It was about ten years ago that I first met Dr. Sidney Coleman. He had just published a text called Structural Fat Grafting and was showing his results which were superior to others I had seen. I had been studying fat grafting since 1991 when I did my first case. I immediately saw the genius behind his methods backed up by beautiful photographic documentation; I purchased his book, had him sign it, bought all of the recommended equipment and was on my way.
It was about this time that it became obvious that adipose tissue was special in ways we had never figured. Our own fat turns out to be the bodies’ primary depository of mesenchymal stem cells, rather than from bone marrow, explaining adipose tissue’s ability to rejuvenate our faces when injected into the face.
After a number of years and hundreds of cases I began to notice a pattern in our results. It became clear that our older (>60 years old) patients seemed to have much less than the 80-90% graft survival that we had become accustomed to. Others had noticed the same phenomenon (PRS 2014 August; 134(z), 227-232) but placed the cut-off at 45 years of age.
Empirically we studied the gross appearance of the suctioned and centrifuged fat noticing there tended to be a demarcation within the fat layer itself. Approximately 30-50% of the fat looked somehow different, less “cellular or robust” if you will. The location of the donor fat areas also seemed to appear different with the entire specimen seeming more cellular. Donor locations have been studied and our observations confirm that flank and upper buttock fat seem more vital than abdominal or thigh fat. For younger patients the opposite seems true.
We also believe, as do others, that stem cells from older individuals seem to lose some of their “potency” in regards to being multi-potential mesenchymal cells. The rejuvenating ability of adipose derived stem cells may age and become less potent over the lifetime of the organism. This observation has practical implications as many people are choosing to donate their adipose stem cells for possible future use as a treatment for certain diseases and possibly even cancer. It makes sense to donate one’s stem cells as early- as young- as possible to have maximum effectiveness. The cryopreservation of adipose tissue is now a growing industry requiring only standard liposuction techniques to obtain the fat which is cryopreserved indefinitely for a small yearly storage fee and a one time set-up fee by the storage facility (not including in-office surgical removal).
Botox and Restylane have become the mantra for those seeking facial rejuvenation without the inconvenience of having a “surgical procedure.” While these off-the-shelf products are enticing, they are expensive, temporary, and can be painful to inject, especially in the lips. For more Plastic Surgeons, these artificial fillers (Restylane, Juvederm, Strattice) are appropriate only for temporary improvements where there are time constraints and the need to be in public within a couple of days. Searching for the perfect facial filler had been elusive until recently. The emergence of fat from your own body (autogenous) has paralleled the refinements in fat harvesting and injection techniques that have elevated the “take” of fat injections to the 80-90% range. Coupled with improvements in local anesthesia and anesthetic agents make the overall experience with the new fat injection techniques less painful and more likely to give a permanent, elegant improvement in facial contours and rhytids (wrinkles). Many non-surgical practitioners complain of the donor site for obtaining the fat. While we must respect the donor site, offering the patient an improvement in body contour by harvesting fat for injection offers the patient the benefits of a liposuction (method of harvesting fat) procedure and cosmetic improvement of the donor site as well as the areas of the face injected with fat.
What does the future hold for facial fillers? Ongoing research using stem cell and growth factor technology may lead to even further improvements in fat injection techniques while artificial filler research tries to make their artificial substances last longer and the cost with longer lasting substances is naturally higher and will continue to increase over time.
Fat injection techniques have proven to be a vast improvement over foreign-body injections for facial rejuvenation. Fat is permanent, soft, cannot be rejected by the body, natural, and requires only small (3-4mm) stab wounds for injection. The patient can request which body area is preferred as a liposuction donor site obtaining body contour improvement at no additional charge. The well informed patient will usually choose the elegance of fat injection over the expediency of foreign material injected in the face.
As an extension of fat technology, we have begun fat injections in the back of hands for hand rejuvenation. The injected fat decreases the appearance of prominent veins, knuckles, and tendons that become more pronounced as we age. No one should let their hand reveal their age when we have the procedures to reduce the signs of the aging hand.
Read more about top fat grafting surgeon Dr. Paul Howard and view fat injection before and after photos.
Facial aging is complicated by genetics, environment, sun damage, smoking, and drinking. There is not a single procedure that works for everyone, therefore it is important that individualized evaluation leads to an operation which is specific for that person. The uniqueness of all faces as well as the patient’s desires may lead to a slightly different surgical approach for each individual. Another way to say this is that the one-size-fits-all facelift has become antiquated. To facilitate individualized care we prefer to look at each part of the face separately leading to a unique surgical treatment plan.
We divide the face into its component parts; forehead, eyes, midface, and neck with primary emphasis on the midface. Midface aging is characterized by sagging of the facial soft tissues causing a deepening of the nasolabial folds, dark circles beneath the eyes, and the development of marionette lines from the corner of the mouth to the jaw line. The jaw line becomes less defined as the sagging facial soft tissues drop below the mandible causing jaw line “bubble.” In addition to the sagging soft tissues aging always involves a loss of volume and a loss skin elasticity. It is the surgeon’s charge to address individual manifestations of aging for each component part of the face. Elevating the soft tissues must be done and requires a specific vector or direction of elevation which may be unique for each face. This maneuver defines the jaw line, improves the deep nasolabial folds, addresses the marionette lines, and elevates the lower eyelid skin. This procedure is always required and must be performed accurately with minimal incisions. Elevation of the cheek tissues is so important that it must be done under direct vision with the results being technique dependent. The incisions are much less obvious than the old facelift scars. While elevating the cheek and malar tissues some augmentation of the malar prominence (cheek bones) is achieved. The need for additional volume can be affected by adding autogolous fat to the procedure. As a rule of thumb, we rarely, if ever, remove fat from the midface but frequently add fat back to replace the soft tissues we lose over time.
The next issue to be addressed is the blending of the cheek elevation with the lower eyelids. These procedures are typically done together; that is lower blepharoplasty and facelift. The elegance and effectiveness of the mid-face lift sets up the rejuvenation of the remaining parts of the face.
Read more about Dr. Paul Howard’s Howard Lift Facelifts