The Modern Facelift: Integrating Ancillary Procedures for Optimal Facelifting Results
In order to address volume deflation and aging, face-lift procedures have advanced beyond the idea of lifting and now incorporate both superficial and deep filling of facial fat compartments. Aside from the traditional face-lift techniques that involve removing excess skin and tightening the underlying soft tissues, ancillary procedures are now crucial to getting the best results. However, autologous fat grafting and ancillary procedures in facial rejuvenation are regularly carried out and safely to address signs of aging and achieve a better aesthetic outcome. Previous studies have shown no difference in aesthetic outcome with respect to face-lift technique.
In this blog post, we will discuss the techniques of combing Face Lifting with
1) Autologous Fat Harvest and Transfer,
2) Blending Lower Eyelid-Cheek Junction,
3) Chin Augmentation,
4) Earlobe Rejuvenation
5) Perioral Area
6) Laser Resurfacing.
A recent study has identified the facial fat compartments and their specific regions that may require augmentation using autologous fat grafting. The study found that the face's superficial and deep compartments are separated by fascial layers. Autologous fat grafting has a high success rate, with a large percentage of grafted fat surviving due to the presence of autologous stem cells and immediate revascularization. However, some portions may be replaced by fibrous tissue. The primary goal of autologous fat grafting is to blend the lower eyelid-cheek junction to achieve an ogee curve, which can be performed simultaneously with a lower lid blepharoplasty. Additionally, volumization of deflated or atrophic regions such as the forehead and periorbitum can help achieve a more youthful appearance. Other areas that can benefit from autologous fat grafting include the chin, submental, earlobe, hand, and perioral regions. The fat compartments of each region have been described, and volume loss is treated by augmenting the specific compartments. Many of these regions in the face are centrally located and cannot be adequately treated with a facelift alone.
See below the key fat compartments in lift-and-fill face-lift (from Plastic Surgery Key):
A lip-lift treatment to shorten an upper lip with labral excess is one of the additional procedures. Last but not least, a "lift-and-fill" face-lift does not address the quality or texture of the skin; therefore, helpful adjuncts like laser resurfacing and chemical peels are advised. The secret to successfully treating face aging is creating a personalized treatment plan for each patient based on a careful facial analysis.
1) Techniques Used for Autologous Fat Harvest and Transfer
To prepare for autologous fat transfer, adipose tissue is taken from the medial thighs with a 10-mL syringe and a 14-gauge cannula, as it causes less pain than other donor sites. No wetting or infiltration solution is used during the harvesting process. The harvested lipoaspirate is then centrifuged at 2,250 rpm for 1 minute, and the infranatant and supernatant are removed to isolate concentrated fat. A small amount of this concentrated fat is then transferred to each facial fat compartment that needs volumization using a 16-gauge blunt cannula and a 1-mL syringe, injected with low pressure in anterograde and retrograde motions.
In comparison, fractionated fat is obtained by emulsifying the concentrated fat. This is done by transferring the concentrated fat between two 10-mL syringes around 50 times. The emulsification process fragments the fat without compromising its viability. The fractionated fat is then injected into periorbital fat compartments using 2-mm blunt cannulas.
2) Techniques Used for Blending Lower Eyelid-Cheek Junction
An aged lid-cheek injuction is created by the abrupt transition of the medial sub-orbicularis oculi fat pad and the malar fat pad. When compared to the surrounding fat compartments, the periorbital and malar cheek fat pads deteriorate earlier in life. The V-deformity, or classic aging indications of the midface, are caused by volume loss and weakening of the holding ligaments. The tear trough deformity and nasojugal groove are both closely related to this deformity. Understanding the main midface fat compartments is essential to treating these abnormalities.
The nasolobial fat compartment is a significant fat compartment that is poorly treated by a standard face-lift. The orbicular retaining ligament forms the superior border of this compartment, which is situated anterior to the medial cheek fat compartment. The medial, middle, and lateral temporal compartments are the three main superficial fat compartments of the cheek. The orbicular retention ligament is superior to the medial compartment, which is inferior to the nasolabial fat compartment. The parotid gland is located over the central and lateral fat compartments. There are three parts to the orbital fat compartments: superior, inferior, and lateral.
The deep medial cheek fat lies beneath the superficial muscular aponeurotic system (SMAS) and the superficial cheek fat compartments. It is positioned in front of the maxilla and Ristow’s space, and comprises both medial and lateral parts, both of which are located medially to the zygomaticus major muscle. Augmentation of the deep cheek compartment with autologous fat grafting helps to reduce the appearance of nasolabial folds and V-deformity, resulting in a more youthful appearance. Additionally, the nasolabial fat compartments and the superficial middle and lateral cheek compartments can be filled as necessary to achieve the desired contour. Addressing these fat compartments is essential in creating a smooth transition between the lower eyelid and cheek. Fat is injected into the deep medial cheek fat and lateral superficial cheek compartments using entry points at the alar base and lateral cheek, and a 2-mm blunt cannula is used to deliver the fat.
The forehead and temporal fat compartments contain a central compartment with a middle compartment lateral to it. The lateral temporal-cheek compartment is lateral to the middle compartment. This compartment is contiguous with the lateral superficial compartment of the cheek. In patients with hollowing of these regions, 1–2 mL of autologous fat can be injected to volumize these regions.
To enhance the periorbital region, fractionated fat is used and injected with small blunt cannulas into the junction of the cheek and orbital rim. The injection is performed below the orbicularis muscle to disrupt the orbital malar ligament. A small incision is made to the lateral side of the orbital rim and a small amount of fat is injected deep to the muscle in the lower eyelid. Overcorrection by 50% is the desired outcome. This technique not only enhances the lower eyelid but also disrupts the malar ligament that causes a tear trough deformity. Although there may be some bruising and swelling associated with grafting to the periorbital region, studies have shown that fractionated fat still contains viable fat cells that can be used for transfer.
See below the where the patient underwent a lift-and-fill face-lift along with periorbital rejuvenation with a 6-step blepharoplasty. Autologous fat grafting using fractionated fat along with the release of the tear trough ligament helped blend the lid-cheek junction and efface the preoperative tear trough deformity. The patient has a more youthful contour in her midface. (From Plast Reconstr Surg Glob Open. 2019)
3) Techniques Used for Chin Augmentation
Another area that is not addressed by a standard face-lift but might exhibit aging is the chin. In this area, rhytids and fat compartment deflation are possible. On the basis of a line drawn from the upper lip to the menton, microgenia is evaluated. Facial fat augmentation is a better solution for treating many chin abnormalities brought on by aging than implant implantation. Labiomental sulcus, microgenia, lateral chin hollowing, and a midline cleft can all be treated by fat grafting. The access points include one for the labiomental crease, two lateral sites for lateral chin hollowing, and the midline to address a bifid chin. Each region receives 1-2 mL of fat concentrate, which is overcorrected 50% in women and 100% in men.
See below a patient who underwent a lift-and-fill face-lift also had chin augmentation with autologous fat. The face-lift helped improve her cervicomental angle and eliminate jowling that was present preoperatively. In addition, her microgenia was corrected with facial fat augmentation (From Plast Reconstr Surg Glob Open. 2019)
4) Techniques Used for Earlobe Rejuvenation
As a person ages, the ear lobule, which lacks cartilage, undergoes atrophy. The ideal ear lobule is round and voluminous, with a length of 1.5-2 cm. Conversely, an aging lobule is flat and thin in appearance. The lower segment of the ear lobule is unaffected by a face-lift procedure. A technique has been described to address this issue through autologous fat grafting. This involves injecting about 1-3 mL of autologous fat onto the front surface of the lobule during a face-lift procedure. Patients are advised not to wear earrings for 2 weeks postoperatively. The results of this procedure have been shown to last for at least a year after surgery.
See below the preoperative (a) and postoperative (b) photographs of a woman who underwent rhytidectomy with autologous fat transfer to her lobule. The patient had a deflated ear lobule preoperatively and after autologous fat transfer, the lobule is wider and more youthful (From Plast Reconstr Surg Glob Open. 2019)
5) Techniques Used for Perioral Area
As a person ages, the perioral area develops wrinkles and loses volume in the fat compartments, which cannot be improved by a conventional facelift. By understanding the facial anatomy and restoring volume to this region, a more balanced and pleasing appearance can be achieved. The desired aesthetic of the perioral region includes a clear border between the vermilion and the skin, a prominent pout, and well-defined philtral columns. Typically, there is a 2-3mm display of upper incisors when the mouth is at rest. The natural curve from the nostril sill to the vermilion border, seen from a side view, is lost with aging. The upper lip is composed of the dry vermilion and the ergotrid and is surrounded by the vermilion border, nasal base, and nasolabial folds. The height of the lip is usually one-quarter that of the labrum, and the volume of the upper lip is 75%-80% of that of the lower lip. As facial volume decreases and descends, the vermilion becomes thin, and fine vertical wrinkles appear.
See below the preoperative (A) and postoperative (B) photographs of a woman who underwent rhytidectomy with perioral rejuvenation using autologous fat. The perioral regions seem more youthful with more fullness after the treatment (From Plast Reconstr Surg Glob Open. 2019)
Lip-lifting is an adjunct used to improve incisal show, boost vermilion eversion, and reduce lip ptosis. This procedure generally treats abnormalities linked to the labrum's height. The procedure entails removing skin and soft tissue from the area above the upper lip, right below the nostril sill.
6) Techniques Used for Laser Resurfacing
Combining face-lifts with laser resurfacing is a reliable and safe method for facial rejuvenation, as it addresses issues such as textural changes, dyschromia, and rhytids. Laser resurfacing is accomplished using the Er:YAG laser, which provides ablative resurfacing and is faster-healing and has a lower risk profile compared to carbon dioxide lasers. To prevent any posttreatment pigmentary changes, this method is only applied to individuals who are classified as Fitzpatrick type I or II. Depending on the patient, laser resurfacing can be applied to the perioral region alone, the central face, or the entire face. The central face includes the forehead, glabella, lower eyelid, perioral area, and medial cheeks.
Patients received tretinoin treatment for 4-6 weeks prior to their laser resurfacing treatment, and lymphatic massage was started two weeks before the procedure. Seven days before the procedure, patients took acyclovir 500 mg four times a day. After the procedure, patients were given a methylprednisolone dose pack. The laser settings were 20-25 J, 80-100 µm ablation, and 50% overlap with at least two passes in non-undermined areas. Spot passes with settings of 5-25 J were done in the perioral region. Similar settings were used for central face and full-face resurfacing. The treated areas were covered with Flexzan dressings postoperatively and removed in 2-4 days. Moisturizing creams were applied to keep the skin hydrated. In their review of fully undermined face-lifts flaps treated with ablative laser resurfacing, there were no cases of skin necrosis or sloughing. The overall complication rate was 3.8%, with three complications being reported in patients who underwent ablative resurfacing at the time of face-lift: hyperpigmentation, prolonged erythema, and delayed wound healing at the tragus.
See below this patient had a combination of facial rhytidectomy and full facial resurfacing with an erbium dual-mode laser, resulting in significant improvement to their skin quality and texture. In the postoperative photo, they appear notably younger, with noticeable improvement to the perioral rhytids, resulting in a fuller and more youthful appearance.
Conclusion
A traditional face-lift procedure mainly deals with the sagging of the lateral facial skin, but it alone cannot rejuvenate and create harmony in all areas of the face affected by aging. However, modern techniques such as autologous fat grafting and a better understanding of the facial anatomy have resulted in ancillary procedures that enhance the effects of a face-lift by restoring volume and filling the areas affected by soft tissue deflation and fat atrophy. Moreover, procedures such as peels and lasers can improve the skin texture and overall appearance, making them an essential part of the modern face-lift.
Reference
Role of Ancillary Procedures in Facial Rejuvenation (2019)
Fat grafting for facial filling and regeneration (2015)
A Comparison of the full and short-scar face-lift incision techniques in multiple sets of identical twins (2016)
Autologous fat transfer in aesthetic facial recontouring (2013)
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