Fat grafting is to correct the other element of facial aging; the loss of volume. This procedure has steadily gained popularity in the last two decades. Refinement to the procedure with blunt cannulae for both the harvest and grafting has made it safer and more predictable. It provides improvement in the nasolabial folds and it is a good way to add volume to the face. So why is it that we still use other fillers? One reason is that despite all the advances in fat grafting, it is not easy to predict how much of the fat will survive. If the fat graft takes unevenly, it can cause lumps in thin areas of the face, for example under the eyelids. Therefore in the face one has to be extremely careful. I would use fat grafting in deeper planes of the face to increase volume and would inform the patient of the need to repeat the procedure if necessary. In this operation the less you do the more predictable the result is. The other reason for using fillers is that they are available out of a syringe and there is no need for a donor site.

Fat grafting to the face can be an office procedure where both donor site, and the recipient area are anesthetized using a local anesthetic.  The amounts of fat required for the face is small and this is one area where I can say that less is more. Recovery depends on the extent of grafting. A small area could heal without much bruising or swelling, but a whole face fat grafting can take a few weeks to heal. As matter of fact, this can take longer to heal than a facelift. The bruising is due to the fact that one is required to do multiple passes with the canulla to lay small amounts of fat per area, so that it can get better blood supply. These multiple passes can cause more trauma to the tissues therefore more swelling and bruising.

 

Fillers:

The advantage of fillers over fat grafting is that these products are available in a syringe ready for injection and are fairly reliable in their effectiveness. They are used in many areas of the face even though they are usually FDA approved for the folds between the corner of the mouth and the sides of the nostrils which we call the nasolabial folds. So please understand that using them in all the other areas of the face is considered an off label use.

The fillers I like to use are Restylane, Juvederm  Ulta Plus and Radiesse. There are other fillers on the market, but they are usually similar in characteristics to the above products. Restylane and Juvederm are both hyaluronic acids which naturally occurs in the body as the ground substance. There are various degrees in cross linking that makes one substance last longer. There are also other characteristics that make one stay in the precise place where you put it (Restylene) and the other to diffuse a little (Juvederm). Experience is required to use the appropriate product for each area to get good results and avoid complications. Radiesse is a hydroxyapatite, suspended in a gel that will absorb. As the gel absorbs the particle of hydroxyapatite will stimulate collagen formation and create volume. This product is good for use where volume is needed.

In general, the longevity is dependent on the product, but it’s also dependent on where it is used. The less mobile an area is, the longer the product lasts. For example, Restylane could last for two years or more in the tear trough, but only six months in the lips where there is a lot of motion. It also depends on the patient. In some patients, I have used Restylane for lip augmentation and I didn’t have to redo it for more than two years. In others, it lasts less than six months. Patients breakdown these products at different rates and the only way to find out is to try.

 

Lips:

I use Restylane to improve and augment the lips. I find this to be the best because Restylane stays where you place it. This allows me to shape the lips better. I don’t like the sausage look that I notice in so many people who have obviously had lip augmentation. Shaping seems simple, but it is a very artistic procedure. Traditionally it is believed that the height of the upper lip should be half of the lower lip. But I have found that in many beautiful and sensual faces, the height of the upper lip is equal to the lower lip. Again, we come to the notion of beauty and proportion. The golden proportion indicated a ratio of 1/1.618 between the upper and lower lip. The shape of a lip can have a profound effect on the aesthetics of the face. Just like the eyes or the nose, the lips are an important element of the facial identity and their shaping requires a keen artistic sensibility which is not easy to teach.

 

The nasolabial folds:

These are the creases that extend from the corner of the mouth to the side of the nostrils. The Juvederm advertisement calls them (parentheses) and says that no one should have them. I feel that these are part of the facial feature. One can see these in young faces and as long as they are not exaggerated, they do not need to be completely erased. There are patients however who show very deep folds that detract from their appearance. In these locations, the skin is attached to the deep layers and as the cheek relaxes the creases appear deeper. In most cases, fillers like Restylane, Juvederm Ultra Plus, or Radiesse injections can improve the situation, but if the creases are deep one needs to release the dermal attachments first and fill at the same time. For the deep nasolabial folds, I prefer to release and use a small fat graft to prevent reattachment. These deep folds also need a mid face lift to redistribute the excess skin.

 

Eyelids:

This is the most delicate area in the face. Fillers are usually used in the crease between the lower lid and the cheek (tear trough) to improve a tired and gaunt look. An intravascular injection with a sharp needle can have disastrous consequences. I do this procedure very carefully with a special needle that is designed to minimize the complication. This is not the kind of procedure that you let anyone with an MD behind their name do. You should always ask yourself the question. Is this doctor offering to do this procedure on me because he wants to supplement his income? or does this kind of procedure constitute his main line of work?

 

Cheeks:

As we age we loose the subcutaneous fat. This is most noticeable in the cheeks as this area is mainly made of soft tissue.

I find that the best filler for this area is Radiesse. It is made of a suspension of hydroxyapatite, which is a constituent of our bones.

Radiesse stimulates collagen formation as it gets absorbed, therefore the results last longer. Fat grafting is another alternative. 

The other product which is effective in this area is Sculptra. This is injectable poly-l-lactic acid. After the injection, the results gradually build up over time. There are patients who suffer from abnormal lipoatrophy which gives them a skeletonized  look. In these patients, Radiesse, sculptra and fat are very effective.

 

Temples:

There are patients who present with hollowness of their temple which makes their orbits stand out too much. In these cases, fillers could be very helpful. Fat can be used as well, but because small asymmetries could be very noticeable in these areas, I would favor fillers which are more predictable in results.