Fat Grafting to Improve Results of Facelift: Systematic Review of Safety and Effectiveness of Current Treatment Paradigms

What comes first: teeth or face? Recommendations for an interdisciplinary collaboration between facial esthetic surgery and dentistry

OBJECTIVE

The aim of the present study was to provide recommendations in order to facilitate communication between dental professionals and surgeons who are collaborating in the field of dentofacial esthetics.

CLINICAL CONSIDERATIONS

Smile esthetics are beyond the scope, both of the surgeons who are collaborating with facial esthetics and of the dentists, as a wide range of treatment options from both sides is available. It can be difficult for the surgeon or the dentist that first comes in contact with the patient to conduct an individualized global treatment plan, in order to find out how the various phases of the treatment can be sequenced, as a workflow for an efficient interaction between facial surgery and dentistry still does not exist in the scientific literature.

CONCLUSIONS

Facial cosmetic procedures and dental treatment have to be planned as individual elements of the whole dentofacial esthetic rehabilitation. The treatment has to be initiated with the design of the smile and the intraoral mock-up, followed by the required surgical interventions, and to be finished with the delivery of the definitive dental restoration.

CLINICAL SIGNIFICANCE

Dentofacial esthetics require comprehensive communication between surgeons and dentists. Following the proposed recommendations, an individualized interdisciplinary treatment plan can be conducted, defining the role of each specialty.

A Systematic Review and Comparative Analysis of Reconstructive Rhytidectomy: Advantages, Disadvantages, and Patient Outcomes

Reconstructive rhytidectomy, commonly known as facelift surgery, is a prominent cosmetic procedure aimed at rejuvenating facial appearance by addressing signs of aging. This paper critically evaluates the advantages and disadvantages of various surgical techniques involved in rhytidectomy, including the superficial musculoaponeurotic system (SMAS), deep plane facelift, and subperiosteal approaches. This systematic review of recent literature highlights key outcomes such as scar quality, postoperative pain management, and patient satisfaction. While the techniques demonstrate significant improvements in aesthetic results and patient quality of life, they also present risks including complications, dissatisfaction with outcomes, and the financial burden of surgery. Future directions indicate a trend toward minimally invasive approaches, integration of regenerative medicine, and personalized surgical planning, aiming to optimize results and minimize risks.

Complications of Fat Grafting and Repositioning for Correction of Lower Eyelid Pouch With Tear Trough Deformity or Lid-Cheek Junction: A Systematic Review

BACKGROUND

Fat grafting and repositioning may serve as a convenient, economical, and effective surgical method for correcting lower eyelid pouch with a tear trough deformity or lid-cheek junction. However, comprehensive systematic reviews and meta-analyses investigating the complications associated with this technique are lacking.

OBJECTIVE

This study aimed to summarize and gather data on complications related to fat grafting and repositioning for the correction of tear trough deformity or lid-cheek junction in lower eyelid blepharoplasty.

METHODS

A thorough search was performed across multiple databases including PubMed, Cochrane, Embase, ProQuest, Ovid, Scopus, and Web of Science. Specific inclusion and exclusion criteria were applied to screen the articles. The occurrence of complications was analyzed using a random-effects model.

RESULTS

A total of 33 studies involving 4671 patients met the criteria for systematic evaluation and were included in this meta-analysis. The overall complication rates were 0.112 (95% confidence interval [CI]: 0.060-0.177) for total complications, 0.062 (95% CI: 0.003-0.172) for unsatisfactory correction or contour irregularity, 0.062 (95% CI: 0.009-0.151) for hematoma, swelling (not specified as bulbar conjunctiva), ecchymosis, or oozing of blood, and 0.024 (95% CI: 0.013-0.038) for reoperation.

CONCLUSIONS

Fat grafting and repositioning for correcting a lower eyelid pouch with tear trough deformity or lid-cheek junction was associated with high rates of complications. Therefore, it is crucial to closely monitor the rates of unsatisfactory correction or contour irregularity, hematoma, swelling (not specified as bulbar conjunctiva), ecchymosis, or oozing of blood, and reoperation. In addition, effective communication with patients should be prioritized.

Static and Dynamic Filler-Associated Tear Trough Deformities: Manifestations and Treatment Algorithm

BACKGROUND

Fillers are popular substances for the correction of tear trough deformity. Despite well-documented complications increasing gradually, standardized treatment algorithm for deformity secondary to improper injection is still limited.

METHODS

Between April 2020 and April 2023, a total of 22 patients with filler-associated tear trough deformity with static bulges or dynamic swells after injection of tear trough were enrolled. For patients who received hyaluronic acid (HA) and unknown fillers, hyaluronidase dissolution was performed. For patients who received non-HA fillers and unknown fillers that failed to dissolve, a magnetic resonance imaging (MRI) examination was conducted. Surgical approaches were selected based on the filler distribution and the condition of the lower eyelid. Ligament releasement and fat transposition were accomplished when fillers were excised. Aesthetic outcomes were evaluated by double-blind examiners using the Global Aesthetic Improvement Scale after patients were followed up.

RESULTS

In total, the study included 3 patients with simple static deformities, 1 patient with simple dynamic, and 18 patients with both. Fourteen patients underwent transconjunctival surgery and 8 patients underwent transcutaneous surgery, among which 18 patients underwent hyaluronidase dissolution and 8 patients underwent MRI prior to surgery. A total of 4 patients with self-limited complications recovered after conservative treatment. 90.9% of patients expressed satisfaction or high satisfaction with the treatment results.

CONCLUSION

Filler-associated tear trough deformities could be classified into static and dynamic deformities, which could appear separately or simultaneously. Treatment of deformities should be based on characteristics of fillers, in which MRI could serve as a promising tool.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Stromal Vascular Fraction Gel (SVF-Gel) Combined with Nanofat for Tear Trough Deformity

BACKGROUND

Tear trough deformity makes patients appear tired. Patients with less severe tear trough deformity prefer a less invasive method to correct the deformity. The infraorbital area is a multilayered tissue, and the aging of various components leads to tear trough deformity. To this end, we utilized the different characteristics of different fat derivatives to correct tear trough deformity.

METHODS

Thirty-two patients with Barton Grade I/II tear trough deformity were enrolled in this study between September 2020 and March 2021. We injected Stromal Vascular Fraction Gel (SVF-Gel) into the suborbicularis oculi fat layer and Nanofat into the subcutaneous. After 12 months of follow-up, we evaluated the changes using standardized clinical photogrammetric techniques, volume, global aesthetic improvement scale, and patient self-evaluation.

RESULTS

There were no major complications in any of the 32 patients. The measured data points demonstrated improvements in all aesthetic parameters. The width of the tear trough and the distance from the pupil to the tear trough improved. The Global Aesthetic Improvement Scale (GAIS) showed a high score (2.45±0.64 points), with patient self-assessment showing satisfactory results.

CONCLUSION

SVF-Gel combined with Nanofat injection can effectively correct tear trough deformities.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Revision Rhytidectomy: Pearls and Pitfalls

While rhytidectomy can yield remarkable results, some patients may subsequently require revision rhytidectomy due to either unsatisfactory outcomes from primary surgery or the natural aging process many years later. Like most other secondary plastic surgical procedures, revision rhytidectomy is a complex undertaking and fraught with potential pitfalls. This can be attributable to natural or postsurgical alterations that can occur with the facial skin, superficial musculoaponeurotic system/platysma muscle, and/or facial nerve landmarks. Additionally, complications such as cobra neck deformity, pixie ear deformity, and synkinesis can add an extra level of complexity to revisional surgery. Furthermore, as more surgeons are performing deep-plane facelifts and more aggressive neck procedures, the risks are further amplified in revisional surgery. In this article, we review the challenges that a facelift surgeon may face when performing revision rhytidectomy and the technical considerations to overcome these obstacles.

Assessment of deep plane facelift in facial feminization surgery: A prospective pilot study

Facial feminization surgery (FFS) is often the first procedure requested by patients wishing to undergo gender-affirming surgery. This study aims to evaluate the applicability and effectiveness of deep plane facelifts in FFS. The authors conducted a prospective study that included patients who requested a deep plane facelift as a standalone procedure to achieve a more feminine facial appearance as the only procedure of FFS. These patients underwent deep plane facelifts to achieve a more feminine oval face shape and increased tissue projection of the zygomatic-malar region. To assess the effectiveness of the procedure and patient satisfaction, the Face-Q scales, Face and Neck lift Objective Photo-Numerical Assessment Scale, the Satisfaction With Life Scale, and the Subjective Happiness Scale were applied preoperatively and one year after surgery. Thirty-six patients were included in the study. A statistically significant difference (p < 0.005) was observed between pre and postoperative scores. The repositioning of the malar fat pads increased the malar volume, providing a more oval overall shape of the face, which is typically feminine. No major complications were observed. Despite our encouraging results, new studies with a larger sample of patients are needed to support the benefits of the deep plane facelift as part of FFS to elevate this technique from an ancillary to a routine procedure for patients undergoing gender affirmation surgery.

Facial Hypertrophy as a Complication of Weight Gain in Autologous Fat Graft Patients: Considerations and Recommendations

Fat grafting can restore facial volume for reconstructive and cosmetic indications. Common practice often involves extracting lipoaspirate from the most abundant anatomic location. However, grafted fat retains the phenotypic characteristics of its original location and can undergo exaggerated hypertrophy with patient weight fluctuations. The aim of this study was to systematically assess the literature to summarize the reported effects of postoperative weight gain on facial hypertrophy in patients after facial fat grafting and to determine potentially avoidable factors. A search through PubMed/MEDLINE was conducted on October 4, 2022, to identify relevant articles with appropriate search terms. No lower date limit was applied and all eligible nonanimal clinical articles in English were included for review. Reports were summarized and presented as descriptive statistics. The search generated 714 articles. After abstract and full-text review of the initial set of articles, 6 were included in our analysis. All articles described poor cosmetic outcomes resulting from nonanatomic hypertrophy of the grafted fat. None of the articles reported a thorough methodology for selecting the donor site to minimize fat hypertrophy with potential future weight fluctuations. Grafted facial fat is susceptible to exaggerated hypertrophy as a result of changes in patient weight. Specifically, harvesting lipoaspirate from maximally abundant areas of the body may increase this risk. Individualizing the area of fat donation may attenuate unwanted fat growth and further contribute to increased patient quality of life.

LEVEL OF EVIDENCE: 4

Evidence-Based Medicine for Lower Facial Rejuvenation

Lower facial rejuvenation is an expanding area in facial plastic surgery with both surgical and nonsurgical treatment options. Evidence-based medicine is essential to providing high-quality care and creating long-lasting results. A systematic approach and understanding of the layers of the aging lower face is important to develop an individualized treatment plan. This review will focus on surgical and nonsurgical treatments for the aging lower face with an emphasis on evidence-based medicine.

A Systematic Review and Meta-Analysis of Early Relapse After Facelift

BACKGROUND

Early relapse is an adverse outcome of facelift surgery. The rate of early relapse is an indirect measure of the longevity and efficacy of facelift techniques. However, early relapse after facelift is ill-defined, under-evaluated, and under-reported, and literature data on the subject are dispersed. In this systematic review, we aimed to analyze facelift studies using relapse-related outcomes (RROs). Our secondary aim was to highlight the importance of early relapse as an essential outcome measure.

METHODS

The study design was a systematic review of the English literature and meta-analysis of RROs after facelift surgery. RROs that occurred within the first 2 years after surgery were considered "early". Performance, analysis, and reporting were performed in accordance with the PRISMA guidelines. The systematic search was conducted using the PubMed database as of February 2020. Initial screening was performed using the keywords "facelift", "rhytidectomy", "surgical rejuvenation", "face lift", "rhytidoplasty", and "facial rejuvenation". Articles were excluded by using a set of inclusion and exclusion criteria.

RESULTS

RROs were reported only in 4.4% (19/433) of the papers that underwent full-text review. The frequency of RROs ranged between 0.2 and 50% among facelift papers. The weighted median rate of RROs after facelift surgery was found to be 2.4% in the meta-analysis.

CONCLUSIONS

Future research on preventive measures will be successful upon acknowledgment of the actual prevalence of this problem. Consensus on its definition and objective criteria for its diagnosis are required for further progress.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Novel Approach for Midface Depression

Background:

Although Le Fort type II, prosthesis detainment, and orthodontic treatment are considered for the management of midface retraction, they may be limited by their high cost, infection risk, and excessive amount of tooth movement. Therefore, the Point A-Koji method was devised as a novel treatment in patients with midface retraction.

Methods:

This is a case report of a 26-year-old woman who presented with a feeling of depressed midface and protrusion of the mouth. Preoperatively, the position of the lip and line connecting the nasal apex and mental muscles (E-line) were normal, but the subnasale was located posteriorly. The patient had a narrow nasolabial angle of 74 degrees and the subnasale-Pog’ to the upper lip of 6.5 mm. After insertion of a metallic-plate implant under the periosteum, the plate was screwed and fixed to the bone. The Point A-Koji method was used for treatment in this patient. This is characterized by the A-point anterior migration technique in which the periosteum of hard tissue A-point circumferential attachment was shifted anteriorly, thereby preventing the return of soft tissue.

Results:

The following changes with respect to preoperative findings were noted 5 months postsurgery: facial convexity from 3.3 degrees to 7.6 degrees; nasolabial angle from 74 degrees to 90.2 degrees; true horizontal line from 50 degrees to 73 degrees; and subnasale-Pog’ to the upper lip from 6.5 mm to 4.7 mm. This resulted in an improved midface retraction.

Conclusion:

The Point A-Koji method may be an ideal method to improve the midface retraction in patients.

The Utilization Of Poly-L-Lactic Acid As A Safe And Reliable Method For Volume Maintenance After Facelift Surgery With Fat Grafting

Background

For age-related volume loss, fat grafting is now recognized as an integral adjunctive procedure with facelift surgery. However, when there is continued and unpredicted volume loss postoperatively, the surgeon has limited options for restoring this lost volume.

Objectives

Poly-l-lactic acid (PLLA) is a proven biostimulator that creates volumetric enhancement. This study is undertaken to demonstrate that PLLA is a safe and efficacious option for maintenance of post-facelift volume loss.

Methods

A retrospective review was conducted to identify all patients who underwent facelift surgery with fat grafting and postoperative PLLA injections from 2010 to 2018 by a single surgeon. Demographic and clinical data were collected and analyzed.

Results

This review identified a total of 241 patients who had undergone a facelift with fat grafting and PLLA injections. Of these, 190 patients were treated with PLLA after facelift and fat grafting, while 51 patients received PLLA injections before their operation. We identified 5 common indications for use of PLLA after facelift surgery and fat grafting. These included unexplained early fat graft loss, significant weight loss in the postoperative period, normal aging process, and patients who had a high perioperative lean body mass. Additionally, PLLA was found to be an effective volumizer for site-specific areas that did not undergo fat grafting during the initial operation. There were no complications reported from the PLLA injections related to nodule formation, papules, or granulomas.

Conclusions

The high degree of variability in the survival of fat grafts with facelift surgery is an accepted reality. PLLA represents a safe and highly effective solution to restore volume loss in patients who have undergone facelifts with fat grafting.

Advanced Facial Rejuvenation After Bimaxillary Surgery in Three Different Facial Types

PURPOSE

Facial aging is the consequence of many mechanisms involving the bones and the "soft tissue" (skin, fat, ligaments, muscles, and periosteum) of the face such as downward migration of the soft tissue, adipose and muscular tissue atrophy, and skeletal resorption. The potential of orthognathic surgery (double jaw surgical advancement) of expanding the skeletal foundation to increase the facial drape support is now recognized and widely popularized by several authors. The aim of this study was to analyze the rejuvenation change of the face after bimaxillary advancement for orthognathic surgery, focusing on the previously mentioned stigmata of the middle and the lower third of the aging face.

MATERIALS AND METHODS

A retrospective monocentric chart review was conducted for all patients affected by aging signs of the face who underwent orthognathic surgery between January 2015 and December 2019 at the Face Surgery Center (Parma, Italy). During the postoperative follow-up examination, all patients underwent anthropometric photographs and esthetic assessment to evaluate facial rejuvenation after double jaw surgical advancement.

RESULTS

After application of the exclusion criteria, the final study sample included 85 patients (53 females, 32 males). Eighty-three patients (97%) showed a degree of rejuvenation after maxillo-mandibular advancement (MMA); the score of the postoperative face was less than the score of the preoperative face. Two patients reported no significant postoperative change; none reported a more aging face, with a successful "reverse face-lift" occurred in 97% of our cases.

CONCLUSION

"Reverse face-lift" by bimaxillary advancement is a surgical procedure which is indicated for a selected group of middle-aged patients with a diagnosis of bimaxillary skeletal retrusion or posterior divergence very motivated to an extreme rejuvenation; this procedure provides support for the facial mask resulting in whole facial rejuvenation.

Regen Fat Code: A Standardized Protocol for Facial Volumetry and Rejuvenation

BACKGROUND

Facial aging is a degenerative process that impairs contour and angle prominence. Rejuvenation is based on tissue replacement, volumization of the atrophic areas, and improving flaccidity and cutaneous photoaging.

OBJECTIVES

The aim of this study was to apply structural fat grafting to manage volumetric deficits of the face, following a new systematic protocol called "Regen Fat Code" (RF Code) that was created to standardize structural lipotransfer methods.

METHODS

This is a prospective clinical trial involving 80 healthy candidates for facial rejuvenation who were split into 2 groups. Group A underwent only structural lipotransfer; Group B underwent replacement of deep facial structures by face-lifting plus structural lipotransfer. Structural lipotransfer followed the protocol "RF Code" and 3 clinical tools were adopted for pre- and postoperative facial volumetric analysis.

RESULTS

Total volume (mL) of lipotransfer in Groups A and B ranged between 1 and 20 mL (mean [standard deviation], 12 [5] mL), distributed to the different areas as follows: nasolabial fold, 3.32 [0.92] mL; superior lip, 2.0 [0.62] mL; inferior lip, 2.76 [0.71] mL; malar, 8.51 [5.25] mL; inferior eyelid, 1.2 [0.54] mL; and chin, 7.18 [1.99] mL. Areas with less mobility showed a lower absorption index than dynamic areas.

CONCLUSIONS

The development of the RF Code protocol demonstrated the potential of grouping many parameters based on the lipotransfer method used to volumize and regenerate atrophic areas of the face. The protocol is easy to apply, and allows different volumizing and regenerative effects to be proposed, according to the demands of each surgical area.

LEVEL OF EVIDENCE: 4

Modern Fat Grafting Techniques to the Face and Neck

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand age-related changes to the face and neck and pertinent anatomy and discuss important aspects of fat graft harvesting, processing, and infiltration. 2. Recognize key differences between common techniques for fat processing and infiltration and develop a plan for patients based on site-specific facial anatomical zones. 3. Appreciate the utility of fat grafting as an adjunct to other facial rejuvenating procedures such as face lift and blepharoplasty procedures and list the potential complications from fat grafting to the face and neck.

SUMMARY

Fat grafting to the face and neck aids in volume restoration, thereby addressing soft-tissue atrophy associated with the aging face, acquired conditions, or congenital malformations. Often, fat grafting may sufficiently restore facial volume alone or in conjunction with other facial rejuvenation procedures. Facial/neck fat grafting requires a systematic and thoughtful approach, with special care to atraumatic technique. This CME article covers the principles and techniques for modern facial fat grafting to the face and neck. Increasing data support the ability of autologous fat to produce significant and sustainable appearance-related changes. The authors follow the general principles of the Coleman technique for facial fat grafting and have observed tremendous success over the years. Other techniques for facial fat grafting are also discussed including microfat and nanofat processing. As the understanding of facial fat compartments continues to evolve, the authors may better predict fat grafting outcomes following augmentation. Finally, the technique described as "lipotumescence" has been successfully used in the breast and other regions of the body that have radiation damage and is discussed in this article specifically for the face and neck.

Adipose Grafting for Volume and Scar Release

ABSTRACT

Adipose fat grafting (AFG) is a popular technique used to add volume in the face, breasts, and other tissue deficient areas of the body. In terms of scar release, not only has fat provided additional soft tissue coverage but also the relief of pain in scars in those patients suffering from disease processes, such as complex regional pain syndrome with steroid-induced atrophy, burn scars, morphea, and lupus. The purpose of this article is to demonstrate the senior author's technique and outcomes of using AFG in the face and body for treating volume deficiency, atrophic scarring, and deformities.A retrospective chart review of 127 AFG procedures of the face and body from September 2006 to September 2019 was performed. Of these, 14 patients had scar releases performed with fat grafting of areas of scar contracture. Fat was harvested from the abdomen, thighs, and flanks using Toomey syringes or an enclosed power-assisted system with 3.7- or 3.0-mm cannulas. Grafting in small areas, such as the face, was performed with the 0.9-mm blunt cannula.The majority of AFG was completed in the face (45%), followed by breasts (22%), and scar contracture (16%). The mean volume of fat grafted in procedures involving the breasts, buttocks, and face was 102, 182, and 21 mL, respectively. For scar contracture, the mean volume was 38 mL and for deformations, 27 mL. Sixteen percent of the cohort required at least 1 additional AFG procedure to achieve satisfactory results. There were no major complications, such as skin loss, vascular injury, embolization, or blindness. Minor complications, such as erythema, edema, and hematoma at the fat harvest or graft site, did occur and were managed with local measures.Autologous fat grafting has consistently resulted in volume correction. In addition, in patients with autoimmune disorders, burn scars, and retracted scars, not only has there been volume correction but also decreased pain in the area of treatment. In our series of patients, we described our technique of AFG for the face, body, and scar contracture. Our results demonstrate that AFG remains an inexpensive, safe, and effective treatment option to achieve volume.

Photographic Comparison of Malar Projection in 100 Facelift Patients Treated with and without Fat Injection

Facelifts are frequently combined with fat injection to restore volume. However, the efficacy of simultaneous fat grafting has not been objectively evaluated in a large number of patients that includes a control group. This study was undertaken to fill this gap in our knowledge base.