make the final decision. I recently coauthored another paper by Ellenbogen that describes treating the “chubby” face with fat grafting, buccal lipectomy, and submental liposuction.2

I give every patient a course of arnica montana to be taken preoperatively and postoperatively to reduce swelling and bruising, and to aid the general postoperative recovery. I also tell them that the herbal tablets’ effects are not scientifically proven and that taking them is strictly optional.

Surgical Technique

Before surgery, the patient is marked for incision placement, locations of fat grafting, extent of dissection, mandibular border, and submental fat to be excised. The patient is marked while sitting up, because mandibular-border markings tend to change when the patient is lying down.

The surgery is usually performed under general anesthesia. This helps to minimize operating time because it eliminates or decreases the need for injections, and sometimes reinjections, of local anesthetics. Facial fat grafting requires injecting local anesthetics into many large areas of the face, and thus exacerbates the problem. I have found that general anesthesia is much easier for both surgeon and patient.

At the start of the procedure, I use a short scar incision that begins at the root of the helix. The incision extends along the posterior aspect of the tragus, and cuts through the attachment of the earlobe to the underlying mastoid fascia. It extends along the postauricular sulcus, and finally turns posteriorly at the level of the superior aspect of the tragus. It does not extend into the hairline in the temporal region or posterior scalp.

The flap elevation is performed along the subcutaneous plane, with a limited area of dissection in the face (Figure 1, page 34). The limited dissection leaves an undisturbed subcutaneous plane for fat grafting at the conclusion of the procedure.

I then perform a SMAS plication using buried 3-0 polyglactin sutures with a trivector technique. At this point, the surgeon can perform the SMAS procedure of his or her choice, as long as the subcutaneous dissection remains somewhat limited to allow for fat grafting in the desired areas.

The mandibular border is marked with gentian violet or a surgical marker over the subcutaneous fat. The marking is made to correspond to the marks on the skin, so as to make the mandibular border as accurate as possible when the patient is sitting up.

Under direct vision, fat superficial to the platysma and inferior to the mandibular border is removed. This is usually best accomplished using a long, curved Metzenbaum scissors and a long-toothed bayonet forceps. The submental fat near the midline is removed via liposuction or by direct excision through a 2-cm incision in the submental region.

The platysma is treated by closure and partial transection only if prominent banding was present when the patient is asked to grimace during the preoperative examination. If there were no descending bands, the platysma is not manipulated and only the overlying fat is removed.

Redrape the Skin

The skin along the premarked mandibular border is gently redraped along a vector directed to the cartilaginous canal of the ear. Excess skin is removed, and the dermis of the skin flap is sutured to the cartilaginous canal with a buried 3-0 nylon suture. The entire lift is suspended on the inferior margin of the cartilaginous canal rather than on soft-tissue sutures above the jawline, thereby avoiding tension on the earlobe and skin closures. This helps prevent a “pixie-ear” deformity (Figure 2).

Figure 3: Locations and average amounts of fat grafting. Reprinted from reference 1.
Area Amount of fat
1Rarely fat-grafted
2Rarely fat-grafted
35–9 mL
42–9 mL
52–5 mL
62–5 mL
71–4 mL
81–4 mL
94–8 mL
101–2 mL

The remainder of the excess skin is excised and closed in standard fashion. I avoid overtightening the skin because this technique does not appear to increase the longevity of the results. Care is taken to re-create a natural pretragal sulcus by direct defatting.

Prior to final closure of the facelift incisions, fat grafting is performed by injecting fat underneath the flap through the incision, lateral oral commisures, and crow’s-feet area, as necessary, with a blunt-tipped cannula. Most patients require replacement of fat over the malar regions (cheekbones), midcheek hollows, nasolabial folds, upper and lower lips, and infraorbital regions to re-create a youthful “ogee,” as described by Little.3 Photos of the patient taken 10, 20, or 30 years earlier can be used to determine the appropriate fat volumes to use to restore a youthful appearance.

Fat is usually harvested from subcutaneous deposits in the abdomen or lateral thighs. The abdomen is usually the first choice, because a small hidden stab incision can be made in the umbilicus. I usually harvest 60 mL of fat in 10-mL cannulae, using a blunt fat-harvesting cannula.

The fat is placed in the centrifuge and spun for 3 minutes. The fluid on the bottom is drained by removing the syringe cap, and the oil on the top is gently decanted. The purified fat is then transferred to 1-mL syringes and injected in stacked and cross-stacked “toothpick”-shaped layers with a limited number of passes to minimize trauma. The photos of the patient when young can be used to help determine where to restore volume. The average amounts of fat grafted in each facial area are depicted in Figure 3.

Deep Grafting

The fat is grafted mainly into the deep subcutaneous layers, with the exception of the infraorbital region, where care is taken to place the fat below the orbicularis muscle and above the periosteum of the infraorbital rim. Fat grafting superficial to the orbicularis muscle can create visible contour deformities. Ellenbogen has described the fat-grafting technique that I use.4 

The incisions are then closed using a running 5-0 chromic skin suture placed in the postauricular sulcus, with care taken to close the dead space of the sulcus by taking bites of the underlying fascia. These sutures are left to fall out on their own; the suture scars are of no concern because they are hidden. The remainder of the incisions are closed with running and interrupted 5-0 nylon sutures, which are removed on day 6 or 7 postsurgery. I usually place a drain along each side of the neck dissection, and remove it the day after surgery. Finally, I apply a compression garment.

Postoperative Considerations

The patient is allowed to shower and wash his or her hair on the first day after surgery. Within 2–3 days, driving a car and performing the usual daily functions are permitted.

Patients who have undergone a volumetric facelift generally show positive results early on, and they are consequently satisfied with the surgery. I usually tell patients that they should look good by 2–3 weeks after the surgery. As all plastic surgeons know, the time necessary to reduce the swelling depends on several factors that vary by patient, including their age, metabolism, and extent of surgery.

I encourage patients to undergo lymphatic massage after the operation, as described by Rubin and Hoefflin.5 Fat “take” can vary by patient, but it is usually the greatest in the cheekbone and infraorbital regions, and the poorest in the lips. Patients are instructed not to massage fat-grafted areas, because it is believed that this may cause a decrease in fat “take.”

I recently attended a course taught by Tolbert Wilkinson, MD, who said that the fat that remains 4 weeks postsurgery is usually “permanent.” In my experience, I have found this to be generally true. In areas with too much “take,” external ultrasound may help to decrease the amount of fat. However, my experience with this is limited because this is almost never a problem with the fat-grafting techniques and amounts I have described.

In summary, the volumetric facelift technique treats the face’s sagging skin, and muscle and volume loss, that occur with aging. The surgery, the concepts that govern it, and the thought processes around it are simple, yet they produce maximum results. The midface and lower face are rejuvenated, and patients have a natural, youthful look with relatively little downtime and discomfort. PSP

Anthony Youn, MD, is a plastic surgeon in private practice in Rochester Hills, Mich. He can be reached at (248) 650-1900 or [email protected]. Megan Callahan is a freelance writer in Rochester, Mich.


1. Ellenbogen R, Youn A, Yamini, D, Svehlak S. The volumetric facelift. Aesth Surg J. 2004;24:514–522.

2. Ellenbogen R, Youn A, Motykie G, Svehlak S, Yamini D. Facial reshaping using minimally invasive methods. Aesth Surg J. 2005;25:144–152.

3. Little JW. Volumetric perceptions in midfacial aging with altered priorities for rejuvenation. Plast Reconstr Surg. 2000;105: 252–266.

4. Ellenbogen R. Fat transfer: Current use in practice. Clin Plast Surg. 2000;27:545–556.

5. Rubin A, Hoefflin S. Treatment of postoperative bruising and edema with external ultrasound and manual lymphatic drainage. Plast Reconstr Surg. 2002;109: 1469–1471.