A well recognized component of facial aging is loss of fat volume. This loss results in a sunken, hollow appearance to the face, which may be difficult to describe, but is easy to recognize. The face looses its round contours and sharp demarcations develop between different regions of the face. Volume augmentation is a large component of comprehensive facial rejuvenation.

Facial volume restoration can be achieved in several ways. There are many commercially available injectible fillers to augment the face. Products such as Restylane, Juvederm, Scupltra, and Radiesse are now a part of the popular culture lexicon. Although these fillers are easy to administer, they lack permanency. Fat grafting is a permanent technique for restoration of facial volume, and an attractive alternative to the commercially available facial fillers.

Dr. Khosh performs fat grafting in Manhattan, as an office based procedure. Small amounts of fat is gently harvested from the lower body, prepared carefully, and then meticulously injected into appropriately chosen areas of the face. Fat transfer can be used to enhance the appearance of the cheeks, brow, temple, and the orbital regions. Patients notice not only improved facial contours, but also more vibrant and healthier skin. A secondary benefit that has been postulated to be due to growth factors or stem cells present in the fat graft.

2010 plastic surgery trends

Happy new year! 2010 promises to be an exciting new year, and hopefully an end to the global recession that affected every one so significantly in the past decade. In light of the continuing advances in the medical field, I have the following predictions in regards to trends in facial plastic and cosmetic surgery.

1. New products that rival Botox Cosmetic in treatment of facial wrinkles will become available. Botox Cosmetic has revolutionized office based facial rejuvenation, by allowing treatment of dynamic wrinkles of the brow and crow’s feet area. In 2009 Dysport was introduced as a competitor to Botox Cosmetic. In 2010 new products such as Pur Tox are likely to become available for use.  Research is also progressing in developing products that can be applied as a cream, and avoid injections. We may have to wait till 2012 before those products are available.

2. Increase in the number of plastic surgery procedures. As the economy recovers, we will see an uptick in the number of cosmetic procedures overall. The greatest increase will be in the minimally invasive treatments such as Botox Cosmetic and dermal filler injections, and skin laser treatments. But we will also see increases in surgical treatments such as face lifts, and rhinoplasties.

3. Fat injection will become more in vogue. Fat transfer from one part of the body into another area will gain more attraction. Facial fat injections for treatment of wrinkles and achieving a fuller and rounder face is well established. In 2010, we will see more fat transfer in other parts of the body such as the breast or the buttocks.

4. Face transplants will become more common. Thus far, there have been eight cases of face transplants in the world. The early success with this procedure will fuel further growth in this highly specialized surgery which is a last resort for patients with massive and catastrophic facial deformities. The biggest advances in face transplant will involve immunosuppressive therapy that will prevent transplant rejection.

A recent article in the Journal of Plastic and Reconstructive Surgery gives scientific credence to the observation of plastic surgeons, that patients who undergo fat grafting to the face show improvement of skin color and texture. Fat grafting is a well known surgical technique for restoration of lost volume to the face. and an alternative to filler injections such as Restylane, Radiesse, or Sculptra. Fat grafting can be performed as an isolated procedure or in combination with other facial procedures such as face lift or blepharoplasty.

It has been my observation  that several months following fat grafting, patients demonstrate improved skin quality in the grafted area. In this journal article, researchers from France injected human fat into the backs of nude mice and later evaluated the quality of the overlying skin. For comparison, adjacent skin was injected with nothing, injected with a growth medium, or treated with subcutaneous tunneling. The results showed thickening of the dermis, increased levels of collagen, and thickening of the extracellular matrix. These microscopic findings are consistent with younger and healthier skin.

Fat grafting will not replace other facial fillers due to higher initial cost, higher technical difficulty, and more prolonged recovery. However, more permanent results from fat grafting and expected improvement of the skin may convince some patients that fat grafting is preferable to filler injections in the face.

The prestigious journal of Plastic and Reconstructive Surgery published a recent study to evaluate the effect of fat transfer in patients who had undergone radiation therapy. Radiation therapy is a common treatment for patients who have cancer affecting the head and neck region. Radiation therapy and surgical excision are sometimes combined to maximize the possibility of cure. The radiation treatment though,  can lead to cosmetic and functional deficits such as scarring, loss of volume, and swallowing difficulty.

The study authors reviewed 11 patients who underwent fat transfer from the abdomen region to the face or neck. The technique is similar to that described in our website, under fat transfer section. Fat was removed from the abdomen, similar to liposuction. The fat was then injected into the neck or face with small needles. In follow up, all but one patient reported both cosmetic and functional improvement.

This study is interesting because although the cosmetic benefits of fat injection into the face are well known, the safety and effectiveness of fat injection into radiated skin had not been previously evaluated. These results will help plastic surgeons offer fat injection as a method of cosmetic and fuctional improvement in cancer survivors who have had radiation therapy in the head and neck region. The following picture depicts the results of fat transfer in a patient who had a congenital abnormality which caused one side of the face to be under-developed.

The New York Magazine recently published a cover page article titled About Face. The catch phrase in the article is: “Out with the gaunt and tight, in with the plump and juicy. There’s a new face in town—and it’s a baby’s”.

Celebrities like Demi Moore, Michelle Pfeiffer, Elizabeth Hurley, and Naomi Campbell were shown as examples of beautiful faces where subtle and minimal cosmetic work enhanced an already attractive face.

On the other hand, pictures of Faye Dunaway, Meg Ryan, Cher, and Melanie Griffith were featured as examples of bad plastic surgery. Where too much was done resulting in unnatural results.

I like the article since I agree with its main premise that a young face is plump and heart shaped, and that any intervention designed in rejuvenating the face should be aimed at restoring those qualities. Thus, facelifts should not be “tight”, fat in the lower eyelids should not be removed aggressively, and fat grafting should be considered in most cases. The article also reflected my thoughts on rhinoplasty. In that a strong profile is much preferable to a washed out nose.

Just as an example, here is a patient who was looking for a younger look. A combination of upper eyelid surgery and fat transfer gave her a totally natural rejuvenated look.

Here is an example of a natural rhinoplasty, where the dorsum was not exessively lowered and the patient retains her ethnic features, albeit in an enhanced form.