Fat grafting is faster, less expensive, and more effective than surgical lifting
rominent malar eminences are a hallmark of beauty in many cultures, and fullness of the malar region conveys a youthful appearance. With aging, there is a loss of this fullness that allows the infraorbital bone to show through the skin as a dark shadow that is separate and distinct from herniated periorbital fat. This telltale sign of aging is a result of the descent of facial fat and, more importantly, a significant loss of facial fat volume. These changes result in greater depth of the nasolabial folds, hollowness of the cheeks, turning down of the corners of the mouth, and the appearance of labiomandibular folds.
A midface lift elevates the malar fat pad in an effort to correct the changes that occur with midfacial aging. However, the procedure does not take into account the loss of facial fat volume that has occurred in the malar fat pad; therefore, it cannot entirely achieve its intended goal. In addition, a midface lift requires a significant knowledge of midfacial anatomy, which can lead to a steep learning curve and a high reoperation rate. The recovery period can be prolonged, and symmetry can be difficult to achieve—even in the most experienced hands.
Facial Fat Grafting
For many years, we have recognized that replacement of volume loss is of primary importance in midfacial rejuvenation; during this time, we have developed and perfected an easy, reproducible, and almost complication-free alternative to the midface lift. We began facial reshaping with facial fat grafting (FFG) more than 25 years ago, and we have performed FFG to the midface region more than 500 times. The procedure takes approximately 20 minutes. Healing is rapid, and FFG can be combined with any other facial-rejuvenation procedure.
At the outset, preoperative markings (Figure 1) are made in the operating room holding area, and general anesthesia is applied for the duration of the procedure. We have abandoned local anesthesia for FFG because catecholamines are known to break down adipose tissue.
Just as hair from the posterior scalp is harvested for hair transplantation because it remains despite male pattern baldness, fat from the waistline and abdomen is harvested for FFG because it persists despite dieting and exercise. The fat is harvested, centrifuged for purification, and immediately injected into the selected areas. In the infraorbital area, the fat is injected directly over the periorbital rim; a finger is used to prevent fat spillage over the orbital rim. In the cheek, the fat is injected directly over the zygoma. Injections are made in the nasolabial folds, cheek hollows, and jawline, as necessary, according to the patient’s particular facial deficits.
An average of 24 mL of fat is injected per patient; rarely is more than 36 mL necessary. A blunt canulla is used multiple times to inject the fat into all facial planes. Fine lines are injected superficially with an 18-gauge needle to release subdermal adhesions. No bandages or compression dressings are necessary after the operation. Acetaminophen is the only pain medication required by most patients afterward, and the majority of them are able to return to work with an acceptable appearance within 3–4 days.
Figure 2 shows the patient whose face was marked up in Figure 1 (page 20). He is a 46-year-old male who underwent a facelift with FFG to the infraorbital area, cheeks, cheek hollows, and nasolabial folds. The patient in Figure 3 is a 56-year-old female who underwent a facelift, brow lift, and FFG to the infraorbital area, cheeks, and cheek hollows.
Overall, FFG seems to be most appropriate for patients who desire a quick recovery with minimal complications, yet expect the highest degree of quality in terms of postoperative shape and contour in the malar region. Restoring volume to the malar region is the key to midfacial rejuvenation, and it is the way to achieve midface reshaping instead of performing a midface lift.
As with all surgical procedures, providing superior outcomes while minimizing complications is the ultimate goal. In the case of midfacial rejuvenation, FFG avoids surgical manipulation of the deeper facial structures and thereby minimizes risk to the lower-eyelid complex and facial nerves. In short, FFG is an extremely powerful tool in midfacial rejuvenation because of its technical simplicity, excellent results, and quick recovery.
Gary Motykie, MD, and Richard Ellenbogen, MD, FACS, are in private practice in Los Angeles. They can be reached at firstname.lastname@example.org or email@example.com.