February 3, 2016

Welcome to the 21st Century

Facial aging is a complex process related to changes in several tissues and structures in the face and neck. For over a century, it has been well known that skin relaxes and becomes redundant in people as we age. The first attempts to rejuvenate the face, in earlier days, were to remove the redundant skin excess. As a result, limited improvement was obtained by eliminating some of the signs of aging, which mainly manifested in the lower face and the neck. This kind of limited skin excision was able to raise, somewhat, the eyebrows; moderately tighten the face; and many times improve the neck in a substantial fashion. During all those years, including the decade of the 60s, facial rejuvenation was then restricted to what was called skin facelift; that is, making incisions in front of the ear, sometimes inside the scalp and around the ear onto the neck, separating the skin from the muscle and then pulling the skin up in order to remove any excess. The benefits of this procedure were limited, mainly in the central portion of the face, where the aging process is related to other causes, which we will soon describe, and also need to be corrected in order to rejuvenate the face. The other two components of facial aging, besides the increased skin laxity secondary to loss of collagen and elastic fibers, are (1) reabsorption of fat, not only subcutaneous fat (the fat under the skin) but also the deep fat deposits that give shape to the face, and (2) involution, i.e. decrease in size of the facial bones. Depending on a person’s genetics, some of these processes are more noticeable than others. Usually, early aging of the face starts with reabsorption of fat from around the eyes and on the cheeks, creating what is called a “tear-trough,” drooping of the malar fat pad and sinking of the mid-face.

Facial lines secondary to thinning of the skin, absorption of the fat and hyperactivity of the muscles on the forehead, or the upper third of the face, can be noticeable in some people sooner, although in other people later, in life. Finally, aging of the lower third of the face, meaning everything located below the upper lip, including the jawline and the neck, usually is secondary somewhat to fat atrophy and bone resorption, but mainly laxity of the skin. As you can imagine, because aging is secondary to different processes, different treatments need to be utilized in order to rejuvenate the face. Wrinkles in the upper third of the face (i.e., the forehead), can be easily treated with Botulinum toxin (Botox, Dysport, etc). These treatments are very effective; however, not all patients are interested in them because they need to be repeated 2-3 times a year and they are somewhat expensive. Surgery on the forehead is mainly aimed at raising the eyebrows, but can do little for the wrinkling of the forehead and between the eyes, which occur secondary to years of repetitive facial expressions, like frowning. Both treatments are indicated according to the patient’s needs. Regarding the eyelids, the skin excess on the upper eyelid is usually manifested by a skin fold that can drape over the eyelashes on the upper lid, and bags protruding below the lower lids, where there may be a component of excess skin as well.

These problems can be addressed with a blepharoplasty that consists of removal of excess skin and fat from both upper and lower eyelids. The mid-face is the area in which surgery has gained the most ground in recent decades, because it has been observed that most of the aging of the mid-face is secondary to fat resorption from the deep and superficial compartments, and not because of relaxing of the skin. This area is now treated with fat grafting in order to replenish subcutaneous fat and correct the deformities that occur secondary to fat atrophy. Furthermore, discovery of the presence of stem cells in the adipose tissue itself has refined this procedure. It can now be performed in more consistent and effective ways by adding, to the fat, stem cells contained in the stromal-vascular fraction, which is the structure of the fat tissue that can be isolated, with proper techniques, from the patient’s own fat. So, combining the patient’s own fat with his/her own stem cells makes these procedures more effective at correcting the problems and provide long-lasting results. With the fat grafting combined with stem cells in the mid-face, we can correct the tear-trough deformity, which is the visible contour of the inferior border of the orbit, as well as raise the cheeks and correct the depressions in the mid-face, all of these symptoms that lead to what is called “skeletonization” of the face, and which are changes that are very easy to observe as people age and reach older stages in their lives. The lower face is treated with more conventional procedures, i.e., removal of skin, removal of fat from the neck and tightening of the muscles of the area. However, it is important to remark that a conventional facelift, which just treats the skin and muscles, will not provide, in many patients, noticeable or satisfactory facial rejuvenation if all the problems created from the fat atrophy are not addressed. The lips also get smaller over time, and can be enlarged with different fillers, and the lines that appear around the mouth and around the eyes, as well as sometimes on the cheeks are treated with new laser resurfacing. Of course, all of these procedures can be performed at one time or in different stages, according to the patient’s needs and desires. Usually, for a full facial rejuvenation, the recovery time would be between 7-10 days, if no laser rejuvenation is performed; if the patient needs a more intensive treatment of the skin with the laser, recovery time may be 3-4 weeks. Rejuvenation of the face with fat grafting could have a 7-day recuperation. A smaller facelift, such as when only the neck is addressed, could also allow the patient to return to work in a week. Finally, ancillary procedures to address significant bone resorption are the placements of implants, not only in the chin but also in the cheeks, although these are not the most common procedures performed these days.


We are presenting in this blog a case that was performed approximately a year ago, in which the benefits of the above-mentioned surgery can be clearly observed. The surgery on the eyes, the neck and the face combined with a brow lift and fat grafting of the mid-face, has remarkably rejuvenated this patient’s face, making her really more confident and happy. In this practice, we specialize in fat grafting combined with stem cells, which provide better, long-lasting results. We are excited and enthusiastic about this procedure, which appears to be one of the most helpful and innovative techniques in the last 2 years in the evolution and improvement of plastic surgery.

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