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Key Points
- One must understand the mechanisms of facial aging in order to recreate the appearance of youth through cosmetic interventions.
- It is important to use unadulterated fat without the addition of local anesthesia or any other substances.
- The "next generation facelift" is about restoring volume and individualizing the surgical technique to achieve natural-appearing elevation and symmetry.
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One of the most exciting developments in facial rejuvenation today is the discovery of facial fat compartments and their role both in facial aging and in the restoration of a youthful appearance. I have been fortunate to be involved with Dr. Joel Pessa at the University of Texas Southwestern Medical Center in groundbreaking research aimed at determining exactly how the subcutaneous fat compartments in different anatomic regions of the face are partitioned as well as how they change, differentially over time, in volume and position. These findings have literally "rewritten the book" on facial anatomy.
It makes sense that one must understand the mechanisms of facial aging in order to recreate the appearance of youth through cosmetic interventions. For at least a decade, aesthetic practitioners have been aware of volume restoration as an important aspect of facial rejuvenation. However, it is only recently that we have begun to understand how facial fat is stored in multiple discrete compartments (Figure 1), a fact which supports the clinical observation that the face ages differently in its various regions and not as a confluent mass. This knowledge is the key to our ability to achieve optimal results with facial fillers, such as fat, and to appropriately analyze patients for total facial rejuvenation.
FILLING FAT COMPARTMENTS
In performing natural facial rejuvenation, my first goal is to restore or refill the deficient fat compartments. Over the past 6 years, I have been able to achieve very gratifying results using autologous fat harvested primarily from the anterior abdomen or the inner thighs. It is important to use unadulterated fat without the addition of local anesthesia or any other substances. I believe that removing the fat as atraumatically as possible, centrifuging it for no more than 1 minute and then injecting it soon thereafter enhances the overall viability of the fat cells. I usually remove about twice as much fat as I will actually use in the procedure. For an average face, I may remove between 20 and 30cc, with about 15cc being used for injection. In general, I over-inject each individual fat compartment by about 50 percent.
Our anatomic research has identified multiple distinct subcutaneous compartments of forehead and temporal, orbital, cheek, nasolabial and jowl fat. With an understanding of the position of the various facial fat compartments, one can inject in a precise manner to reconstruct the shapes and contours of youth. Injections beneath the skin between compartments have the effect of softening the transition between regions. These superficial injections decrease wrinkling and can significantly reduce the signs of aging. Deep injection into the fat compartments is essential; the deeper the fat is injected, the longer it will remain.
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Preoperative analysis is critical. I am careful to note any facial asymmetries that indicate the need for more fill in particular compartments on one side versus the other side. In the live-surgery demonstration that I performed for the Johns Hopkins University School of Medicine/National Cosmetic Network CME series Excellence in Cosmetic Surgery 3, I started on the patient's left side (her fuller side) injecting just medial to the nasolabial fold to restore the deficient nasolabial fat compartment. Next, I injected the commissures. Then, in the deep malar area, at 1 finger-breadth below the malar rim, I injected almost onto the periosteum. This injection, along with a lower lid blepharoplasty that included release of the orbital retaining ligament, effectively effaced the tear trough. Next, I injected deeply and precisely into the fat compartments of the lateral-temporal, medial and middle cheek.
