By Babak Azizzadeh, M.D.
Modern 21st Century facial rejuvenation has evolved tremendously especially in the last decade. Historically, the aging process was considered to be secondary to laxity and gravity, which resulted in sagging skin. However, over the last decade research and physician experiences have revealed that the aging process has multiple components. The primary components of the aging process include skin photo damage, decreased elasticity of the skin, volume deflation, bony resorption of the entire facial skeleton and resultant laxity from both gravitational as well as volume loss. As a result, traditional two-dimensional facelift procedures no longer provide the aesthetic rejuvenation that patients are seeking. Facial rejuvenation and facial procedures need to have a three-dimensional facet in order to create natural, youthful and long-lasting results.
In analyzing the entire face, neck and eyelid region, we realize that the entire area needs to be assessed at the time of the facial rejuvenation procedure to address both the volume deflation, skin and laxity issues that are the root of the aging process. The brow and mid face regions affect the eyelids tremendously, The eyebrow region undergoes both atrophy as well as drooping with the aging process, while the mid face area creates a hollowing effect of the lower eyelids leading to teartrough deformity and overall atrophy of the region. Furthermore, the structural foundation of the eyelids weakens leading to increase laxity of the upper eyelid skin and herniation of fat pads in the lower eyelid. In the lower face, jowling and skin laxity in the neck occur secondary to gravitational laxity and decreased volume in the area of the chin and around the mouth. Furthermore, some fatty deposits occur in the neck area and banding of the neck muscles occur leading to further progression of the aging process.
Historically, two-dimensional facelifts served as a primary role for facial rejuvenation. Coronal brow lifts, aggressive eyelid surgery and aggressive facelift procedures were the norm in the 80s and early 90s when patients presented to the plastic surgeon for facial rejuvenation. Furthermore, fat grafting and bony restoration were not identified as serving a role in facial rejuvenation with the exception of a few cutting edge plastic surgeons. Even though fat grafting has been in the armatarium of facial plastic surgeons, the results historically were not predictable. Aggressive suctioning of the fat, poor processing and injecting of the fat just underneath the skin into lines led to unpredictable results. Over the last decade, extensive research has shown that fat grafting has excellent viability if the fat is not aspirated aggressively, the processing is done gently and the injection process is done gently into multiple layers underneath the skin and near the muscle and bone areas creating a structural scaffold that addresses volume loss rather than line filling. Over the past five years I have termed this concept as “multilevel fat grafting” to truly describe the process of fat grafting. Utilizing multilevel fat grafting in conjunction with short scar facelifts, conservative eyelid rejuvenation and endoscopic brow lifts has transformed the outcome of these facial rejuvenation procedures.
In my current approach, I proceed with harvesting of the fat from the abdomen, flank inner or outer thigh region. The fat is then processed gently to avoid rupture of the fat cells. We try to maintain some of the serum that comes out as there has been research showing that there are stem cells present in the serum. We next proceed with endoscopic brow lift, conservative blepharoplasty (eyelift) and/ or short scar facelift procedures depending on the patient’s need to address the excess laxity and create structural support for the face. At the conclusion of the procedures, fat grafting is utilized to volumize the face in a three-dimensional format in the brow area, in the teartrough, cheek and the region around the mouth. This approach allows a three-dimensional facial rejuvenation that creates a much more natural aesthetically pleasing outcome. Multilevel fat grafting in approximately 90% of patients needs to be performed only once. In 5 to 10% of individuals repeated grafting under local anesthesia may be necessary.
If patients who have significant volume deficits, other volume restoration technique such as submalar cheek implants and chin implants may need to be utilized to structurally balance the face and these can be done in conjunction with multilevel fat grafting with the procedures we have discussed. Multilevel fat grafting can also be done as a standalone procedure in patients with early volume changes that do not desire other surgical procedures. This can be done under local anesthesia in the office setting with four to five-day downtime. In many of our patients we also utilize aggressive skin care treatments as well as fractional laser resurfacing and conservative chemical peeling to address the skin changes that occur with photodamage and decreased elasticity.
In conclusion, fat grafting provides an excellent rejuvenating tool in patients with aging changes and can be performed as a standalone procedure or in combination with endoscopic brow lifts, blepharoplasty and facelifts to create a three-dimensional facial rejuvenation. Overall, the risks and complications with the operation are minimal in the hands of an experienced surgeon and the results can be amazing.
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About Dr. Azizzadeh:
Dr. Babak Azizzadeh is a Harvard-trained Facial Plastic Surgeon who specializes exclusively in the cosmetic and reconstructive surgery of the face, eyes and nose. He is the Director of The Center for Facial and Nasal Plastic Surgery and board-certified by the American Board of Facial Plastic & Reconstructive Surgery as well as the American Board of Otolaryngology-Head & Neck Surgery. His expertise in cosmetic and reconstructive plastic surgery has made him one of the most sought-after surgeons in the country. He has been featured in The Oprah Winfrey Show, The New York Times, Discovery Health, and numerous other media for his expertise in facial plastic surgery.
Dr. Azizzadeh’s Website: www.facialplastics.infonone