We now recognize that replenishing lost facial volume, the refill is just as important as tissue repositioning: the redrape in facial rejuvenation. A facelift alone is purely a repositional procedure. Plastic surgeons may meticulously mobilize about a cc of fat from the orbit into the tear trough, or pull up on the buccal (cheek) fat pad, which contains a measly 4 ccs of fat, using suspension sutures that don’t work very well in the first place. These are tiny volumes and the fat is likely to be flattened by the suturing. Not surprisingly, it is difficult to appreciate volume or contour differences on photographs after these procedures. If there is a difference, it may be due to postoperative swelling on an early postoperative photograph. No study has provided quantitative evidence of its effectiveness.

To provide youthful facial fullness, introduction of fat harvested from another area of the body (such as the abdomen) is the key. This is the only way to truly restore lost facial volume. Rather than repositioning a few grams of fat from one part of the face to another, borrowing from Peter to pay Paul, it is possible to introduce a much greater volume of new fat, in quantities of 10, 20, 30, or more cc’s. Fat injection has been the biggest advance in my facial rejuvenation surgery in the last decade (Laser resurfacing was the biggest advance in the decade before that). I have not had a patient yet in whom I thought I injected too much fat.

Even counting on some resorption of injected fat, say 50%, there is still a net gain, which is better than the zero net gain of any transpositional technique. To determine changes in volume after fat injection at the time of facelift study, patients at our center were studied with MRI’s before and at various times after surgery. This study demonstrated a significant and lasting improvement in cheek volume. All five patients studied showed an increase in cheek thickness at one month, and no significant loss at subsequent times after one month.

The successful integration of fat injection with facelifting is an important advance in facial rejuvenation. However, it is still done by only a minority of plastic surgeons. The usual explanation is “I find the results inconsistent.” The irony is that few plastic surgical procedures can be counted on to produce consistent results and fat injection of the malar areas does provide lasting and consistent improvement.

I believe that part of the problem is that fat injection is perceived by plastic surgeons as a painstakingly slow and tedious procedure. A facelift is already a meticulous and time-consuming procedure. Dr. Sydney Coleman, who popularized fat injection, injects one cc at a time and spends hours doing it (he does not do a facelift simultaneously). However, this time commitment is unnecessary. Fat may be injected in larger volumes, using five or ten cc syringes, under low pressure, using atraumatic technique, without a need for centrifugation (I use the Lipivage™ system) and using fewer passes to reduce tissue trauma and swelling. Using this “macro” technique, fat can be harvested and injected in 30 minutes or less, making the technique an ideal adjunct to facelift surgery- a lot of result in a minimal amount of time.