Centrofacial Rejuvenation

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The 58-year-old woman in Fig. 6-14 presented with sun-damaged décolleté skin

of SNIF into the vertical rhytids and 15 cc of nanofat into the décolleté area. The
result after 1 week shows bruising from the injections and a mild erythema. At
2 weeks most erythema had subsided, and only the remnants of the ecchymosis
-
ids have disappeared, and the whole décolleté skin has a regenerated appearance.
Fig. 6-14
tids and an elastotic skin surface was treated w ith 4 cc of sharp needle intraderm al fat and
15 cc of nanofat. A, Preoperatively. B, At 1 week postoperatively. C, At 2 weeks postoperatively. D, At
6 months postoperatively.
B
A
D
C

• Nanofat Grafting
The 68-year-old wom an in Fig. 6-15 presented w ith sun-dam aged, w rinkled
décolleté. Treatment consisted of 7cc SNIF injected with a 23-gauge needle into
the vertical rhytids, combined with 15 cc nanofat injected with a 27-gauge nee-
dle into the whole décolleté area. The result is shown 6 months postoperatively
-
provement of the skin between the wrinkles.
Fig. 6-15 This 68-year-old woman presented with a sun-damaged décolleté and was treated with
7 cc sharp needle intradermal fat and 15 cc nanofat. A, Preoperatively. B, At 1 week postoperatively.
C, At 6 months postoperatively. D, At 3 years postoperatively.
B
A
D
C

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

The 71-year-old woman in Fig. 6-16 attended a consultation for facial rejuvena-
tion. She had a minimal access cranial suspension (MACS) lift with centrofacial
rejuvenation by microfat grafting and Erbium laser resurfacing. The laxity of the
skin was corrected by the lifting procedure, but the enhancement of the quality
of the skin is a result of the nanofat injection. The disappearance of the solar ker-
atoses (red arrows) in the postoperative images and the long-term stability after
3 years (see Fig. 6-16, H) are notable. For the neck correction, 6 cc of SNIF was
injected through a 23-gauge needle into the horizontal rhytids, and the whole
anterior neck area was injected with 15 cc of nanofat through a 27-gauge needle.
Fig. 6-16 A 71-year-old wom an who had a m inim al access cranial suspension (MACS) lift with
centrofacial rejuvenation by m icrofat grafting and Erbium laser resurfacing for facial rejuvena-
tion. A, Preoperatively. B, At 3 months postoperatively. C, At 3 years postoperatively. D, At 4 years
postoperatively.
B
A
D
C

• Nanofat Grafting
Fig. 6-16, cont’d E, Skin m arkings for the MACS lift and the areas for m icrofat grafting, sharp
needle intraderm al fat (SNIF) grafting, and nanofat grafting. The whole anterior neck is m arked
for nanofat injection. The horizontal neck rhytids are marked for SNIF. Detail of the change in
neck skin quality before (F) and 6 m onths (G) and 3 years (H) after nanofat treatm ent. The solar
keratoses have disappeared.
E
H
G
F
Solar
keratoses

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The 43-year-old woman in Fig. 6-17 wanted neck rejuvenation without surgical
lifting. The neck skin shows little laxity but mainly elastotic changes, with sharp
horizontal rhytids and dermal thickening. The treatment consisted of injection
of 7 cc of SNIF with a 23-gauge needle into the horizontal rhytids and 16 cc of
nanofat injected with a 27-gauge needle into the whole anterior neck region. The
treatment was performed under local anesthesia and took 70 minutes. Softening
of the skin texture and an 85% reduction of the horizontal rhytids are visible in
the 6-month postoperative images. The improvement of the skin quality between
the wrinkles is obvious. The slight overcorrection of the SNIF injections (see Fig.
6-17, F) is temporary and resolves within 2 to 3 weeks.
Fig. 6-17 A 43-year-old woman who was treated with 7 cc of sharp needle intradermal fat injected
with a 23-gauge needle into the horizontal rhytids and 16 cc of nanofat injected with a 27-gauge
needle into the whole anterior neck region for neck rejuvenation. A and B, Preoperatively. C and
D, At 6 months postoperatively.
D
C
A

B

• Nanofat Grafting
Fig. 6-17, cont’d E, Intraoperatively, at the end of the needle surgery. F, At 1 week postoperatively.
F
E

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

The 67-year-old wom an in Fig. 6-18 experienced a blunt-force traum a in a bi-
cycle accident, which caused a skin abrasion and a focal necrosis of facial cheek

and atrophic scar (see Fig. 6-18, B and C). Treatment involved a combination of

nanofat intradermally. The result is shown 6 months postoperatively. The contour

normal skin architecture is restored after one nanofat treatment.
Fig. 6-18 A, A 67-year-old patient im mediately after a blunt-force traum a. B and D, Scarring and
contour irregularity 6 months after the accident. C and E, Results 6 months after treatment with

nanofat intradermally.
C
B
E
D
A

• Nanofat Grafting
PROBLEMS AND COMPLICATIONS
-
ticular deserves discussion: In our early series of dark circle treatment, we had
four patients who experienced a persisting yellow discoloration at the injection
-
sulting in survival of too high a percentage of adipocytes. This problem has only
occurred in the lower eyelid, and not in any of the other areas treated.

process, which involves 30 passes through a 2.4 m m Luer-to-Luer connector,
followed by a second 30 passes through a 1.2 m m Luer-to-Luer connector, as
described previously. The persisting adipose show has not reoccurred with this
method.
Obviously all precautions recommended for preventing intravascular injection
-
tion upon withdrawal only, injection under low pressure, and small aliquots per
passage. This is valid for any injectable.
Technical Pearls
• Only microfat should be used as a source for nanofat.
• -
nique is essential.
• The straining step cannot be skipped; it prevents blockage of the 27-gauge
injection needle.
• Intravascular injection must be prevented.

-
tive for chronic intractable radiation injuries. Radiat Prot Dosimetry 151:656-660, 2012.
Aronowitz JA. Reply: Adipose stromal vascular fraction isolation: a head-to-head comparison
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separation at the point of care. Ann Plast Surg 75:666-671, 2015.
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Stem Cell Res Ther 5:95-102, 2010.
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Baptista LS, do Amaral RJ, Carias RB, et al. An alternative method for the isolation of mesen-
chymal stromal cells derived from lipoaspirate samples. Cytotherapy 11:706-715, 2009.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy


Exp Cell Res 268:189-200, 2001.
Bertheuil N, Chaput B, Menard C, et al. Adipose-derived stromal cells: history, isolation, immu-
nomodulatory properties and clinical perspectives. Ann Chir Plast Esthet 60:94-102, 2015.
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fat tissue derivative highly enriched in pericyte-like elements by mild mechanical forces
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uncultured hum an stromal stem cells: alteration of gene expression after in vitro cell
culture. Mol Biol Cell 16:1131-1141, 2005.
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adult stem cells. Biochem Biophys Res Commun 330:142-150, 2005.
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thelial cells in vitro and improve postnatal neovascularization in vivo. Biochem Biophys
Res Comm un 332:370-379, 2005.
Cattoretti G, Schiro R, Orazi A, et al. Bone marrow stroma in humans: anti-nerve grow th factor
receptor antibodies selectively stain reticular cells in vivo and in vitro. Blood 81:1726-
1738, 1993.
Charles-de-Sá L, Gontijo-de-Amorim NF, Maeda Takiya C, et al. Antiaging treatment of the facial
skin by fat graft and adipose-derived stem cells. Plast Reconstr Surg 135:999-1009, 2015.
Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast
Surg 19:421-425, 1995.

Coleman SR, Mazzola RF. Fat Injection: From Filling to Regeneration. St Louis: Quality Med-
ical Publishing, 2009.
Condé-Green A, Rodriguez RL, Slezak S, et al. Comparison between stromal vascular cells’ iso-
lation with enzymatic digestion and mechanical processing of aspirated adipose tissue.
Plast Reconstr Surg 134(4S):1-54, 2014.
Dasiou-Plakida D. Fat injections for facial rejuvenation: 17 years experience in 1720 patients.
J Cosmet Derm atol 2:119-125, 2003.
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matol 28:875-884, 2000.
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rived stem cells in dynamic 3D-environments. Biomaterials 34:1004-1017, 2013.
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2635, 2008.

autom ated processing system: bench and bed analysis. J Tissue Eng Regen Med 7:864-
870, 2013.



stem cells from patients with lipoaspirate transplant. Cell Transplant 19:1225-1235, 2010.

• Nanofat Grafting

supported by stem cells. World J Gastroenterol 21:3330-3336, 2015.

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temic sclerosis: an open-label phase I trial. Ann Rheum Dis 74:2175-2182, 2015.

tissue-derived stromal cells. J Cell Physiol 189:54-63, 2001.
Guven S, Karagianni M, Schwalbe M, et al. Validation of an automated procedure to isolate
hum an adipose tissue-derived cells by using the Sepax technology. Tissue Eng Part C
Methods 18:575-582, 2012.
Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Re-
constr Surg 72:591-597, 1983.

through an interleukin-6-mediated mechanism. Plast Recon Surg 134:470-480, 2014.
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mercial cell separation systems. Plast Reconstr Surg 133:889e, 2014.

Cytotherapy 14:1159-1163, 2012.
Mahdavian Delavary B, van der Veer WM, van Egmond M, et al. Macrophages in skin injury
and repair. Immunobiology 216:753-762, 2011.

adipose-derived stem cells obtained with a nonenzymatic method and device: a novel
approach to multipotency. Cell Transplant 23:1489-1500, 2014.

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Neuber G. Fetttransplantation. Verh Dstch Ges Chir 22:66, 1893.
Nguyen PS, Desouches C, Gay AM, et al. Development of m icro-injection as an innovative au-

Aesthet Surg 65:1692-1699, 2012.
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tems for adipose tissue-derived cells: current state of the art. Cell Regen (Lond) 4:7, 2015.
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fat grafting. Arch Aesth Plast Surg 20:92-96, 2014.
Oh JS, Park IS, Kim KN, et al. Transplantation of an adipose stem cell cluster in a spinal cord
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cells from hum an adipose tissue-derived m ulti-lineage progenitor cells improve left
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135:1618-1628, 2015.

derived adult stem cells: comparison with bone marrow mesenchym al stem cells. Br

Quirici N, Scavullo C, de Girolamo L, et al. Anti-L-NGFR and -CD34 monoclonal antibodies
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Raposio E, Caruana G, Petrella M, et al. A standardized m ethod of isolating adipose-derived
stem cells for clinical applications. Ann Plast Surg 76:124-126, 2016.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
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poaspirate transplant: a healing process mediated by adipose-derived adult stem cells.
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Shah FS, Wu X, Dietrich M, et al. A non-enzym atic m ethod for isolating hum an adipose
tissue-derived stromal stem cells. Cytotherapy 15:979-985, 2013.

adipose-derived stem/progenitor cells. Stem Cells Dev 18:1201-1210, 2009.
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rived m esenchymal progenitor cells. J Bone Joint Surg Am 80:1745-1757, 1998.

stem cells derived from adult human tissues. Cell Immunol 259:150-156, 2009.
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a comparison between micromass and pellet culture system s. Biotechnol Lett 32:1339-
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for cell-based therapies. Tissue Eng 7:211-228, 2001.

Chapter
5
The MACS-Lift
Short-Scar Face Lift
Technical and Strategic
Considerations
Mark Laurence Jewell • Mark Laurence Jewell
Chapter
7
Centrofacial
Rejuvenation: Putting
It All Together
Patrick L. Tonnard • Alexis M. Verpaele
It is not what you look at that matters,
it is w hat you see.
HENRY DAVID THOREAU
The eye sees only w hat the mind
is prepared to comprehend.
W ILLIAM ROBERTSON DAVIES
A
B
C
D
C
B
A
A
B
C
D
C
B
A
1
2
3
4
5
6
7

Chapter Videos
7-1 Introduction by Dr. Patrick Tonnard and Dr. Alexis Verpaele
7-2 Interview with Dr. Thomas Biggs and Dr. Patrick Tonnard: MACS-Lift
7-3 Interview with Dr. Thomas Biggs and Dr. Patrick Tonnard: Fat Grafting
7-4 Chapter I: Analysis of the Aging Face
7-5 Chapter II: Markings
7-6
(MACS)-Lift Solution
7-7 Chapter IV: Submental Liposuction
7-8 Chapter V: Microfat Harvesting
7-9 Chapter VI: Microfat Preparation
7-10 Chapter VII: Nanofat Preparation
7-11 Chapter VIII: Nanofat Injection Technique
7-12 Chapter IX: Microfat Injection Technique
7-13 Chapter X: Sharp Needle Intradermal Fat Injection (SNIF)
Technique
7-14 Chapter XI: Simple Minimal-Access Cranial Suspension (MACS)-Lift
7-15 Chapter XII: Temporal Lift
7-16 Chapter XIII: Skin Redraping, Resection, and Suturing
7-17 Chapter XIV: Lip Lift
7-18 Chapter XV: Summary on Contralateral Side
7-19 Chapter XVI: Results

• Centrofacial Rejuvenation: Putting It All Together

istorically facial rejuvenation surgery initially focused only on correction of
laxity and apparent skin excess in the face, completely disregarding the other as-
pects of the aging process such as volume loss and structural changes in the skin
surface. As a consequence, many operations resulted in a tight facial appearance
but were defective in restoring a natural youthful appearance. This situation was
further exacerbated by secondary and tertiary facelift surgeries.
Parallel with facelift evolution, other modalities for facial rejuvenation were de-
veloped, including volume restoration either with nonautologous or autologous
m aterials and surface enhancem ent by either physical (laser) or chem ical pro-
cesses.
Around the turning of the millennium the awareness that physical aging of the
face is a m ultifactorial process was grow ing. Aging is now understood to con-
sist of facial sagging and skin laxity, changes in skin texture and pigmentation,
changes in volum e in certain areas of the face, and contraction of certain facial
muscles producing permanent folds and rhytids.
If the surgeon does not actively consider the contribution of all these factors to
facial aging, it will be impossible to reproduce or even approximate the lost nat-
ural appearance of youth. As David Thoreau w rote, “It is not what you look at
what matters, it is what you see.” For decades aesthetic surgeons have overlooked



to see it in virtually every aging face. Or, as quoted from William Davies, “The
eye sees only what the mind is prepared to comprehend.”
This understanding has caused a true paradigm shift in the way surgeons now

centrofacial area, which consists of the periorbital and perioral areas.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Fig. 7-1 Im ages from Yarbus’ study on the tracking of eye m ovem ents of an individual while
looking at faces, highlighting the importance of the eyes and the mouth in facial evaluation. (From
Yarbus AL. Eye Movements and Vision. New York: Plenum Press, 1967. With kind permission from
Springer Science and Business Media [Figs. 114 and 115 in original].)
Based on studies of eye-tracking movements it is apparent that, when looking at
a human face, the observer scans the eyes and the mouth following an inverted
triangular pattern 1 (Fig. 7-1). The accepted explanation for this is that the eyes
and the mouth are the source of facial expression, which radiates the emotional
status of the person. The centrofacial area harbors the emotional expression of
the face, which explains the importance of restoring it.
It is not only the appearance of old age, but also the physical appearance of fear,
grief, pain, doubt, fatigue, and other negative states that people wish to remove

• Centrofacial Rejuvenation: Putting It All Together
w ith the help of a facial rejuvenation procedure. A simple cervicofacial lifting
-
not change this emotional expression of the face.
Com bined w ith surgical correction of skin laxity, the various m odalities of fat
grafting have becom e an integral and indispensable part of the m odern facial

modalities of facial rejuvenation worked synergistically toward a natural facial
rejuvenation result. In all these cases the change in emotional expression of the
-
dure that works in the peripheral areas of the face. A striking example of centro-
facial aging can be seen in the facial aging process of Fabiola de Mora y Aragón,
late Queen of Belgium (1928–2014; Fig. 7-2).
B

C
A
D

E

F
Fig. 7-2 Aging in the face of Fabiola de Mora y Aragón, Queen of Belgium. A, At the age of 32 years.
B, In her early 40s. C, In her 50s. D, In her 60s. E, In her 70s. F, At the age of 86 years. (A and C From
Photonews/Photonews/Getty Im ages; B
D
from Raym ond Reuter/Sygm a/Getty Im ages; E from Mark Renders/Getty Im ages Entertainm ent/
Getty Images; F and H from Benoit Doppange/AFP/Getty Images.)

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Despite the peripheral laxity in the jowls and the neck, the centrofacial volume
loss in the perioral and the periorbital region are much more important with re-

(Fig. 7-2, G) and 86 (Fig. 7-2, H) highlights that the most important aging changes
occur in the central oval of the face. This underscores the importance of centro-
facial rejuvenation and the techniques described in this book.
Fig. 7-2, cont’d G and H, The aging changes in the central part of the face over a 54-year in-
terval are circled. These changes illustrate the importance of centrofacial rejuvenation. (G From
Photonews/Photonews/Getty Im ages; H from Benoit Doppange/AFP/Getty Images.)
H
G

• Centrofacial Rejuvenation: Putting It All Together
CASE STUDIES
The 51-year-old woman in Fig. 7-3, a smoker, presented for a facial rejuvenation
procedure (Fig. 7-3, A). After the consultation she decided to postpone the sur-
gery and underwent a gastric bypass procedure because she felt slightly over-
weight. She lost 20 kg in 3 years; the result of the weight loss on her facial ap-

(Fig. 7-3, B). At that time, at the age of 54, she again presented for facial rejuve-
nation. Compared w ith her appearance at the age of 28 years (Fig. 7-3, C), the

Sagging of the peripheral area is visible, with drooping of the tail of the eyebrow,
-
cially on the left side. Fine w rinkles in the frontal, glabellar, and perioral area
appear together w ith a lengthening of the vertical height of the upper lip and

B
A

C
Fig. 7-3 A, Preoperatively at age 51 years, before gastric bypass surgery. B, Preoperatively at age
54 years, after losing 20 kg. C, Comparison of the patient at age 28 years.
Nonsurgical Plan
The nonsurgical treatment plan consisted of the following:
• Smoking cessation
• A Retin-A skin care program
• Botulinum toxin in the glabellar and frontal area

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Surgical Plan
The surgical treatment involved the following:
• Simple minimal access cranial suspension (MACS) lift with retroau-
ricular incision
• Open neck procedure with platysmarrhaphy and partial transec-
tion of the platysma at the level of the hyoid
• Short-scar temporal lift
• Upper augmentation blepharoplasty with skin-only resection
• Lower skin-pinch blepharoplasty
• Microfat grafting, 80 cc, harvested from the abdomen

– Infrabrow: 2 cc/side

– Malar: 13 cc/side

– Nasolabial fold: 1.5 cc (including 0.25 cc after subcision)

– Marionette grooves: 2.5 cc/side

– Sharp needle intradermal fat (SNIF), 21-gauge needle:
Upper white roll: 1.3 cc
Lower white roll: 1.0 cc
Philtrum: 0.4 cc

– SNIF, 23-gauge needle:
Barcode (upper lip): 1.2 cc
Frontal wrinkles: 2.0 cc
Glabella: 0.5 cc
Cheek rhytids: 2.3 cc
Nasolabial rhytids: 2.0 cc
• Nanofat in the anterior neck area (17 cc)
• Liplift

The 1-year postoperative result demonstrates the correction of the neck laxity

restored by correction of the jowling. The degree of platysmal banding required
a platysmarrhaphy and consequently a full facelift incision. Most important was

her appearance at age 28 years, the rejuvenation is very natural, with the essen-
tial replenishment of the upper eyelids, the malar area, and the perioral area. The


the lip contours to her younger appearance. The glabellar and frontal rhytids are

view in downward gaze (the Bruce Connell view), the restoration of the cervi-
comental angle and the stable correction of the platysmal banding are evident.
The improvement in the quality of the neck skin is a result of the microfat in the
horizontal rhytids and nanofat in the whole anterior surface of the neck.

• Centrofacial Rejuvenation: Putting It All Together
Fig. 7-4 Left, Preoperative views. Right, At 1 year postoperatively. The top right photo is a com -
parison of the patient at age 28 years.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

-
-
tion is clearly much more important than the actual lifting procedure (Fig. 7-5).
Both techniques work synergistically toward a total natural facial rejuvenation.
Fig. 7-5 A and B,
the jawline and the lower neck. The centrofacial area has been m asked in black. C and D,
the centrofacial rejuvenation (augmentation blepharoplasty and perioral replenishment), which
clearly has more rejuvenating power than mere lifting. The peripheral facelifting areas have been
masked in black.
A

B

C

D
Centrofacial

• Centrofacial Rejuvenation: Putting It All Together
The wom an in Fig. 7-6 consulted for facial rejuvenation at the age of 64 years.
Analysis of and comparison with her picture at the age of 20 years reveals that
the sagging component of her facial aging is m oderate (m ainly in the neck and
-
orbital and perioral area. She has bilateral very lax lower eyelids, with a positive
-
lids, midface, and upper and lower lips, including loss of vermilion and philtral
-
tomalar groove, nasal tip, mental groove, and chin) shows that in the periorbital
and midface regions, all anatomic landmarks stay exactly at the same position.
-
ing place in these areas. The only feature that comes down in the central part of
the face is the upper lip, where an obvious lengthening of the vertical height of
the upper lip is visible in the aged face, which is a good indication for a surgical
liplift. A m arked change in em otional expression is also obvious between the
young and the aged face.
In the preoperative photos, a slight inclination of the head on the cervical spine
was obvious. When asked to put the head straight, she revealed that she was not
able to do so, as she has a degenerative condition in the cervical vertebrae that
has caused her to be in pain for the last 15 years. This pain is in part responsible
for the emotional expression of the face. Changing this emotional expression was
the m ost important m ission of this facial rejuvenation case. This was planned

Fig. 7-6 A, At age 20 years. B, Preoperatively at age 64 years.
A
B
C
D
C
B
A
A
B
C
D
C
B
A
1
2
3
4
5
6
7
B
A

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Nonsurgical Plan
The nonsurgical treatment plan consisted of the following:
• A Retin-A skin care program
• Botulinum toxin in the glabellar and frontal areas
Surgical Plan
The surgical treatment involved the following:
• Simple MACS lift with limited postauricular dissection
• Open neck procedure with platysmarrhaphy and partial transec-
tion of the platysma at the level of the hyoid
• Short-scar temporal lift
• Augmentation blepharoplasty

– Upper: skin-only resection plus microfat grafting

– Lower: fat redraping and microfat grafting of the malar area
• Bilateral canthopexy
• Microfat grafting, 65 cc harvested from the abdomen

– Infrabrow: 3 cc/side

– Malar: 10 cc/side

– Nasolabial folds: 2 cc, including 0.5 cc after subcision

– Marionette grooves: 3 cc/side

– SNIF, 21-gauge needle:
White roll, upper and lower: 2.0 cc
Philtrum: 1.0 cc

– SNIF, 23-gauge needle:
Barcode (upper lip): 2 cc
Nasolabial rhytids: 2.2 cc
Frontal wrinkles: 1.8 cc
Glabella: 0.7 cc
• Nanofat in the perioral area (10.5 cc)
• Liplift
• Erbium-YAG laser resurfacing in the perioral area
• Excision of tuberous nevi on left upper eyelid and upper lip

• Centrofacial Rejuvenation: Putting It All Together


(Fig. 7-7). This case illustrates the importance of adding volum e in the central
part of the face as part of a total facial rejuvenation procedure. The correction of
the neck laxity and the restoration of the cervicomental angle is important, but

areas is indispensable. The periorbital hollowness that occurred with aging has

aspect of the eyelids is very similar to that at age 20 years, with a full infrabrow
-
ent approach from the traditional resection blepharoplasty, which in her case
would have m ade her eyelids tighter and m ore hollow but would not have re-
sulted in a true rejuvenation.
Three-dimensional sculpting of the upper and lower lips was accomplished with
several techniques: volum e augm entation by m icrofat grafting and enhanced

height of the upper lip by the liplift; and improved skin quality by laser resurfac-
ing and nanofat injection. All these techniques work synergistically.
The 4-year postoperative pictures show the stability of the result (see Fig. 7-7,
D, G, and J).

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Fig. 7-7 A, At 20 years. B, Preoperatively at age 64 years. C, At 1 year postoperatively. D, At 4 years
postoperatively.
B
A
D
C

• Centrofacial Rejuvenation: Putting It All Together
Fig. 7-7, cont’d Left, Preoperative appearance at age 64 years. Center, At 1 year postoperatively.
Right, At 4 years postoperatively.
F
E

G
H

I

J

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The wom an in Fig. 7-8 presented at the age of 55 years for facial rejuvenation.
When her current appearance was compared with a picture taken at the age of
20 years, the following features were observed:
• Laxity of peripheral facial tissues, with temporal hooding, jowling, loss of

submental skin laxity.
•
-
-
-
onette grooves, and deepened oral commissures.
Vertical positional analysis of the anatom ic landm arks of the face shows no
change in position of most centrofacial features, except for the upper lip, which
shows a discrete vertical lengthening.
B
A
Fig. 7-8 A, At age 20 years. B, Preoperatively at age 55 years. Vertical positional analysis of the
anatomic facial landmarks reveals a stable position of most centrofacial features except the upper
lip, which shows vertical lengthening.

• Centrofacial Rejuvenation: Putting It All Together
Surgical Plan
The surgical treatment involved the following:
• Simple MACS lift with a “hockey-stick” extension and a limited
postauricular dissection
• Submental liposuction
• Short-scar temporal lift
• Augmentation blepharoplasty

– Upper eyelid
Conservative skin resection
Microfat grafting of the upper eyelid sulcus: right, 1.6 cc; left, 1.7cc

– Lower eyelid
Augmentation of the malar area: 9 cc of microfat per side
Skin-pinch blepharoplasty
• Microfat grafting, 35 cc, harvested from the abdomen

– Infrabrow: right, 1.6 cc; left, 1.7 cc

– Malar: 9 cc/side

– SNIF, 21-gauge needle:
White roll, upper and lower lips: 1.6 cc
Philtrum: 0.8 cc

– SNIF, 23-gauge needle:
Barcode (upper lip): 0.5 cc
Nasolabial rhytids: 1.2 cc
• Nanofat in the perioral area (5 cc)
• Erbium-YAG laser perioral resurfacing of individual rhytids with a
2 mm spot at 200 mJ
• Liplift

The results are shown at 1 year and 4 years postoperatively (Fig. 7-9); the cor-
rection of the peripheral laxity by the surgical lifting procedures is evident:

-
duced by the restoration of centrofacial volumes. In the periorbital area the aug-
mentation of the infrabrow and malar area are obvious. In the perioral area the

and nanofat grafting.
This case illustrates very clearly the necessity of incorporating fat grafting in the
surgical rejuvenation procedure. Classic resection blepharoplasty would not have
restored the fullness of the periorbital area to its younger appearance. Many sur-
geons would propose a surgical midfacelift procedure for this patient. Although
expert surgeons can produce consistently good results w ith m idfacelift tech-
niques, this procedure involves a prolonged recovery and a risk of very serious
complications like scleral show and ectropion. Because the central part of the

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

lifted. Compared with often complicated and dangerous midfacelift techniques,
fat grafting of the m idface is simple, is quick, has a sw ift recovery, and is very
safe w ith regard to possible complications, assum ing that the right technique
and adequate instrumentation is used.
In this case the cervicom ental lift procedure was responsible for about 20% of
the total facial rejuvenation. The remaining 80% was produced by the centrofa-
cial rejuvenation (periorbital and perioral fat grafting and laser resurfacing). The
liplift is an integral and essential part of centrofacial rejuvenation, as illustrated
in the postoperative result.
Fig. 7-9 Left, Preoperatively at age 55 years. Center, At 1 year postoperatively. Right, At 4 years
postoperatively.

• Centrofacial Rejuvenation: Putting It All Together
The woman in Fig. 7-10 presented at 55 years of age for facial rejuvenation. She
had marked sagging of the cervicomental area, producing an obtuse cervicomen-
tal angle and obvious jowling. She had good zygomatic bony structure but some
soft tissue loss in the anterior m alar area and in the m edial part of the upper
eyelid (A-frame deformity) and the nasolabial groove.
B
A
Fig. 7-10 A, At age 28 years. B, Preoperatively at age 55 years.

Surgical Plan
The surgical treatment was performed under local anesthesia and in-
volved the following:
• Simple MACS lift
• Submental liposuction
• Short-scar temporal lift
• Upper augmentation blepharoplasty with resection of skin only
and fat grafting of the medial part of the upper eyelid (1.3 cc)
• Microfat grafting (20 cc) of the upper eyelids (1.3 cc), nasojugal
groove (0.4 cc), nasolabial crease (2.0 cc), marionette groove
(2.0 cc), upper lip (0.6 cc), SNIF in the upper and lower lip white
roll (1.3 cc), forehead rhytids (0.6 cc), upper lip (0.6 cc), nasolabial
area (2.0 cc), and sublabial scar (0.8 cc)

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy

The results are shown 1 and 3 years postoperatively (Fig. 7-11). Most of the re-
-
gular to triangular and of the change in the emotional expression of the face by
discretely altering the perioral and periorbital area. The upper augm entation

to the appearance at the younger age (28 years).
Fig. 7-11 A, At 28 years. B, Preoperatively at age 55 years. C, At 1 year postoperatively. D, At
3 years postoperatively.
B
A
D
C

• Centrofacial Rejuvenation: Putting It All Together
Fig. 7-11, cont’d Left, Preoperatively at age 55 years. Center, At 1 year postoperatively.
Right, At 3 years postoperatively.
F
E

G
H

I

J

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The 63-year-old wom an in Fig. 7-12 presented for facial rejuvenation. She had
undergone a facelift procedure 15 years previously. She had a moderate laxity in
-
orbital area and the m idface and in the perioral area. Skin quality changes are


craqueléd, sun-damaged skin.
Fig. 7-12 Preoperatively at age 63 years.
Nonsurgical Plan
The nonsurgical treatment plan consisted of a Retin-A skin care program.

• Centrofacial Rejuvenation: Putting It All Together
Surgical Plan
The surgical treatment involved the following:
• Simple MACS lift with retroauricular incision
• Posterior cervicoplasty with complete undermining of the pla-
tysma and en block suspension of the musculocutaneous cervical

• Short-scar temporal lift
• Upper augmentation blepharoplasty (only fat grafting)
• Liplift (3 mm)
• Microfat grafting, 100 cc, harvested from the anterior thighs

– Infrabrow: 1 cc/side

– Malar: left, 6 cc; right, 7 cc

– Marionette grooves: 2 cc/side

– Upper lip: 2 cc

– Lower lip: 2 cc

– SNIF, 21-gauge needle:
White roll, upper and lower: 2 cc
Philtrum: 1 cc

– SNIF, 23-gauge needle:
Barcode (upper lip): 2 cc
Frontal wrinkles: 2.3 cc
Glabella: 0.7 cc


• Neck nanofat: 17.8 cc
• Full-face croton oil peel: frontal area, cheeks, nose, 0.2%; perioral,
0.4%

The 1-year postoperative result demonstrates the importance of focusing on the
centrofacial rejuvenation by means of fat grafting and skin resurfacing with the
croton oil peel, especially in patients who have had previous lifting procedures
(Fig. 7-13). Most of the aging that occurred 15 years after the lifting procedure
was from deterioration of the skin quality and volum e loss in the central part
of the face. The combination of liplift and volume augmentation by fat grafting
with croton oil resurfacing produces a very natural rejuvenation of the perioral
area. The change in quality of the cheek skin by the croton oil resurfacing is ob-
vious. The quality of the neck has improved considerably by the combination of
SNIF and nanofat grafting. The lateral tightening of the neck skin was performed
by complete subplatysmal undermining from the lateral side without detaching
the skin from the platysma muscle. This is indicated when platysmal bands are
present under very thin neck skin. A stable correction of the platysmal bands is
seen 1 year postoperatively without opening the anterior neck.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Fig. 7-13 Left, Preoperatively at age 63 years. Right, At 1 year postoperatively.

• Centrofacial Rejuvenation: Putting It All Together
Fig. 7-13, cont’d Left, Preoperatively at age 63 years. Right, At 1 year postoperatively.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The wom an in Fig. 7-14 had concerns that she had a tired look at the age of
49 years. She had m oderate laxity in the peripheral areas (neck, jowls, tail of

periorally) with heavy nasolabial grooves.
B
A
Fig. 7-14 A, At age 25 years. B, Preoperatively at age 49 years.

• Centrofacial Rejuvenation: Putting It All Together
Surgical Plan
The surgical treatment involved the following:
• Simple MACS lift
• Short-scar temporal lift
• Augmentation blepharoplasty

– Upper eyelid
Conservative skin resection
Microfat grafting of infrabrow area (1.5 cc bilaterally)

– Lower eyelid
Skin-pinch lower blepharoplasty
Augmentation of malar area (10 cc of microfat per side)
• Microfat grafting, 30 cc, harvested from the abdomen

– Infrabrow: 1.5 cc bilaterally

– Malar: 10 cc bilaterally

– Nasolabial grooves: 1.5 cc, plus 1 cc after subcision

– Marionette grooves: 2 cc bilaterally
• Liplift: 2 mm

The 6-month, 2-year, and 5-year postoperative results are shown (Fig. 7-15). The

total treatment. The centrofacial rejuvenation, consisting of replenishment of the
periorbital and perioral areas, produces a marked change in her facial expression,

the stability of the measures taken for centrofacial rejuvenation.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Fig. 7-15 A, At 25 years. B, Preoperatively at age 49 years. C, At 6 m onths postoperatively. D, At
2 years postoperatively. E, At 5 years postoperatively.
A
C
B
E
D

• Centrofacial Rejuvenation: Putting It All Together
Fig. 7-15, cont’d F, Preoperatively at age 49 years. G, At 6 months postoperatively. H, At 2 years
postoperatively. I, At 5 years postoperatively.
G
F
I
H

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The wom an in Fig. 7-16 complained of facial aging at the age of 48 years after
a 10 kg body weight loss. She had m inim al peripheral sagging and jowling but

a fuller midface and periorbital area.
B
A
Fig. 7-16 A, At age 29 years. B, Preoperatively at age 48 years.

• Centrofacial Rejuvenation: Putting It All Together
Surgical Plan
The surgical treatment involved the following:
• Simple MACS lift
• Short-scar temporal lift
• Augmentation blepharoplasty

– Upper eyelid
Conservative skin resection
Microfat grafting of medial infrabrow area (1.5 cc bilaterally)

– Lower eyelid
Skin-pinch lower blepharoplasty
Augmentation of the malar area (4 cc of microfat per side)
• Microfat grafting, 30 cc, harvested from the abdomen

– Infrabrow: 1.5 cc bilaterally

– Malar: 4 cc bilaterally

– Nasolabial grooves: 2 cc, plus 0.5 cc after subcision

– Marionette grooves: 2 cc bilaterally

The 1-year and 3-year postoperative results are shown (Fig. 7-17). A m anifest
change in the facial expression was mainly obtained by the centrofacial replen-
ishm ent, in contrast to the facelift procedure, which is alm ost an accessory to
the overall rejuvenation procedure.
She has restoration of the youthful fullness of her eyelids. In the upper orbit the

the zone between the upper eyelid margin and the eyebrow. In the lower lid the

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
Fig. 7-17 A, At 29 years. B, Preoperatively at age 48 years. C, At 1 year postoperatively. D, At
2 years postoperatively.
B
A
D
C

• Centrofacial Rejuvenation: Putting It All Together
Fig. 7-17, cont’d Left, Preoperatively at age 48 years. Center, At 1 year postoperatively.
Right, At 2 years postoperatively.
F
E

G
H

I

J

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The woman in Fig. 7-18 presented at the age of 55 years for facial rejuvenation.
She had moderate sagging in the cervicomental region with discrete jowling, loss

m alar area, especially in the anterior part, the nasolabial area, and m arionette
groove. Skin quality changes are visible as spotty pigmentation and general sal-
lowness of the whole facial skin. The upper lip also shows a lengthening of the

columns. The general emotional expression of this face is tiredness and sadness.
Fig. 7-18 A, At age 26 years. B, Preoperatively at age 55 years.
B
A

• Centrofacial Rejuvenation: Putting It All Together
Nonsurgical Plan
The nonsurgical treatment plan consisted of a Retin-A skin care program.
Surgical Plan
The surgical treatment involved the following:
• Simple MACS lift
• Short-scar temporal lift
• Liposuction of the inferior part of the jowls
• Augmentation blepharoplasty

– Upper eyelid
Conservative skin resection
Microfat grafting of medial infrabrow area (1 cc bilaterally)

– Lower eyelid
Augmentation of malar area (6 cc of microfat per side)
Skin-pinch excision
•
from the abdomen

– Malar: 6 cc/side

– Nasolabial groove: 1 cc/side

– Marionette grooves: 2 cc/side

– SNIF, 23-gauge needle:
Small nasolabial rhytids: 2 cc
Barcode (upper lip): 1 cc
Frontal rhytids: 2 cc

– SNIF, 21-gauge needle:
White roll, upper lip: 1 cc
White roll, lower lip: 1 cc
Philtral columns: 0.8 cc
• Liplift (approximately 4 mm)

The 2-year postoperative results are shown (Fig. 7-19). The surgical correction
of the laxity in the peripheral part of the face is of secondary importance com -
pared with the centrofacial rejuvenation by means of the volume correction of


and the temporal lift, resulting in a younger shape of the eyebrow. A reduction
of shadowing in the face is evident, especially in the nasojugal grooves, the na-
solabial folds, and the marionette grooves. The change in the architecture of the
lips is notable, with a reduction of the vertical height of the upper lip and a bet-

similarity with the picture of the patient at the age of 26 years.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
A
B

C
Fig. 7-19 A, At 26 years. B, Preoperatively at 55 years. C, At 2 years postoperatively.

• Centrofacial Rejuvenation: Putting It All Together
D

E
F

G
Fig. 7-19, cont’d Left, Preoperatively at age 55 years. Right, At 2 years postoperatively.

• Fat Grafting: From Volume Restoration to Regenerative Cell Therapy
The woman in Fig. 7-20 presented at 52 years of age for facial rejuvenation. She
had a discrete sagging in the cervicomental region, minimal jowling, and discrete



philtral columns.
B
A
Fig. 7-20 A, At age 24 years. B, Preoperatively at age 52 years.