Richard Ellenbogen, MD; Anthony Youn, MD; Dan Yamini, MD; and Steven Svehlak, MD Dr. Ellenbogen, Dr. Yamini, and Dr. Svehlak are in private practice in Los Angeles, CA. Dr. Youn is in private practice in Los Angeles, CA, and Rochester Hills, MI. Background: Many face lift techniques that manipulate the superficial musculoaponeurotic system (SMAS) in order to correct a perceived descent of deeper facial structures have been presented. However, such procedures can result in insufficient volume restoration, which may be correctable only by actual fat replacement. Objective: We describe a face lift technique that combines volume restoration by fat grafting and results in removal of descended fat below the mandible as well as conservative skin redraping. Methods: A short-scar incision was utilized and limited flap dissection was performed in the subcutaneous plane. Direct defatting of the fat superficial to the platysma and inferior to the mandibular border was performed. Submental fat near the midline that could not be excised was removed by lipoplasty under direct vision. The platysma was treated only if prominent banding was present preoperatively. The skin was redraped utilizing a suspension suture between the flap and the cartilaginous canal of the ear, and excess skin was excised. Fat grafting was performed into volume-deficient areas using a blunt-tipped cannula. The SMAS and other deeper layers were not manipulated. Results: A retrospective review of 83 consecutive patients revealed high patient satisfaction and an overall complication rate of 6% after a mean follow-up of 12 months. Conclusions: The described procedure represents an evolution to a simpler and effective technique that produces a natural, youthful appearance with minimal morbidity and downtime. (Aesthetic Surg J 2004;24:514-522.) The history of face lift surgery encompasses a wide spectrum of techniques, ranging from relatively simple skin-only procedures to more complex approaches. During the last decade or so, surgical techniques have focused on various methods of manipulating the superficial musculoaponeurotic system (SMAS) to correct a perceived descent of deeper facial structures. 1-4 It has been our observation that facial aging is primarily caused by the loss of facial fat volume and the descent of upper facial fat below the mandibular border. This process is similar to a deflating balloon. Many techniques have attempted to address this issue by lifting or repositioning the SMAS and other layers to restore volume to the face. However, in our experience, this often produces insufficient volume correction and a pulled look, which may only be correctible by subsequent fat restoration. In our experience, an approach that combines replacing fat in areas where it has been lost, removing fat below the mandible, and conservative skin tightening and redraping can effectively reverse the signs of aging and produce a natural, younger appearance (Figure 1, A and B). In most situations, manipulation of the SMAS and any other deeper facial structures is not required. Thus, this approach provides for a simpler operative technique with durable natural results, as well as for a smoother, less painful, and more rapid recovery. Methodology and Surgical Technique A short-scar incision was utilized, beginning at the root of the helix. The incision extended along the posterior aspect of the tragus, incising through the attachment of the ear lobule to the underlying mastoid fascia. It then extended along the postauricular sulcus, and finally turned posteriorly at the level of the superior aspect of the tragus (Figure 2). The incision did not extend into the hairline in the temporal region or posterior scalp. The flap elevation was performed along the subcutaneous plane and involved dissection of only a limited facial area (Figure 3). Defatting superficial to the platys- 514 A ESTHETIC S URGERY J OURNAL ~ NOVEMBER/DECEMBER 2004
A B Figure 1. A, Descent and loss of volume of the malar fat pad and the mid cheek fat pad contribute to accentuation of the nasolabial fold and jowl formation. B, Replacement of fat to appropriate areas in which it is lost can result in a natural, younger appearance. A youthful ogee can be created when combined with a skin tightening procedure. 1, malar area; 2, midcheek; 3, nasolabial fold; 4, lips; 5, infraorbital area. ma and inferior to the mandibular border was performed under direct vision. Submental fat near the midline that could not be excised under direct vision was removed by lipoplasty. The platysma was treated by closure and partial transection only if prominent banding was present preoperatively with the patient grimacing. If there were no descending bands preoperatively, the platysma was not manipulated and only the overlying fat was removed. The skin along the jawline was gently redraped along a vector directed to the cartilaginous canal of the ear (Figure 4). Excess skin was removed and the dermis of the skin flap was sutured to the cartilaginous canal with a buried 3-0 nylon suture. The entire lift was suspended on the inferior margin of the cartilaginous canal rather than on soft tissue sutures above the jawline, thereby avoiding tension on the earlobe and skin closures. This helped to A ESTHETIC S URGERY J OURNAL ~ November/December 2004 515
Figure 2. A short scar incision was utilized, extending from the helical root to the posterior hairline. The lobule was detached, and the incision extended along the postauricular sulcus (dotted line). The incision did not extend into the temporal region. Figure 3. Flap elevation was performed in the subcutaneous plane, with a limited dissection to expose the jowls bilaterally for direct excision. A C B Figure 4. A, The skin of the jawline was redraped along this vector of pull and sutured to the inferior border of the cartilaginous canal of the ear. B, The posterior closure lay along the postauricular sulcus, with sutures connecting the dermis of the redraped flap to the underlying fascia in order to prevent descent of the closure. C, Attention was paid to recreating a pretragal hollow by appropriate defatting when performing the anterior closure. 516 Aesthetic Surgery Journal ~ November/December 2004 Volume 24, Number 6
Table. The frequency of ancillary procedures performed in the same surgical session as the volumetric facelift (83 patients) Number Percentage Procedure of patients of patients Forehead lift 42 51 Perioral dermabrasion 42 51 Lower blepharoplasty 40 48 Upper blepharoplasty 25 30 Chin augmentation 20 24 Primary rhinoplasty 10 12 Secondary rhinoplasty 9 11 Earlobe reduction 6 7 Corner of mouth lift 5 6 Upper lip lift 2 2 Figure 5. Diagram depicting average amount of fat grafting per region. Areas 3, 5, 6-8, and 10 are the most frequently grafted. prevent a postoperative pixie-ear deformity. The remainder of the excess skin was excised and closed in standard fashion. Care was taken to recreate a natural pretragal sulcus. Fat grafting was performed before final closure of the face lift incisions by injecting fat underneath the flap through the incision, lateral oral commissures, and/or crow s feet area with a blunt-tipped cannula. The fat was extracted from various areas (abdomen, thigh, inner and/or outer waist, or buttocks), depending on the individual patient s anatomy. It was extracted using 10-mL syringes and centrifuged in the syringes using sterile technique for 3 minutes at 5000 rpm. The supernatant was removed and the fat was transferred to 1- and 3-mL syringes for injection. After centrifuging, 6 syringes yielded approximately 36 ml of viable fat. We almost never required more than this amount. The donor site was injected with 1/8% lidocaine 1:800,000. A #3 Coleman injector (Byron Medical, Tucson, AZ) was used exclusively. Most patients required replacement of fat over the malar regions (cheekbones), midcheek hollows, nasolabial folds, upper and lower lips, and infraorbital regions (Figure 5) in order to recreate a youthful ogee, as described by Little. 5 Photographs of the patient at an earlier age were used to determine the appropriate fat volumes for restoration of a more youthful appearance. Average amounts of fat grafted per area are depicted in Figure 6. The fat was placed in stacked and crossstacked toothpick shaped layers with limited passes in order to minimize trauma. Local anesthetic was not infiltrated into these areas in order to preserve maximum adipocyte viability. Because in our clinical experience catecholamines may result in vasoconstriction and decrease fat survival, epinephrine-free graft sites are desired. A recent in-depth description of this technique provides further details. 6 The dressings and drains (if present) were removed on the first postoperative day. The patient was allowed to shower and wash his or her hair on the first postoperative day as well, and was A ESTHETIC S URGERY J OURNAL ~ November/December 2004 517
Figure 6. Fat may be grafted over the infraorbital rim to treat tear trough deformities and camouflage herniating orbital fat. A B C D E F Figure 7. A, D, Preoperative views of a 46-year-old man. B, E, Two-month postoperative views after volumetric face lift and chin augmentation with an alloplastic implant. C, F, One-year postoperative views. Note persistence of grafted fat in the malar regions. 518 Aesthetic Surgery Journal ~ November/December 2004 Volume 24, Number 6
A B C D E Figure 8. A, Preoperative view of a 55-year-old woman. B, One-week postoperative photo after volumetric face lift and perioral dermabrasion. Note improvement in volume of the midface and lack of significant swelling. C, Six-week postoperative photo. D, E, Photos comparing the patient at 25 years of age and 55 years of age (at 1 month postoperatively). Note replacement of volume in the cheeks and the sharp jawline in the latter, both consistent with the photo from 30 years before. allowed to drive a car and perform usual daily functions within 2 to 3 days. Results A retrospective chart review was performed on 83 consecutive patients who underwent the volumetric face lift between February 1999 and December 2002. Of these patients, 74 were female and 9 were male. The average length of surgery (including all ancillary procedures) was 3.6 hours. Each patient underwent an average of 3.6 additional procedures concurrent with the face lift. These included forehead lifts (51%), perioral dermabrasion (51%), and lower eyelid blepharoplasty (48%) (Table). The mean amount of fat grafted was 25 ml per patient. After a mean follow-up of 12 months, the total complication rate was 6% (5 patients). Three patients developed postoperative hematomas (1 necessitating reoperation, the other 2 requiring small aspirations), 1 patient developed a suture dehiscence of the earlobe, and 1 patient presented with a seroma. It was our impression that the visibly good early results achieved by the volumetric face lift helped to boost patient satisfaction (Figures 7-10). A ESTHETIC S URGERY J OURNAL ~ November/December 2004 519
A B C D E F G H I Figure 9. A,D,G, Preoperative views of a 55-year-old female. B,E,H, Three-week postoperative views after volumetric facelift and bilateral upper blepharoplasty. Note the youthful improvement in the volume of the malar regions. C,F,I, Ten-months postoperative views. Note persistence of volume in the midface and youthful appearance. 520 Aesthetic Surgery Journal ~ November/December 2004 Volume 24, Number 6
A B C D E Figure 10. A, Preoperative view of a 61-year-old woman. B, One-day postoperative view after volumetric facelift and bilateral lower blepharoplasty. C, One-week postoperative photo. D, Sixteen-months postoperative photo. Note persistence of replaced volume in the malar regions and tighter skin. E, Photo of the patient at 50 years of age. When compared with the previous photo of the patient at 62 years of age, one can appreciate the significant youthful improvement attributed to the volumetric facelift, even when compared to a photo from 12 years earlier. Conclusion Primary considerations in face lift surgery are a natural and significant facial rejuvenation, safety, and patient satisfaction. Secondary, but no less important, considerations include the durability of results, minimization of pain and discomfort, and quick return to social activity. The described procedure is a simpler and more effective technique that has evolved over the course of a career spanning nearly 30 years. This approach produces a natural, youthful appearance, with minimal morbidity and downtime, and nearly universal patient satisfaction. A ESTHETIC S URGERY J OURNAL ~ November/December 2004 521
References 1. Hamra ST. The deep-place rhytidectomy. Plast Reconstr Surg 1990;86:53-61. 2. Connell BF, Semlacher RA. Contemporary deep layer facial rejuvenation. Plast Reconstr Surg 1997;100:1513-1523. 3. Stuzin JM, Baker TJ, Baker, TM. Refinements in face lifting: enhanced facial contour using vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg 2000;105:290-301. 4. Little JW. Three-dimensional rejuvenation of the midface: volumetric resculpture by malar imbrication. Plast Reconstr Surg 2000;105:267-284. 5. Little JW. Volumetric perceptions in midfacial aging with altered priorities for rejuvenation. Plast Reconstr Surg 2000;105:252-266. 6. Ellenbogen R. Fat transfer: current use in practice. Clin Plast Surg 2000;27:545-556. Accepted for publication July 12, 2004. Reprint requests: Richard Ellenbogen, MD, 9201 Sunset Boulevard, Suite 202, Los Angeles, CA 90069. Copyright 2004 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$30.00 doi:10.1016/j.asj.2004.08.006 522 Aesthetic Surgery Journal ~ November/December 2004 Volume 24, Number 6