Cosmetic Surgery - Fat Grafting

Fat Rebalancing: The New “Facelift” 

The structural changes in the face throughout life are due solely to the redistribution of fat.  From infancy through adulthood it is fat that characterizes the shape of the face. A baby has an identifiable distribution of fat in the form of chubby cheeks jowls and neck rolls.  Interestingly this distribution is seen again in the older adult, but we mistake it for loose skin and push the blame on gravity.  Gravitational aging is the basis for all conventional cosmetic surgery.  The premise of gravitational descent has founded such surgical corrections as facelift, blepharoplasty (eye lift), brow lift, neck lift and even laser resurfacing. But naming gravity as the culprit of facial aging and skin sagging is flawed. There are no animal models for gravitational aging.  Parrots living to 60 years of age don’t sag or droop and even among different humans there is tremendous variability in the degree of sagging from one individual to the next. With aging comes fibrosis, which is a stiffening of tissues (can anyone touch their toes like they used to?).  We become more stable against the forces of gravity as we age. But the most important argument against gravity is that we spend half of our lives perpendicular to the force of gravity (when lying down) therefore the forces should cancel each other out. Sagging occurs in the aging face not because of gravity but because of the changes in the fat compartments that accompanies aging. A young face has a very smooth ample distribution of fat. It is one continuous structure like a “gently rolling plain”. Each area blends into the neighboring area seamlessly. This is because the fat is evenly distributed throughout the young face and therefore the face appears balanced.

Now, think of the aging face as a series of “hills and valleys”. The hills are the areas where there is too much fat accumulated.  In very thin individuals these hills may be minor or even absent, but in most middle-aged adults the hills occur in the jowl region, the sides of the laugh lines and under the chin. The valleys in contrast occur universally around the eyes, around the mouth under the cheeks and around the jaw line. These are all areas where fat has disappeared with aging. This hill and valley topography unbalances the face and occurs because of alterations under the skin in the fat. It is the single most characteristic change in the aging face. The goal therefore of any rejuvenation procedure should be to rebalance these fat compartments and restore harmony in the face. This is easily done by microliposuction of the fatty “hills” and fat transfer to the sunken “valleys”. This eliminates sagging by emptying the areas where heavy fat causes the skin to stretch and droop, and filling up the areas that there is skin redundancy as a result of being devoid of fat. On the initial consult visit, the patient’s face is examined in relation to a photograph of when they were 10-15 years younger.  The dermatologic surgeon then forms a “blueprint” or map of the areas to be augmented with fat and the areas to be suctioned.  The entire face is addressed, not just specific folds or wrinkles.  This effects a change in the underlying structure of the face.

The principles of facial fat rebalancing are as follows:

1.) Fat is harvested (collected) from a donor site that can benefit the patient cosmetically, and have the greatest lipogenic (fat storing) activity. These areas are typically the buttock, outer thigh or abdomen. 

2.) Fat is harvested with as little trauma to the fat cells as possible.  A dilute local anesthetic tumescent solution is used.  The fat is extracted with an open tipped cannula attached to a 10cc syringe.  The plunger on the syringe is withdrawn by hand only 1cc at a time, generating small negative pressures.  Suction machines are never used for fat collection.

3.) The fat is centrifuged under sterile conditions for no more than 30 seconds at 3400 RPM.

4.) The spun fat is then transferred to 1cc syringes stopping short of the liquid fat layer.

5.) The recipient sites on the face are anesthetized with facial blocks when possible to avoid distortion, then supplemented with local infiltration of lidocaine.

6.) Areas on the face to be suctioned are anesthetized with dilute tumescent anesthesia.

7.) Entry sites on the face are made with an 18g NocorÒ.  Only blunt tipped 18g (or larger) cannulas are used to place the fat subcutaneously. 

8.) Fat is suctioned from the face by a hand held 10 cc syringe.  18 blunt tipped cannulas are use to conservatively remove fatty deposits. Suction machines are never used on the face.

9.) Fat is transferred in less than 0.1cc aliquots, depositing thin strands during withdrawal. Fat is transferred to all layers of tissue starting closest to bone when possible and weaving fat in a crosshatched 3-D design.  In the periorbital (eye) area fat is placed deep to the muscle and very conservatively. 

10.) Fat is only deposited in “virgin” tissue making fresh tunnels with each pass.   

11.) Fat is not only placed in folds, but in deep tissue distal to fold to “suspend” skin.  All areas of the face are addressed at the same time.

12.) Extra fat is stored in a medical plasma freezer and labeled in triplicate with name, date and SS#.

13.) “Touch-ups” are usually performed with frozen fat 4-8 week s later adhering to the above placement principles.

14.) The patient will need 1-3 fresh transfers with or without additional frozen transfers over the course of a year for total correction to take place.

This technique allows the patient gradual improvement over the course of a year, and with little to no “down time” fits well into an active lifestyle. Patients truly “de-age” over time since the blueprint for these procedures is fashioned after their younger selves. Each transfer/suction makes them look 2-5 years younger.  Excellent retention of the fat is accomplished by gradual minimal correction, repeat injections and woven placement of fat grafts.  Grafts don’t shift or move, but are stably anchored in existing fat. Serious complications are rare to absent. Possibilities include infection, absorption of grafts, bruising, swelling and under-correction (incomplete filling).  Over-correction (over-filling) is not seen with this technique since the changes in appearance are gradual, minimal and incremental. The patient maintains complete control over the course of the treatment and can decide to alter the “blue print” on return visits. Since patients will continue to age even after the rebalancing series of treatments is completed, they should plan on maintenance visits of 1-2 transfers a year to keep up with their aging, and continuously “turn back the clock”.  However, if they choose to stop treatments, they will merely age as normal from that point on, the transplanted fat behaving like their own facial fat.

Question 1.):
Many physicians claim that fat doesn’t work.  They say it doesn’t last and that it can shift or lump up.  Why is that?
Answer:  Fat transfer results are notoriously technique dependant. In developing this procedure many recommendations from the literature on fat transfer longevity, and the highlights in technique of many different successful fat transplant surgeons were integrated and combined.  In essence this technique is “the best of the best”.  Common pitfalls of fat transplantation with other techniques are:       
 
A) Underestimating the amount of fat it truly takes to effect a volume change. When you think that most of the full face transfers only place 1 ½ tablespoons of fat over the entire face, you begin to understand that it typically takes more than one of these to change the shape of the face. 

B) Placing  too much fat in one session.  Not only will the fat not live, but there is an increased risk of lumps and fat cysts, especially around the eye area. 

C)    Assuming incorrectly that the volume change seen early on after the fat transfer is from the fat.  When blunt instruments are used to place the fat, there is a lot of swelling.  Patients usually like this swelling because it allows them to “preview” the final results. However, if one assumes this swelling (lasting in a mild form for up to 2 months) is the fat, then one also may assume that as the swelling goes down, the fat didn’t last.

D) Filling the folds only.  Every fold in the face is a secondary result of tissue shifting            from “further up stream”.  For instance in most cases the nasolabial fold (smile lines on the sides of the mouth) are due to loss of central cheek mass.  When the cheek is full it projects forward and pushes up on the fold.  The same is true of the upper lid and brow.  

Question 2.):
This technique uses frozen fat.  Can you explain why and what evidence there is that frozen fat is viable?       
Answer: Using a patient’s own frozen fat obliterates the need to re-suction them each time.  It is mostly for convenience sake, but I think it works differently than fresh fat. Many busy fat transplant surgeons have commented at meetings and in writing that frozen fat appears to "take" as well as fresh fat. The jury is still out on this point however, so we do the majority of   procedures with fresh fat. 

Question 3.):
Why would someone do this procedure instead of a facelift?
Answer: Fat rebalancing can be done much earlier than a facelift to effect minor aging corrections over time.  It makes the patient look like they used to look, not different. There is no skeletonization of the face or unnatural pulling on the skin. It is perfect for the 55 year old that wants to look like she did at 40 or the 40 year old that wants to look 30 again. In contrast to facelifts which “tailor “ the skin around the aging framework, fat rebalancing replaces the lost framework so the skin can once again assume its normal position on the face.  

Question 4.): 
What is the difference between this procedure and bovine collagen, Laser resurfacing or BotoxÒ?
Answer:  The best way to explain this is to use two different analogies. If we picture the aging face like a weathered, collapsed roof, collagen would be analogous to re-tarring the roof to fill in cracks in the asphalt and Laser resurfacing like replacing the old shingles on the roof with new ones. Fat rebalancing replaces the support beams in the roof and restores it to its normal structure and shape. The second analogy is if you picture the face like a roman shade.  When it is young the shade is made of a thick foam, so tugging on the cord produces few ripples in the shade.  However as the face ages it becomes made of tissue paper so the slightest tug on the cord produces a multitude of ripples in the shade.  BotoxÒ stops the tugging on the cord.  Facial rebalancing with fat replaces the thickness of the shade.

Biography
Lisa M. Donofrio M.D.
Assistant Clinical Professor Dermatology Yale University School of Medicine 
As graduate of Quinnipiac University and Tulane University School of Medicine, she completed an internship in Internal Medicine and a residency in Dermatology at Tulane where she also served as Chief Resident.  While at Tulane Dr. Donofrio trained with renowned instructors in the fields of Dermatologic and Cosmetic Surgery, and was recipient of the Peterkin Award for excellence in research.   She has conducted cancer research at Yale Medical School in the departments of Pathology and Therapeutic Radiology, and has publications on Structural fat transfer, liposuction and surgical technique.  She has lectured on fat transfer and liposuction at the annual meetings of the American Academy of Dermatology, the American Society for Dermatologic Surgery, the International Society for Dermatologic Surgery, the Annual International symposium on Aging Skin, the American Society of Liposuction Surgery World Congress and is an invited speaker at many international surgery meetings. Dr. Donofrio is in private practice at The Savin Center for Dermatology and Cosmetic Surgery in New Haven, CT and the Laser and Skin Surgery Center in New York City . She is an Associate Clinical Professor of Dermatology at Yale University School of Medicine and an Assistant Clinical Professor of Dermatology at Tulane University School of Medicine.

Dr. Donofrio is board certified in Dermatology and is a member of the American Society for Dermatologic Surgery, the American Society of Liposuction Surgery and a Fellow of the American Academy of Dermatology.

Dr. Donofrio lives in  Connecticut  with her husband Brian Valzania a gallerist and book art dealer.  They are avid yoga practitioners and have recently developed aliveyoga.com an audio-based Internet yoga site.