The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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VIII Surgical Rejuvenation of the Face and Neck
side, and a dog-ear will often be present at the inferiormost
portion of the occipital incision. This should not be arbitrarily
chased down the occipital hairline, as an obvious scar in the
fine hair on the nape of the neck will typically result. A better
result is obtained under these circumstances if the wound length
discrepancy is managed in two ways. First, a significant portion
of the wound length discrepancy can be reduced by suture place-
ment in a manner that ´microgathersµ the longer skin flap side.
That is, the half-buried vertical mattress sutures of 4–0 nylon are
placed 10 mm apart on the scalp side but 12 to 14 mm apart on
the skin flap side (Fig. 49.58). :ith each such suture placement
the wound length discrepancy is incrementally reduced. In most
cases, if this manner of suture placement is continued as one
proceeds inferiorly, by the time the inferiormost part of the inci-
sion is reached the majority of the wound length discrepancy has
been addressed and is no longer present, and typically what was
once a large dog-ear has been markedly reduced or eliminated.
The second maneuver used to address wound length discrep-
ancy along the occipital incision and the residual dog-ear still
present after microgathering of the majority of the discrepancy
on the skin flap side of the closure by the suture technique just
described is to inset the remaining dog ear posteriorly into the
occipital scalp, above the junction of thick and fine hair. This
typically requires a small extension of the incision inferiorly and
that a small ellipse of scalp then be excised from the scalp side
of the incision. This maneuver simultaneously lengthens the still-
slightly-shorter scalp side of the incision (a curve is longer than a
straight line), creates a cutout into which the dog ear can be inset,
and moves the end of the incision into dense hair where it is well
concealed (Fig. 49.59).
Trimming and Closure of the Temporal Incision
Once closure of the postauricular area has been completed,
attention is typically turned next to the temple area. If the
temporal portion of the facelift incision has been made in the
temporal scalp (see Fig. 49.9; typically patients under 45 years
old), the incision is closed in one layer, without excision of any
hair-bearing temporal tissue, with multiple simple interrupted
sutures of 4–0 nylon. A small amount of cheek skin and scalp only
will be excised, immediately above the ear at the completion of
the closure. It is clinically unproductive, a conceptual error, and
a serious technical mistake to excise scalp over the temple region
in attempt to improve the forehead, upper lateral face, or “crow’s
feet” area. 1o deep sutures are necessary or are used. In fact, if
skin is overtrimmed along this part of the incision, a wide scar
will result regardless of whether deep sutures are placed.
In most cases a modest wound length discrepancy will be
present, with the flap edge side longer than the scalp edge side,
and this can be managed by the ´microgatheringµ technique dis-
cussed previously for management of wound length discrepancy
along the occipital hairline incision: simple interrupted sutures
of 4–0 nylon are placed 10 mm apart on the scalp side but 12 to
14 mm apart on the flap side. :ith each such suture placement
the wound length discrepancy is incrementally reduced. In most
cases, if this manner of suture placement is continued as one pro-
ceeds superiorly, by the time the superiormost part of the incision
is reached, the majority of the wound length discrepancy has
been addressed and is no longer present. If not, the incision can
be extended superiorly slightly to allow a well-aligned closure.
Because the incision on the temporal scalp will be beveled when
properly made, sutures, and not staples, are generally required
to obtain a well-aligned wound and avoid malalignment and
stepoffs, which can be troublesome for patients.
If open forehead plasty is to be performed as part of the pro-
cedure, closure of the temporal portion of the facelift incision, if
made in this location, is delayed until after the forehead plasty
is complete. This preserves access to the upper lateral face and
affords precise realignment of tissue in this area.
If the temporal portion of the facelift incision has been made
along the temporal hairline (typically patients over 45 years old;
see Fig. 49.10), skin will be trimmed only when the incision is
closed. A facelift marker (see Fig. 49.54) should be used to gauge
temporal and subsideburn skin excess and the flap intentionally
trimmed with 2 to 3 mm of redundancy. If trimming is performed
correctly, wound edges should abut one another, and no gaps
should be present, before sutures are placed. The incision is then
closed in one layer with a combination of half-buried vertical
mattress sutures of 4–0 nylon with the knots on the scalp side and
simple interrupted sutures of 6–0 nylon. This plan will provide
precise wound edge alignment and will prevent cross-hatched
scars (suture marks).
1o deep sutures are necessary or used. In fact, if skin is over-
trimmed along this part of the incision from the skin flap, a wide
scar will result regardless of whether deep sutures are placed.
Staples should not be used either, because this incision, if properly
made, will be beveled, and attempts to staple a beveled incision
closed will typically result in wound edge malalignment and
stepoffs that can be unaesthetic and troublesome for the patient.
Fig. 49.58 “Microgathering” of skin to reduce wound length
discrepancy along occipital incision. When the postauricular skin flap
is advanced along an optimal posterosuperior vector roughly parallel
to the mandibular border, a wound length discrepancy will typically
occur, with a longer incision on the skin flap side and a shorter incision
of the scalp side. This can be reduced by “micro-gathering” of the skin
on the flap side. This is accomplished by placing half-buried vertical
mattress sutures of 4–0 nylon with the knots tied on the scalp side 10
mm apart from each other on the scalp side and 12 to 14 mm apart
on the skin flap side. Each suture placement reduces wound length
discrepancy and the amount of dog-ear present at the inferiormost
part of the incision. (Copyright © Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
675
Trimming and Closure of
the Preauricular Incision
Preauricular skin flap trimming and closure should be performed
next. Skin flap redundancy should be gauged using a facelift
marker (see Fig. 49.54) while the pretragal portion of the skin flap
is held down into the pretragal hollow with an instrument by the
assistant (Fig. 49.60a). This ensures that enough skin will be pres-
ent to fill the pretragal sulcus and to provide a natural transition
from the cheek to the ear once healing is complete. This is also
is a key step in avoiding ´retracted tragusµ and ´buried tragusµ
irregularities.
Using marks made with the facelift marker as points of refer-
ence, the prehelical portion of the cheek skin flap is trimmed first
with 2 to 3 mm of redundancy to form a soft curve that matches
the prehelical incision. If trimming is performed correctly, wound
edges should abut one another and no gaps should be present
before sutures are placed (Fig. 49.60b). In most cases the cheek
skin flap will be thicker than the fine skin along the anterior helix,
and approximating the thick cheek flap to the delicate skin of the
ear will obscure the natural prehelical sulcus and result in an
unnatural appearance. For this reason the edge of the cheek flap
should be defatted using a .aye scissors or similar instrument to
match the fine skin on the helix. The incision is then closed in one
layer with multiple simple interrupted sutures of 6–0 nylon. 1o
deep sutures are necessary or used. As elsewhere, if skin is over-
trimmed from this part of the skin flap, a wide or hypertrophic
scar will result regardless of whether deep sutures are placed.
The prelobular (subtragal) portion of the cheek skin flap is
trimmed next, guided by the marks made with the facelift marker.
If trimming is performed correctly, 2 to 3 mm of redundancy
should be present, wound edges will abut one another, and no gaps
should be present before sutures are placed. In all but the unusual
case, the cheek skin flap will be much thicker than the fine skin
along the anterior lobule and approximating a thick cheek flap to
the delicate skin of the earlobe will obscure the natural contours
in that area and result in an unnatural appearance. For this reason
the edge of the cheek flap to be approximated to the anterior
border of the lobule should be defatted using a .aye scissors or
similar instrument. The incision is then closed in one layer with
several simple interrupted sutures of 6–0 nylon. As elsewhere, no
deep sutures are necessary or used; if skin is overtrimmed along
this part of the incision, a wide or hypertrophic scar will result
regardless of whether deep sutures are placed.
Once the prehelical and prelobular areas have been closed, the
stage is set to trim the tragus. This must be performed with great
care while the assistant holds the pretragal portion of the skin
flap into the pretragal hollow (Fig. 49.60c). As elsewhere in the
preauricular closure, the tragal flap should be trimmed with 2 to 3
mm of redundancy, and the margin of the posterior border of the
tragal skin flap should be defatted using a .aye scissors or similar
instrument to match the fine skin present along the margin of the
tragus. Closure is then made with simple interrupted sutures of
6–0 nylon. The tragal flap itself should not be thinned or defatted,
and no deep sutures are necessary. Trimming the tragal skin flap
too short is a serious artistic error that will result in tragal retrac-
tion and an unnatural ´chopped-off,µ ´buried,µ or ´retractedµ
tragal appearance (see Fig. 49.18).
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Before insetting the lobule into the cheek flap the surgeon
should consider its shape and size and the transition it made to
the cheek preoperatively to see whether it can be made more
youthful and natural appearing. Often the earlobe will be seen
to be suboptimally shaped, too large, or abnormally attached
to the cheek. In these situations an improved and more natural
appearance can be obtained by reconfiguring the earlobe before
insetting it into the cheek flap (Fig. 49.61).
Earlobe reconfiguration is begun by marking the redundant
portion on both the outer and inner sides of the lobule. Often the
existing pierced ear hole can be used as a radius about which the
line can be drawn (red dotted line in Fig. 49.61b). Once marked,
the lobule is hyperinflated with local anesthetic solution. This
makes incising the skin along the marked lines and resecting the
Fig. 49.59 (a) Insetting the postauricular dog-ear at the inferior
aspect of the occipital incision. A wound length discrepancy is typically
present at the inferiormost aspect of the occipital portion of the
postauricular incision, resulting in a dog-ear at its inferior aspect on
the skin flap side. When a dog-ear does form, as shown, the redundant
tissue is best managed by insetting it into the occipital scalp (green
line). Trimming the dog-ear off in a traditional fashion (red line) will not
fully accommodate the wound length discrepancy present and will
move the scar into a more visible location in the fine hair on the nape
of the neck. (b) Lengthening the scalp side and creating an inset for
the dog-ear by excision of an ellipse of tissue from the scalp side. The
incision has been extended inferiorly a short distance parallel to the
hair follicles, and an ellipse of scalp tissue (in forceps) is excised from
the scalp flap side of the incision, into which the dog-ear will be inset
(note that the dog-ear itself on the neck side is only minimally trimmed
or not trimmed at all). This creates a curved, geometrically longer
(longer distance between two points) curved surface into which the
dog-ear will be fitted on the scalp side. (c) Ellipse of scalp excised and
dog-ear inset. The ellipse of tissue has been excised from the scalp side
of the incision and removed, and the wound length discrepancy has
as a result been eliminated. The dog-ear itself has been undermined
and released, but not trimmed (or trimmed only a small amount) and
has not been sutured. (d) Completed insetting of the dog-ear into the
inferior aspect of the occipital hairline incision. After suturing, it can
be seen that the dog-ear has been eliminated by insetting it into the
cutout made on the opposite, scalp side, and the inferiormost part of
the incision has been moved into thicker hair on the scalp, where it is
less visible than if it had been excised in a traditional fashion (red line in
a). (Copyright © Timothy Marten.)

676
VIII Surgical Rejuvenation of the Face and Neck
redundant tissue easier and reduces oozing from the cut edges. If
the earlobe is floppy and lacking in turgor, skin only can be excised
and the fat spared pushed into the lobule upon wound closure.
Closure is then made meticulously with a simple running suture
of 6–0 polypropylene (Prolene, Ethicon, Somerville, 1-) or other
suture of choice. Care should be taken to ensure that the closure
is not overly tight and that the wound edge is well approximated
and not scalloped. Once reconfigured, the lobule can then be inset
into the cheek as described subsequently.
A variation of earlobe reconfiguration is earlobe reduction, in
which the lobule is simply not reshaped but actually reduced in size.
In such cases a longer incision is made and a larger piece of tissue
is removed as appropriate for the situation and in keeping with the
characteristics of the rest of the ear. :hen the earlobe is reduced,
often existing pierced ear holes are sacrificed or need to be punched
out with a biopsy punch and closed to avoid having them too close to
the margin of the reconstructed lobule. Reducing the earlobe when
it is overly large creates a more youthful and natural look, reduces
a ´grandfatherlyµ or ´grandmotherlyµ appearance, and helps avert a
telltale ´young face–old earµ appearance (Fig. 49.62). Once reduced,
the lobule can then be inset into the cheek as described as follows.
Insetting the Lobule
There is nothing as telltale and aesthetically objectionable as
abnormal position of the earlobe following facelift surgery, and
Fig. 49.60 (a) Preserving a pretragal sulcus and avoiding the “buried tragus” and “retracted tragus” deformities. The cheek skin flap should be
held down into the pretragal sulcus by the assistant while the cheek skin flap is marked and subsequently trimmed by the surgeon if a natural and
aesthetic appearance is to be obtained. Note that a facelift marker is being used to mark the location of the superior aspect of the tragus and to
define and mark the amount of skin to be excised from the skin flap along the anterior border of the helix. (b) Trimming the prehelical skin flap. The
prehelical part of the preauricular incision has been trimmed. Note that the skin edges abut one another before any sutures are placed. (c) Trimming
the tragal skin flap. The prehelical and prelobular portions of the skin flap have been trimmed and sutured. Note that the surgical assistant holds skin
in the pretragal sulcus while the skin along the (retro) tragal part of the preauricular incision is trimmed by the surgeon. (d) Completed trimming of
the tragal skin flap. Note that following trimming of the tragal skin flap, the skin edges abut one another before any sutures are placed and that a
distinct depression is present in the pretragal sulcus. (e) Completed closure of the preauricular incision. Note that, following trimming and closure
of the component parts of the pretragal incision along the preauricular skin flap, a tension-free approximation of tissue has been made, natural
contours are present, incisions are situated along natural anatomic interfaces, and a distinct depression is present in the pretragal sulcus. (Copyright
© Timothy Marten.)
Fig. 49.61 Earlobe reconfiguration. The earlobe can be reconfigured
when unaesthetically and unnaturally shaped to provide a more
youthful and natural, rounded overall shape and to create a more
natural-appearing transition between the lobule and the cheek, even if
it was more inferiorly situated and square before surgery. (a) A patient
who has undergone a previous facelift. The earlobe is unnaturally square
in shape, is joined unaesthetically with the cheek, and appears heavy
and masculine. Note that the tragus has an unnatural “chopped-off”
appearance as well. (Procedure performed by an unknown surgeon.)
(b) The red dotted line shows the portion of the lobule that is excised to
obtain a more natural shape. The wound is then closed with a simple
running suture of 6–0 Prolene, and the resulting scar will be situated
on the lobule margin. (c) Same patient after secondary facelift that
included earlobe reconfiguration. The earlobe is smaller; has a more nat-
ural, rounded, feminine shape; and no longer has a telltale “attached”
appearance. The natural cleft between the lobule and the cheek has also
been reestablished, and the perilobular scar no longer sits in a visible
location and is tucked up into a location where it cannot be seen. The
“chopped-off” tragus has also been corrected. (Procedure performed
by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
677
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last step in the closure of the periauricular area. Cutting into and
trimming the cheek flap to inset the lobule must be performed
with great care and artistic sensitivity and should always be
performed incrementally in stages to prevent inadvertent over-
excision of cheek skin, which will result in an abnormal position
and configuration of the earlobe. If the surgeon overexcises skin
when insetting the earlobe, it will inevitably migrate inferiorly
into an unaesthetic position regardless of whether deep sutures
are placed, whether the earlobe is anchored to auricular carti-
lage, or whether other such attempts are made to suspend it.
The cheek flap should be trimmed and the earlobe inset in
such a manner that the lobule ends up situated in a posterior and
somewhat superior position, even it if was naturally in a more
anterior or inferior position and was square in shape before sur-
gery. This is because the long axis of the earlobe of an artistically
ideal, ´nonsurgicalµ-appearing ear ideally sits approximately 15
degrees posterior to the long axis of the ear itself in the lateral
view (Fig. 49.63). As this angle is reduced or shifted anteriorly,
or if the lobule is mistakenly placed too far inferiorly, an old,
unnatural ´facelift lookµ is produced (Fig. 49.64). Moreover, the
lobular–facial junction should sit in a concealed, elevated position
and not in a lower, more visible location (Fig. 49.65).
Insetting the lobule into the cheek so that its long axis sits pos-
terior to the long axis of the rest of the ear typically requires that
the lobule be released from tethering tissue, and this is typically
performed using electrocautery. It is then secured in two layers.
The first layer consists of several deep dermal sutures of 5–0
poliglecaprone 25 (Monocryl; Ethicon, Somerville, 1-) or similar
suture. These sutures provide initial alignment and protect the
incision from disruption during the first few weeks after surgery if
patients inadvertently pull clothing, jewelry, or other items off over
their heads and catch their earlobe while doing so. Final approxi-
mation is then made with simple interrupted sutures of 6–0 nylon.
If the lobule has been inset into the cheek flap correctly with
its long axis pushed slightly posterior to the long axis of the ear,
a wound length discrepancy and skin redundancy will often be
present on the posterior surface of the ear at the lobular–conchal
junction. This is easily and conveniently managed and a couture
fit obtained by conservatively excising a triangle of skin (´Ristow’s
triangleµ) corresponding to the tissue redundancy in this area.
Closure is made in one layer with several simple interrupted
sutures of 4–0 nylon or other suture of choice (Fig. 49.66). Care
must be taken to avoid any tension or scar thickening, and hyper-
trophy may occur. If wound length discrepancy is not addressed
in this or in some other manner and the wound edges are simply
gathered during closure in this area, small pockets and crypts
will typically result that can accumulate desquamated debris and
sebaceous secretions, which can be problematic for the patient.
Fig. 49.63 Correct insetting of the lobule. The long axis of the earlobe
(red line) of an artistically ideal, “nonsurgical”-appearing ear ideally sits
approximately 15ƒ posterior to the long axis of the ear itself (black line)
in the lateral view. (Procedure performed by Timothy Marten, MD,
FACS. Copyright © Timothy Marten.)
Fig. 49.64 Incorrect insetting of the lobule. If the earlobe is inset into
the cheek so that the long axis of the earlobe (red line) sits anterior to
the long axis of the ear (black line) in the lateral view, the ear will have
an unnatural, “facelifted” appearance. (Procedure performed by an
unknown surgeon. Copyright © Timothy Marten.)
Fig. 49.62 Earlobe reduction. Reducing the earlobe when it is overly
large creates a more youthful and natural look and helps avert a telltale
“young face–old ear” appearance. (a) A patient seen preoperatively
with a large, “grandfatherly” earlobe. (b) Same patient after facelift
and related procedures that included earlobe reduction. The earlobe
is smaller and has a more youthful and natural appearance. (Procedure
performed by Timothy Marten, MD, FACS. Copyright © Timothy
Marten.)
a
b

678
VIII Surgical Rejuvenation of the Face and Neck
Closure of the Submental Incision
If a submental incision has been made as part of the facelift pro-
cedure, it is typically left open but covered with a moist sponge
until all other incisions have been closed and other procedures
have been performed to allow for a final inspection of the neck
area before leaving the OR. :hile ostensibly straightforward,
closing this incision must be done meticulously and with care if
an inconspicuous scar is to be obtained. Even a small irregularity
in this area can become a significant concern to the patient and
spoil an otherwise excellent result.
The submental incision is closed in two layers to ensure precise
approximation of subcutaneous fat and skin and to prevent a
depressed scar. Typically, the inferior wound edge has been sub-
ject to trauma from retractors, and often there is a discrepancy in
the amount of subcutaneous fat present on the two sides, with the
chin side thicker and the submental side thinner. This discrepancy
must be addressed and wound edges matched in thickness before
closure is begun. The first layer of closure is accomplished using
several deep dermal sutures of 5–0 Monocryl (or similar suture).
Final approximation is made with simple interrupted sutures of
6–0 nylon.
49.6.15 Completion of Concurrently
Planned Procedures
Upon completion of the face, neck, and forehead lift portions of
the procedure, attention is turned to upper blepharoplasty, lower
blepharoplasty, upper lip lift, and other planned procedures, as
indicated. Perioral resurfacing and buccal fat reduction, if indi-
cated, are typically performed last.
49.6.16 Dressings
After all planned procedures have been completed and all inci-
sions have been closed, the patient’s hair is washed with sham-
poo and rinsed with warm water. A final inspection of sutured
incisions is then made. If poor alignment is found in any area, it
is locally reprepped, and sutures are removed and replaced as
required.
Once the patient’s hair has been shampooed and rinsed,
conditioner is applied and the hair carefully detangled with a
wide-toothed comb. Failure to wash, condition, and detangle the
patient’s hair adequately after completion of the procedure can
result in matting and tangling that can be problematic in the post-
operative period. Once conditioned and detangled, the patient’s
hair is typically placed in a loose braid (if long).
No dressing is required or applied, as the use of closed suction
drains has supplanted their use. The traditional facelift dressing
of mineral oil–soaked cotton and rolled gauze is unnecessary if
closed suction drains are used, and a strong argument can be
made that a facelift dressing is actually counterproductive and
Fig. 49.66 Accommodating wound length discrepancy when insetting
the lobule. If the lobule has been inset correctly, a wound length
discrepancy and skin redundancy will typically be present on the
posterior surface of the ear at the lobular-conchal junction. This is
managed by excising a triangle of skin (black dotted lines) correspond-
ing to the tissue excess in this area. Closure is made in one layer with
several simple interrupted sutures of 4–0 nylon or other suture of
choice (see also Fig. 49.57); red dotted line shows location of typical
postauricular incision plan. (Courtesy of Timothy Marten, MD, FACS.
Copyright © Timothy Marten.)
Fig. 49.65 Concealing the perilobular scar. The cheek flap should be
trimmed and the earlobe inset in such a manner that the lobule ends
up situated in a superior position with a rounded overall shape and a
modest cleft between the lobule and the cheek, even it if was more
inferiorly situated and square in shape before surgery. (a) The perilob-
ular scar is tucked up in a concealed location and is not visible, and a
cleft is present between the lobule and cheek. (Procedure performed
by Timothy Marten, MD, FACS.) (b) The perilobular scar has been made
too low, and the natural cleft between the lobule and the cheek has
been obliterated. The scar sits in a visible location, and the lobule has
a telltale “attached” and square and unnatural shape. (Procedure
performed by an unknown surgeon. Courtesy of Timothy Marten, MD,
FACS. Copyright © Timothy Marten.)
a
b

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
679
of potential harm to the patient. This is because these dressings
place unnecessary and potentially dangerous pressure on thin
flaps of cervicofacial tissue and can compromise already tenuous
circulation in them. In addition, they preclude inspection and
monitoring of tissue perfusion in the operative site and can dis-
guise and delay the diagnosis of serious problems such as hema-
toma, flap ischemia, and pressure necrosis. Most patients also
find the traditional facelift dressings cumbersome, confining, and
claustrophobic, and their family members are often frightened by
them.
Patients are typically discharged with a hat, scarf, and sun-
glasses. If perioral resurfacing or lip augmentation has been
performed, a rigid, disposable surgical mask (´cone maskµ) that
rests off of the perioral area is also provided to patients to use
to conceal and protect that area during the healing period when
away from their homes.
49.7 Postoperative Care
Performance of the procedure itself fulfills only part of our
obligation to the patient, and the care that patients receive
postoperatively is arguably as important as the surgery itself.
Diligent postoperative care will also ensure the best result and
limit the likelihood that problems and complications will occur.
All patients are discharged to an aftercare specialist with
specific written instructions as to the care they are to receive.
:e are always available to answer questions and see any patient
if needed. Patients are asked to rest quietly and apply cool (but
not icy cold or ice) compresses to their eyes and face for 15 to 20
minutes of every hour they are awake for the first 3 days after
surgery, even if they have not had eyelid surgery as part of the
procedure. For most patients, edema peaks at about this time. It
is not necessary or productive to apply cool compresses contin-
ually throughout the day, or at night. If the patient has had fat
grafting to the lips, cool compresses are applied to the perioral
area in a similar manner and on a similar schedule. If perioral or
lower eyelid resurfacing has been performed, these areas can be
covered with plastic wrap (´Saran :rapµ) before cool compresses
are applied.
Compresses should be cool but not ice cold. Ice, ´ice packs,µ
´blue ice,µ and ice in plastic bags and the like should never be
applied directly to the face, as this can frostbite facial skin and
damage fat grafts. For some time, most of our patients have used
a facial cooling mask and cool water system (AqueCool Masque,
Aqueduct Medical, San Francisco, CA) that provides dry, thermo-
statically controlled, consistent cooling. This system is convenient
and comfortable for the patient and can be used by many patients
even when they sleep.
All patients are provided oral analgesics, sleeping pills, anti-
emetics, and preservative-free ophthalmic ointment and ´artifi-
cial tearsµ solution, in addition to specific instructions for their
use. Patients are required to use preservative-free ophthalmic
ointment each night for the first 3 weeks after surgery or until
all signs of eye irritation have abated. Preservative-free artificial
tears are used throughout the day as needed. Patients should be
reminded that eye drops are not sufficient for nocturnal use.
Contrary to tradition, patients are instructed to sleep flat
on their backs without a pillow. A small cylindrical neck roll is
permitted if the patient requests it. This posture ensures an open
cervicomental angle and averts dangerous neck flexion, folding
of the neck skin flap, and obstruction of regional lymphatics that
inevitably occurs if the patient is allowed to “elevate the head on
a pillowµ as is commonly recommended. In addition, swelling
will drain to the back of the head instead of the jowl/jawline and
anterior neck when the patient lies flat in this position, where it
is not harmful, is less noticeable and is more rapidly transmitted
away from the head and neck area when the patient sits upright.
Patients are shown an ´elbows on knees at the coffee tableµ
position, which ensures an open cervicomental angle while sit-
ting. This posture places the patient’s book, magazine, paperwork,
notebook computer, or meal in a position that allows reading,
writing, eating, and TV watching to be performed comfortably and
safely with the patient’s chin up and cervicomental angle open.
All patients should be examined the morning after surgery if
possible. This visit is important if incipient problems are to be
identified early in a treatable stage. All sutures should be checked,
and any appearing too tight should be cut but left in place.
Releasing potentially overtight sutures prevents skin necrosis,
alopecia, and suture marks. Leaving the cut suture in place, rather
than removing it, averts annoying bleeding from the suture site
that inevitably occurs if the suture is completely removed at that
time.
All flaps are carefully inspected as well. Whenever incipient
compromise is noted, one must be suspicious that a tight closure
has resulted in excessive tension over that area. If compromise is
suspected, offending sutures should be removed, even if wound
separation may result. Secondary healing of the separated incision
is always superior to and easier to revise than a large area of more
anteriorly situated full-thickness skin necrosis.
Patients are advised to take a soft, wet, easy-to-chew diet as tol-
erated after surgery and are encouraged to avoid dry, salty, sour,
and difficult-to-chew foods, with a primary focus on maintaining
hydration over eating (´salivary rest dietµ). Patients are asked
to abstain from the intake of alcohol for 2 weeks after surgery
and until they are no longer taking pain pills (acetaminophen
included) or sleeping medication.
Patients begin a daily routine of showering and shampooing no
later than 3 days after their procedures, but they may shower the
day after their surgery if they wish (´name tagµ–type lanyards are
provided to patients to attach their drain reservoirs to). This helps
remove crusting about the suture lines, keeps incisions clean
and bacteria counts down, and usually improves the patient’s
general overall well-being. It also facilitates suture removal at
the patient’s follow-up visits. Patients are instructed that they
need not be as thorough as usual when washing their hair after
their procedure and that they need not attempt to remove all
dried blood and crusts. They are also assured that shower water,
shampoo, and conditioners are not harmful and will not cause
infection. Showering and shampooing are permitted even when
drains are in place.
Drains are usually left in place until the first suture removal
visit. This is because drain output often quickly falls on the first or
second day during the time the patient is mostly supine and resting

680
VIII Surgical Rejuvenation of the Face and Neck
but then picks up again when the patient begins to spend more
time upright and starts to move the head about more. Leaving the
neck drain in longer, for 4 to 5 days, will reduce the likelihood that
small collections will form and will speed the overall resolution
of edema, ecchymosis, and induration in the neck area. This is
especially the case if deep-layer neck lift maneuvers have been
performed, such as subplatysmal fat excision and submandibular
gland reduction.
Sutures are removed in two visits over a period of 7 days. 6–0
nylon sutures are removed on the first visit, 4 to 5 days after
surgery. Half-buried vertical mattress sutures and scalp sutures of
4–0 nylon are removed on the second visit, 7 days after the proce-
dure. It is usually not productive to try to remove sutures hidden
under dried blood or crusts along suture lines if present. These
are usually removed at a third visit, approximately 2 weeks after
surgery, at which time crusts are gone and remaining sutures can
be readily identified.
Patients should be warned that their scalp and parts of their
face may be partially numb after surgery and that they must be
careful when bathing that shower water is not too hot and that
hair dryers are not used on high heat settings. Patients are also
instructed not to ´perm,µ tint, dye, highlight, color, or otherwise
chemically treat their hair for 2 weeks after surgery, as these
treatments can result in hair breakage or hair loss. ´Hot curlersµ
and ´curling ironsµ must be used with care for several months, as
patients can unknowingly burn their foreheads and scalps using
them.
:hen patients return to work and to their social lives will
depend upon their tolerance for surgery, their capacity for healing,
the type of work they do, the activities they enjoy, and how they
feel overall about their appearance. Patients are asked to set aside
2 to 3 weeks, to recover from surgery, and additional time off is
recommended before an important business presentation, family
gathering, vacation, or like event. If the patient is doing well and
not experiencing problems, she or he is allowed to return to light
office work and casual social activity 9 to 10 days after surgery. It
is often wise that they begin with a limited workday at first and
to adjust their schedules thereafter. If a patient’s job entails more
strenuous activity or physical labor, a longer period of convales-
cence may be required. Patients are advised not to drive for the
first 10 days after surgery and until they are feeling well, their
vision is clear, and they are off pain medications.
Patients are advised to avoid all strenuous activity during
the first 2 weeks after surgery including heavy lifting, stooping,
straining, and bending forward, and they are informed that aero-
bic activities and exercise during this time can precipitate bleed-
ing and hematoma formation. Two weeks after surgery, patients
are allowed to begin light exercise and gradually work up to their
presurgical level of activity. Four to six weeks after surgery they
are allowed to engage in more vigorous activities, including most
sports, as tolerated.
Patients are informed that will often take 2 to 3 months to look
good in a photograph or to be seen at an important function or
event. They are also advised to expect some firmness in the face
and submental areas for 6 to 9 months and that numbness will
typically be present in some areas for 12 to 18 months. If patients
have had fat injections as part of their procedures, additional
recovery time may sometimes be required before patients feel
presentable.
49.8 Case Studies
49.8.1 Case 1
This 42-year-old woman is shown before (on the left in each
view) and 13 months after surgery (on the right in each view)
in Fig. 49.67. She had had no prior plastic surgery. On the
preoperative views, note suboptimal eyebrow position and
configuration, sagging cheeks and jowls, and atrophy in the
cheeks and infraorbital area. She has a sad and melancholic
appearance even when she is smiling. She appears tired and
unfit even though she is trim and in excellent overall health.
1eck laxity and poor neckline suggest an older and unfit
appearance.
She underwent a facelift, neck lift, limited incision forehead
lift, conservative upper and lower blepharoplasties, fat transfer,
and upper lip lift. 1o skin resurfacing, facial implants, or other
ancillary procedures were performed, but after this surgery she
had her teeth whitened and straightened. A nevis on the neck was
also removed.
On the postoperative views, note the soft, natural facial con-
tours and the absence of a tight, pulled, or facelifted appearance.
Improved eyebrow position provides a more feminine and alert
appearance. The cheeks and jawline have been repositioned and
redundant skin removed. Atrophy in the upper cheek and infra-
orbital areas has been corrected by lifting sagging cheek tissue to
a youthful position and by fat transfer. 1ote restoration of cheek
fullness, improved transition from lower lid to cheek, elevation
of corners of mouth, smooth jawline, and improved neck. The lip
lift has shortened the distance from the base of the nose to the
upper lip border and improved the appearance of her mouth. Note
also that that her scars are well concealed, no distortion of the ear
is present, and the earlobe is in normal position. She appears fit,
decisive, and more attractive.
49.8.2 Case 2
This 65-year-old woman is shown before (on the left in each
view) and 13 months after surgery (on the right in each view) in
Fig. 49.68. The patient had had previous upper and lower eyelifts
performed by an unknown surgeon. On the preoperative views,
note her high forehead, asymmetric eyebrows, frown lines,
cheek and jawline laxity, neck bands, labiomandibular groove,
and atrophy of the lips, cheek, and infraorbital areas. Despite a
bright smile she has a tired and melancholic appearance. 1ote
also that the patient has a large submandibular salivary gland,
evident as a fullness in the upper neck area.
The patient underwent a facelift, neck lift, hairline lowering
forehead lift, upper and lower eyelifts, dermabrasion of lip lines,
and fat transfer to the cheeks and lips. 1o skin resurfacing, facial
implants, or other ancillary procedures were performed.
On the postoperative views, note the soft, natural facial con-
tours and the absence of a tight, pulled, or facelifted appearance.
Eyebrow asymmetry has been improved and the hairline lowered.

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
681
The cheeks and jawline have been lifted and redundant skin
removed. Atrophy in the upper cheek and infraorbital areas has
been offset by fat transfer to create a more youthful appearance.
An improved neckline can also be seen even in the frontal view.
Her lips are fuller, no scars are visible, no distortion of the ear
is present, and the earlobe is in normal position. The enlarged
salivary gland has been reduced in size to obtain optimal neck
contour.
49.8.3 Case 3
This 37-year-old woman is shown before (on the left in each
view) and 1 year and 3 months after surgery (on the right in
each view) in Fig. 49.69. She had had prior upper blepharoplasty,
rhinoplasty, chin implant, and neck liposuction performed by
unknown surgeons. On the preoperative views, note cheek sag-
ging and jawline laxity. 1ote also upper eyelid hollowness result-
ing from her previous blepharoplasty procedure. She shows a sad
appearance, even when she is smiling. 1ote also neck fullness
and poor neck line, despite prior submental liposuction.
The patient underwent an early maintenance facelift, neck
lift, temple lift, lower blepharoplasty, and fat injections. She
also had cosmetic eyebrow, eye line, and lip tattooing. 1o skin
resurfacing, facial implants, or other ancillary procedures were
performed.
On the postoperative views, the patient has soft, natural
facial contours and does not have a tight, pulled, or facelifted
appearance. 1ote improved eyebrow position and configuration,
improved cheek fullness, improved jawline, and overall more
alert, fresher, and more feminine appearance. Fat injections
have reduced hollowing in the upper and lower eyelid areas,
filled the tear trough areas, blended the chin and jawline, and
subtly augmented the lips. There is no distortion or change in
appearance of her smile. The patient appears more rested and
engaged. Her face has a fresher, fitter, more athletic, and more
feminine appearance. 1ote also restoration of cheek fullness,
improved transition from lower eyelid to cheek, elevation of
corners of mouth, smooth jawline, and improved neck. 1o scars
are visible, no distortion of the ear is present, and the earlobe is
in normal position.
Fig. 49.67 Case 1: a woman aged 42 years at time of treatment, who had had no prior plastic surgery. (a) Anteroposterior (AP) view. (Left) Before
surgery. Note suboptimal eyebrow position and configuration, cheek and jawline laxity, and atrophy in the cheeks and infraorbital area. (Right)
Same patient, 13 months after facelift, neck lift, limited incision forehead lift, conservative upper and lower eyelifts, fat transfer, and upper lip lift.
No skin resurfacing, facial implants, or other ancillary procedures were performed. Note soft, natural facial contours and the absence of a tight,
pulled, or facelifted appearance. Note also improved eyebrow position, providing a more feminine and alert appearance. The cheeks and jawline
have been repositioned and redundant skin removed. Atrophy in the upper cheek and infraorbital areas has been corrected by lifting sagging cheek
tissue to a youthful position and by fat transfer. (b) AP smiling view. (Left) Before surgery. Note that she has a sad and melancholic appearance even
when she is smiling. (Right) Same patient, 13 months after surgery. Note that the patient had her teeth whitened and straightened after the surgery
was performed. (c) Oblique view. (Left) Before surgery. (Right) Same patient, 13 months after surgery. A nevis on the neck was also removed. Note
improved position and configuration of the eyebrow, restoration of cheek fullness, improved transition from lower lid to cheek, elevation of corners
of mouth, smooth jawline, and improved neck. The lip lift has shortened the distance from the base of the nose to the upper lip border and improved
the appearance of her mouth. (d) Lateral view. (Left) Before surgery. Note that the patient appears tired and unfit even though she is trim and in
excellent overall health. (Right) Same patient, 13 months after surgery. Note that her scars are well concealed, no distortion of the ear is present,
and the earlobe is in normal position. She appears fit, decisive, and more attractive. (e) Lateral flexed view. (Left) Before surgery. Note neck laxity
and poor neckline, suggesting an older and unfit appearance. (Right) Same patient, 13 months after surgery. (All surgical procedures performed by
Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

682
VIII Surgical Rejuvenation of the Face and Neck
49.8.4 Case 4
This 55-year-old Hispanic woman is shown before (on the left in
each view) and 1 year and 6 months after surgery (on the right
in each view) in Fig. 49.70. She had had no prior plastic surgery.
On the preoperative views, note the sagging cheeks, heavy jowls,
protruding lower eyelid fat, nasolabial lines, hollow under-eye
areas, and thin lips. Also note the tear trough, labiomandibular
groove, and weak chin. The patient has a stern and disapproving
appearance. To accentuate this, Fig. 49.70b presents a frowning
view, in contrast to the smiling views given for the previous
cases; it shows her strong frown muscles that produce deep
creases and an intense angry look.
The patient underwent a facelift, neck lift, limited incision fore-
head lift, upper and lower blepharoplasties, chin augmentation,
and fat transfer to the lips and cheeks. 1o skin resurfacing or other
ancillary procedures were performed.
On the postoperative views, note smooth facial contours,
more youthful facial shape, and absence of a pulled or a
facelifted appearance. The lower eyelid fullness has been
reduced, and a smooth transition is present between the lower
eyelid and cheek. 1ote also that her lips and cheeks are fuller
as a result of the fat injections. She is no longer able to frown
as severely because of muscle modification performed as part
of the forehead lift procedure. The chin implant has produced
a more attractive and balanced profile. 1o scars are visible, no
distortion of the ear is present, and the earlobe is in normal
position.
49.8.5 Case 5
This 68-year-old man is shown before (on the left in each view)
and 1 year and 9 months after surgery (on the right in each view)
in Fig. 49.71. On the preoperative views, the patient has degraded
eyebrow position and configuration; full, hooded upper eyelids;
sagging cheeks; deep cheek folds; and jowls. Loss of youthful
facial contour can be seen in the cheek and jowl areas. A protrud-
ing submandibular salivary gland can also be seen in the neck
Fig. 49.68 Case 2: a woman, aged 65 years at time of treatment, who had had previous upper and lower eyelifts performed by an unknown surgeon.
(a) Anteroposterior (AP) view. (Left) Before-surgery. Note high forehead, asymmetrical eyebrows, cheek and jawline laxity, neck bands, and atrophy
of the lips, cheeks, and infraorbital areas. (Right) Same patient, 13 months after facelift, neck lift, hairline-lowering forehead lift, upper and lower
eyelifts, dermabrasion of lip lines, and fat transfer to the cheeks and lips. No skin resurfacing, facial implants, or other ancillary procedures were
performed. Note soft, natural, facial contours and the absence of a tight, pulled, or facelifted appearance. Eyebrow asymmetry has been improved
and the hairline lowered. The cheeks and jawline have been lifted and redundant skin removed. Atrophy in the upper cheek and infraorbital areas
have been offset by fat transfer to create a more youthful appearance. (b) AP smiling view. (Left) Before surgery. Note that despite a bright smile she
has a tired and melancholic appearance. (Right) Same patient, 13 months after surgery. Her smile is natural. An improved neckline can also be seen
even in this front view. (c) Oblique view. (Left) Before surgery. Note eyebrow asymmetry, frown lines, and oblique neck with bands. Note also that
the patient has a large submandibular salivary gland, evident as a fullness in the upper neck area. (Right) Same patient, 13 months after surgery. Note
improved transition from lower eyelid to cheek, smooth jawline, and attractive neck line. The enlarged submandibular gland has been reduced in size
to obtain optimal neck contour. (d) Lateral view. (Left) Before surgery. Note lower eyelid fat protrusion, labiomandibular groove, and poor neckline.
(Right) Same patient, 13 months after surgery. Note elevation of corners of mouth; well-defined jawline; and attractive, youthful-appearing neckline.
Note that lips are fuller and no scars are visible, no distortion of the ear is present, and the earlobe is in normal position. (e) Lateral flexed view.
(Left) Before surgery. Note how neck laxity and poor neckline lend an unfit and elderly appearance. (Right) Same patient, 13 months after surgery.
Note fuller lips, elevation of corners of mouth, well-defined jawline, and attractive and fit-appearing neckline. (All surgical procedures performed by
Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
683
area. He has a tired and disinterested appearance even with a
broad smile.
The patient underwent facelift, neck lift, closed forehead lift,
upper and lower blepharoplasties, minor partial facial fat transfer,
and earlobe reduction.
On the postoperative views, note improved eyebrow position
and configuration, corrections of hooded eyelids, diminished
cheek folds, elimination of jowls, and restoration of youthful and
masculine facial shape without a tight or pulled appearance. The
protruding portion of the submandibular gland has also been
removed. The face has a natural appearance, and all scars are
well concealed despite the patient’s short haircut. Note also that
the earlobe has been subtly reduced, giving an antiaging effect.
:hen smiling, he has an alert and composed appearance and fit,
masculine-appearing jawline. He looks rested, fit, decisive, and
virile.
Clinical Caveats
• It is not possible to design or use a “universal” facelift tech-
nique. Each patient will present with a unique set of problems
that require precise anatomic diagnosis and an appropriately
planned and individualized surgical repair.
• Attractive and natural-appearing rejuvenation of the face is
not possible without diverting tension away from the skin to
the SMAS and platysma, and unless other deep-layer struc-
tures and the aging midface are addressed.
• Skin was meant to serve a covering function and not a struc-
tural or supporting one. Using skin as the vehicle to support
sagging deep-layer tissue corrupts its function and results in
abnormal tension and related secondary problems including
poor scars, tragal retraction, earlobe malposition, and a tight
and unnatural appearance.
• The young, attractive face is characterized by a youthful
distribution of tissue and not tightness, and the goal in
Fig. 49.69 Case 3: a woman, aged 37 years at time of treatment, who had had prior upper blepharoplasty, rhinoplasty, chin implant, and neck
liposuction performed by unknown surgeons. (a) Anteroposterior (AP) view. (Left) Before surgery. Note cheek sagging and jawline laxity. Note
also upper eyelid hollowness resulting from her previous blepharoplasty procedure. (Right) Same patient 1 year and 3 months after facelift, neck
lift, temple lift, lower blepharoplasty, and fat injections. She has also had cosmetic eyebrow, eye line, and lip tattooing. No skin resurfacing, facial
implants, or other ancillary procedures were performed. The patient has soft, natural facial contours and no tight, pulled, or facelifted appearance.
Note improved eyebrow position and configuration, improved cheek fullness, improved jawline, and overall more alert, fresher, more feminine
appearance. Fat injections have reduced hollowing in the upper and lower eyelid areas, filled the tear trough areas, blended the chin and jawline, and
subtly augmented the lips. (b) AP smiling view. (Left) Before surgery. Note a sad appearance, even though she is smiling. (Right) Same patient 1 year
and 3 months after surgery. Note improved facial shape, soft, natural facial contours, and the absence of distortion or a change in appearance of her
smile. The patient appears more rested and engaged. (c) Oblique view. (Left) Before surgery. Note cheek sagging and jawline laxity. Note also upper
eyelid hollowness resulting from her previous blepharoplasty procedure. (Right) Same patient 1 year and 3 months after surgery. Note improved
facial shape, restoration of cheek fullness, improved transition from lower eyelid to cheek, and smooth jawline. Note also subtle filling of lips achieved
with fat injections. The patient’s face has a fresher, fitter, more athletic, and more feminine appearance. (d) Lateral view. (Left) Before surgery. Note
hollow upper eyelid, tear trough, sagging cheek, labiomandibular groove, and poor jawline. Note also neck fullness and poor neck line, despite prior
submental liposuction. (Right) Same patient 1 year and 3 months after surgery. Note restoration of cheek fullness, improved transition from lower
eyelid to cheek, elevation of corners of mouth, smooth jawline, and improved neck. Note also that no scars are visible, no distortion of the ear is
present, and the earlobe is in normal position. (e) Lateral flexed view. (Left) Before surgery. (Right). Note elevation of corners of mouth; improved
jawline; and fit-appearing, attractive neckline. (All surgical procedures performed by Timothy Marten, MD, FACS. Cosmetic tattooing performed by
Athena Karsant, RN. Copyright © Timothy Marten.)

684
VIII Surgical Rejuvenation of the Face and Neck
facelift surgery and related procedures is to reposition ptotic
tissues—not to tighten the face. Overtightening any layer of
the face, including the skin, SMAS, and platysma, is concep-
tually flawed and will result in unnatural appearances and
secondary deformities.
• Careful evaluation of most patients who need a midface lift
will show that they also need a facelift. It is rare to encounter a
patient with significant midface aging who does not also have
sagging in the cheek and jowl, and midface lifts are arguably
more logically performed in conjunction with a formal facelift
procedure than as isolated, stand-alone procedures.
• Using the SMAS to lift and reposition sagging facial tissues
and restore lost youthful facial contour circumvents the prob-
lems associated with skin-only facelifts, as the SMAS is an
inelastic structural layer capable of providing meaningful and
sustained support. Although skin must be excised in SMAS
procedures, only redundant tissue is sacrificed and closure
can be made under normal skin tension.
• The conventional “deep-plane” “low” cheek SMAS flap, ele-
vated below the zygomatic arch, suffers the drawback that it
cannot, by design, provide an effect on tissues of the midface,
perioral, and infraorbital regions. Planning the flap “higher,”
along the superior border of the zygomatic arch, overcomes
this problem and produces an improved result.
• “Lamellar” dissections, in which the skin and SMAS are dis-
sected as two separate layers, offer the important advantage
that skin and SMAS can be advanced different amounts,
along separate vectors, and suspended under differential
tension. This allows each layer to be addressed individually as
indicated and, in turn, results in a more comprehensive and
natural appearing improvement.
• Rarely does isolated aging occur in the lower face and neck,
and nearly all patients requesting facelift surgery are candi-
dates for forehead and eyelid surgery as well. Patients do not
always recognize this fact, however, and must be carefully
counseled in this regard.
Fig. 49.70 Case 4: a Hispanic woman, aged 55 years at time of treatment, who had had no prior plastic surgery. (a) Anteroposterior (AP) view. (Left)
Before surgery. Note sagging cheeks, heavy jowls, protruding lower eyelid fat, nasolabial lines, and thin lips. The patient has a stern and disapproving
appearance. (Right) Same patient 1 year and 6 months after facelift, neck lift, limited incision forehead lift, upper and lower blepharoplasties,
chin augmentation, and fat transfer to the lips and cheeks. No skin resurfacing or other ancillary procedures were performed. Note smooth facial
contours, more youthful facial shape, and absence of a pulled or a facelifted appearance. The lower eyelid fullness has been reduced and a smooth
transition is present between the lower eyelid and cheek. Note also that her lips and cheeks are fuller as a result of the fat injections. (b) AP frowning
view. (Left) Before surgery, she has strong frown muscles that produce deep creases and an intense angry appearance. (Right) Same patient, 1 year
and 6 months after surgery. She is trying to frown in this photograph, but she is no longer able to do so to the same extent because of muscle
modification performed as part of the forehead lift procedure. (c) Oblique view. (Left) Before surgery. Note sagging cheeks, sagging jowl, and hollow
infraorbital areas. (Right) Same patient, 1 year and 6 months after surgery. Note restoration of cheek fullness, improved transition from lower eyelid
to cheek, elevation of corners of mouth, smooth jawline, and improved neck. (d) Lateral view. (Left) Before surgery. Note protruding lower eyelid fat,
tear trough, sagging cheek, sagging jowl, labiomandibular groove, poor neckline, and weak chin. (Right) Same patient, 1 year and 6 months after
surgery. Note restoration of cheek fullness; improved transition from lower eyelid to cheek; elevation of corners of mouth; well-defined jawline;
fuller lips; and attractive, youthful-appearing neckline. Note that the chin implant has produced an attractive and more balanced profile. Note also
that no scars are visible, no distortion of the ear is present, and the earlobe is in normal position. (e) Lateral flexed view. (Left) Before surgery. Neck
laxity and poor neckline produces an older, unfit appearance. (Right) Same patient, 1 year and 6 months after surgery. Note fuller lips, restoration
of cheek fullness, improved transition from lower eyelid to cheek, elevation of corners of mouth, well-defined jawline, and attractive neckline. Her
chin appears stronger and in better balance with the rest of her face. (All surgical procedures performed by Timothy Marten, MD, FACS. Copyright ©
Timothy Marten.)

49 Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline
685
• Proper analysis, careful planning, and the use of an incision
along the hairline, when indicated, can avert hairline notch-
ing and displacement without compromising the overall
outcome of the procedure. This is particularly true of patients
with marked skin redundancy and those presenting for sec-
ondary procedures.
• SMAS flaps should be advanced along a posterosuperior
vector, parallel to the long axis of the zygomaticus major
muscle. If a “vertical” or posterior vector is used, the func-
tion of the zygomaticus major muscle will be corrupted and
abnormal appearances during animation may result.
• Inappropriate excision of skin over the apex of the occip-
itomastoid defect in the postauricular area along a vector
parallel to the long axis of the sternocleidomastoid muscle is
the underlying cause of hypertrophic healing in the postau-
ricular region and, ultimately, of a wide postauricular scar.
Although an apparent excess of skin will appear to be present
in this area when the patient is supine on the operating table,
this skin is needed once the patient’s shoulders drop in the
upright position and is necessary for side-to-side head tilt.
• The opportunity to perform a facelift is a unique artistic
privilege granted to us by our patients, which carries a sig-
nificant responsibility. It deserves nothing less than our best
effort. The goals we set for ourselves will define the amount
of improvement we obtain. Creating beautiful things and
obtaining a quality result require more effort and take more
time. It is not how fast we can do it—it is how good we can
make it, and a few extra hours of our time in the OR benefit
our patients for the rest of their lives.
• Rejuvenation of the face is a considerable undertaking, and
its difficulty should not be underestimated. The procedure
must be carefully planned, meticulously carried out, and the
patient’s safety and well-being unfailingly ensured.
• Performance of the facelift procedure itself only fulfills part
of our obligation to the patients, and the care they receive
perioperatively is arguably as important as the surgery itself.
Diligent perioperative care will ensure the best result and
reduce the likelihood that problems and complications will
occur.
Fig. 49.71 Case 5. Man, aged 68 years at time of treatment. (a) Anteroposterior (AP) view. (Left) Before surgery. The patient has degraded
eyebrow position and configuration, full upper eyelids, sagging cheeks, deep cheek folds, and jowls. Loss of youthful facial contour can be
seen in the cheek and jowl areas. (Right) Same patient, 1 year and 9 months after facelift, neck lift, closed forehead lift, upper and lower
blepharoplasties, minor partial facial fat transfer, and earlobe reduction. Note improved eyebrow position and configuration, corrections of
hooded eyelids, diminished cheek folds, elimination of jowls, and restoration of youthful and masculine facial shape without a tight or pulled
appearance. (b) AP smiling view. (Left) Before surgery. Note tired and disinterested appearance despite broad smile. (Right) Same patient, 1
year and 9 months after surgery. Note alert and composed appearance and fit, masculine-appearing jawline. (c) Oblique view. (Left) Before
surgery. Note poor eyebrow position and configuration, hooded upper eyelid, sagging cheek, and loss of youthful jawline. (Right) Same patient,
1 year and 9 months after surgery. Note improved eyebrow position and configuration, restoration of cheek fullness, diminished nasolabial
fold, smooth masculine jawline, and improved neck contour. The patient has a rested, fit, decisive, and virile appearance. (d) Lateral view. (Left)
Before surgery. Note lower eyelid fullness, sagging cheek, poor jawline, heavy jowl, and neck laxity. A protruding submandibular salivary gland
can also be seen in the neck area. (Right) Same patient, 1 year and 9 months after surgery. The lower eyelid fullness has been reduced; the cheek
position has been improved; the earlobe reduced, and a fit, masculine-appearing jawline and neckline can be seen. The protruding portion of
the submandibular gland has also been removed. The face has a natural appearance and all scars are well concealed despite the patient’s short
haircut. Note also that the earlobe has been subtly reduced. (e) Lateral flexed view. (Left) Before surgery. Note poor neckline when looking
down. (Right) Same patient, 1 year and 9 months after surgery. Note improved neck contour in the flexed position. The face has a natural
appearance, and all scars are well concealed. Note also antiaging effect of earlobe reduction. (All surgical procedures performed by Timothy
Marten, MD, FACS. Copyright © Timothy Marten.)

686
VIII Surgical Rejuvenation of the Face and Neck
Suggested Reading
[1] Connell BF, Marten T-. Deep layer techniques in cervico-facial rejuvenation.
In: Psillakis -M, ed. Deep Face-lifting Techniques. 1ew Publishers; 1994
>2@ Connell BF, Marten T-. Facial rejuvenation: facelift. In: Cohen M, ed. Mastery
of Plastic and Reconstructive Surgery. Boston, MA: Little, Brown Publishing;
1994:1873–1902
>3@ Marten T, Elyassnia D. Short scar neck lift: neck lift using a submental incision
only. Clin Plast Surg 2018;45(4):585–600
>4@ Marten T, Elyassnia D. 1eck lift: defining anatomic problems and choosing
appropriate treatment strategies. Clin Plast Surg 2018;45(4):455–484
>5@ Marten T, Elyassnia D. Management of the platysma in neck lift. Clin Plast Surg
2018;45(4):555–570
>6@ Marten T-. Lamellar high SMAS face and midface lift: a comprehensive technique
for natural-appearing rejuvenation of the face. In: 1ahai F, ed. The Art of Aesthetic
Surgery: Principles & Techniques, 2nd ed. St. Louis, MO: 4uality Medical Publish-
ing; 2011
[7] Marten T-. Facelift. Planning and technique. Clin Plast Surg 1997;24(2):269–308
[8] Marten T-. Facelift with SMAS flaps. In: Guyuron B, Eriksson E, Persing -A, et
al, eds. Plastic Surgery: Indications and Practice. St. Louis, MO: :B Saunders;
2008:1445–1472
[9] Marten T-. High SMAS facelift: combined single flap lifting of the jawline, cheek,
and midface. Clin Plast Surg 2008;35(4):569–603
>10@ Marten T-. Lamellar high SMAS face and mid-lift: improved design of the SMAS
facelift for better results in the mid-face and infra-orbital region. In: 1ahai F,
ed. The Art of Aesthetic Surgery: Principles & Techniques. St. Louis, MO: 4uality
Medical Publishing; 2005
[11] Marten T-. Secondary facelift. In: Mathes S-, ed. Plastic Surgery, Vol 2: The Head
and Neck, 2nd ed. St. Louis, MO: :B Saunders; 2005
>12@ Marten T-. Facelift: state of the art. Semin Plast Surg 2002;16(4):303
>13@ Marten, T-, Maintenance facelift: early facelift for the younger patient. Semin
Plast Surg 2002;16(4):375–390
Appendix 49.1 Marten Clinic of
Plastic Surgery Facelift Tray
Scalpels
• (4) scalpel handle (round) (Padgett P-650)
Skin Hooks
• (2) double pronged skin hook (10 mm) (Padgett P-5379)
Needle Holders
• (4) needle holder³long (7µ Ryder narrow carbide jaw) (V
Mueller ( CH 2492)
• (4) needle holder³medium (6µ carbide jaw) (Padgett P-2410)
• (4) needle holder³small (5µ :ebster smooth jaws Titanium)
(Storz 1 5712)
Scissors
• (2) Metzenbaum medium curved (flap dissection) scissors
(Padgett P-6468)
• (1) .aye Blepharoplasty (flap trimming) Scissors (Padgett
P-29065)
• (1) Metzenbaum small curved (suture scissors) (Storz 15104)
• (1) Mayo (utility) straight scissors (Pilling LL3) (V Mueller SU
1820) (Padgett PM 0460)
Forceps
• Adson (carbide with fine teeth and tying platform) (Padgett
P-2511)?
• (1) Adson (carbide with medium teeth and tying platform)
• (1) DeBakey (8µ fine toothed jaws) (Codman 37-1011) (V
Mueller CH5895)
• (1) coagulating forceps³straight (insulated) (Snowden Pencer
0531)
• (1) coagulating forceps³curved tip (insulated)
• (4) Allis forceps (Storz 1-5600)
• (6) mosquito hemostats (Storz)
• (1) curved .elly hemostat
• (1) straight .elly hemostat
• (2) Snitz forceps (8.5µ V Mueller MO 1700)
• (1) Mixter right angle forceps (8.5µ Codman 19 5581)
Retractors
• malleable (small) Padgett 4206)
• (1) malleable (large) (Padgett P-4341)
• (1) Army-1avy (Codman 50-4071)
• (1) Freeman ribbon (Padgett P-491)
• (1) Freeman rake (four pronged) (Padgett P-509)
Misc
• (6) Bachus piercing towel clips (sm) (9 cm)
• (4) Bachus piercing towel clips (large) (13 cm)
• (1) Obwegeser periosteal elevator (Padgett 7710)
• (1) Bois elevator
• (1) metal ruler
• (1) metal comb
• (1) Marten facelift flap marker (Medicon)
• (1) • (1) Frazer suction and stylet
• (2) instrument retainer
Misc Other
• (2) hair clip
• (1) ring / sponge forceps
• (4) =immer blue plastic clips
• (1) headlight joystick
Disposable
• Colorado cautery needle tip
• (1) cautery (flat blade) long tip
• (1) cautery (flat blade) short tip
Sutures
• 3-0 Vicryl
• 4-0 nylon
• 6-0 nylon
• 5-0 Monocryl

50 Simultaneous Facelift and Facial Fat Grafting
687
50 Simultaneous Facelift and Facial Fat Grafting
Timothy Marten and Dino Elyassnia
Abstract
Despite what we formerly thought, ´liftingµ cannot correct all
aspects of the aging change of the face, and fat grafting allows
treatment of age-associated loss of facial volume not addressed
by facelift surgery. Fat grafting constitutes the ´missing linkµ
in facial rejuvenation, and it stands as the most important new
addition to facelift surgery since the introduction of the superfi-
cial musculoaponeurotic system (SMAS) technique.
Abundant clinical and scientific evidence, however, exists
confirming that fat grafting produces a persistent and worthwhile
improvement. Fat grafting works best when sagging tissues have
been repositioned and redundant skin excised, and simultaneous
facelift and fat grafting will provide a better result than either
technique performed alone.
Fat grafting is an artistically powerful adjunct to a facelift that
results in a more healthy, fit, youthful, sculptural, and sensual
appearance than facelift alone. Patient and surgeon preoccupation
with the swollen face stands as evidence that volume addition
has artistic merit. Fat grafting may be functionally important in
the facelift patient and provide support to the lower eyelid and
other facial tissues. Patients with full faces often have regional
atrophy and can benefit from fat grafting. In many instances fat
grafting can replace or preclude the need for facial implants, and
adding fat grafting to a facelift procedure essentially provides the
opportunity to perform simultaneously, and at a much reduced
cost, the equivalent of a chin implant, pre–jowl groove implant,
malar implant, submalar implant, jawline (Taylor) implant, ´tear
troughµ implant, and temple implant.
:hile controversy continues as to which facelift technique is
´best,µ incorporating fat grafting into facial rejuvenation proce-
dures is arguably more important than what facelift technique is
used. Fat grafting may result in an improvement in skin quality
mediated through a stem cell effect. Fat grafting is often more
important to rejuvenating the secondary facelift patient than the
facelift itself. These benefits may offset the drawbacks of increased
operating time, uncertainty of graft take, and a longer period of
recovery associated with the fat grafting procedure.
Keywords
fat grafting, fat injections, autologous fat grafting, fat transfer,
micro fat grafting, lipofilling, facelift, secondary facelift, stem
cell facelift
50.1 The Aging Face and the Need
for Fat Injections
Recognizing the components of the aging change of the face
and appreciating the underlying anatomic abnormalities is
essential to the recommendation of appropriate treatment and
the planning of surgical procedures. Careful analysis will reveal
that most patient problems will fall into three broad categories:
1. Aging and breakdown of the skin surface
2. Facial sagging, skin redundancy, and loss of youthful facial
contour
3. Facial hollowing, wasting, atrophy, and/or age-related lipo-
dystrophy
Proper treatment will depend upon the types of problems pres-
ent, the patient’s priorities, and the time, trouble, and expense
she or he is willing to endure to obtain the improvement desired.
Patients primarily concerned with surface aging of their face
may not require formal open surgical procedures and may achieve
the type of improvement they desire through salon care and der-
matologic surface treatments of the skin such as skin peels, laser
skin resurfacing, dermabrasion, intense pulsed light (IPL), chemo-
denervation (neurotoxin injections), hyaluronic acid (HA)-based
filler injections, and various forms of cutaneous laser and other
treatments designed to remove or reduce ´age spots,µ ´spider
veins,µ wrinkles, and other age-related skin surface imperfections.
Patients primarily concerned with facial sagging, skin excess,
and loss of facial contour will achieve little if any improvement,
however, if surface treatments of the skin only are employed.
These patients will require formal surgical lifts, in which sagging
tissue is repositioned and redundant tissue is excised, if these
problems are to be properly addressed and an attractive and
natural-appearing improvement is to be obtained. The misappli-
cation of surface treatments of the skin to the sagging face with
excess tissue that has lost youthful shape will produce little more
than a smooth saggy face with no improvement in contour. This
sort of ´smooth-saggy look,µ typically seen in the older patient
who has undergone laser resurfacing, is inconsistent with a nat-
ural appearance, as patients with loss of facial contour generally
also have concomitant skin surface aging. It is arguably more
attractive and natural-appearing to have a well-contoured face
with a few wrinkles and surface imperfections than a smooth but
saggy one.
Patients with significant facial atrophy and age-related hol-
lowing and loss of facial fat will generally achieve suboptimal
improvement from both surface treatments of facial skin and
surgical lifts. Smoothing skin will not hide a drawn appearance
due to loss of facial volume, and it is difficult to create natural
and attractive contours by lifting and repositioning tissues that
have abnormally thinned and involuted with age. Restoring lost
facial volume using fat injections is a powerful technique that is
now acknowledged by most plastic surgeons and other physicians
engaged in treating the aging face as ´the missing linkµ and the
most important advance in aesthetic surgery in several decades or
more. Properly performed, the addition of fat to areas of the face
that have atrophied due to age or disease can produce a significant
and sustained improvement in appearance unobtainable by other
means.

688
VIII Surgical Rejuvenation of the Face and Neck
50.1.1 Why Perform a Facelift and Fat
Injections?
:hy perform a facelift and fat injections" :hy not perform
just the facelift, as we traditionally have" The answer to these
questions lies in the multifactorial origin of facial aging just
discussed and in the fact that fat is predictably lost from the face
and areas of the face becomes hollow as one ages, in addition to
sagging, drooping, and other gravitational effects. The isolated
facelift procedure, even when aggressively and comprehensively
performed, addresses only tissue ptosis and redundancy and
often produces a lifted, but telltale hollow and underrejuve-
nated, look sometimes referred to as a ´cougarµ appearance in
lay media. Fat injections, however, allow the loss of facial fat to
be treated simultaneously with the facelift, and these objec-
tionable appearances to be avoided. All things being otherwise
equal, simultaneous facelift and fat injections will produce a
better result than either technique performed alone, and when
a facelift is performed in conjunction with fat injections, both
loss of contour and facial atrophy can be corrected and optimal
improvement can be obtained (Fig. 50.1).
50.1.2 Volumetric Rejuvenation, Tissue
,nWegrDWiRn Dnd SWem &eOO (̵eFW
Fat injections have other previously unavailable advantages for
the surgeon who performs facelift procedures. Fat injections
provide volumetric rejuvenation: a new and different means by
which to improve facial appearance, and a new dimension for
plastic surgeons to work in. Unlike injectable fillers, fat is autol-
ogous and actually integrates with facial tissues and becomes a
part of the face, promoting a more natural appearance during
facial movement and producing a sustained and long-lasting
improvement. In addition, mounting scientific evidence now
supports the often-cited clinical observation that fat injections
actually induce an improvement in facial tissue quality through
a ´stem cellµ effect and, when performed with a facelift, may
constitute, for the first time, rejuvenation in the true sense of
the word.
50.2 Nomenclature
The nomenclature for autologous fat transplantation can be
confusing because surgeons and others injecting fat into the face
have put forth various terms to best describe the procedure. In
addition, in an effort to market the procedure, many proprietary
marketing names and catch phrases have also been created, and
these can be especially confusing to patients. In essence, how-
ever, the commonly used terms fat transfer, fat grafting, microfat
grafting, autologous fat grafting, autologous fat transplantation,
fat injections, lipo fiOOLQJ, and lipo-injection all refer to the same
basic procedure. :e typically use the terms fat injections and fat
transfer in our discussions with patients, as these are straight-
forward descriptive terms that do not include medical jargon
and are most easily understood and remembered.
Additional confusion has been created by the term ´stem cell
facelift,” a procedure in which fat is variously injected into the
face with the purported but unproven benefit of tissue tightening
and rejuvenation mediated through a ´stem cellµ effect. In most
cases only fat is injected, but in some cases limited traditional
facelifts (´mini-lifts,µ ´S lifts,µ ´skin-onlyµ lifts) are simultaneously
performed. Currently it is a stretch of available scientific fact to
call fat injections a “facelift,” and it is medically more correct to
refer to the two procedures simply as combined but separate and
distinct surgeries.
50.3 Drawbacks of Fat Injections
Performing fat injections in conjunction with a facelift has
certain disadvantages that must be acknowledged including the
learning curve associated with any new procedure, an increase
in operating room time, increased postoperative edema, a longer
period of recovery, uncertainty of graft take, and the potential
for problems and complications such as asymmetries, lumps,
and other irregularities. In addition, certain patient (and often
surgeon) misconceptions will also be encountered and will have
to be overcome, including misguided beliefs held by some that
injected fat can migrate or fall or that fat injections will make
the face ´look fat.µ
50.4 Why Not Just Inject Fat?
Age-related loss of facial fat rarely exists as an isolated event in
the healthy patient, and thus patients troubled by it are rarely
logically or appropriately treated by fat injections alone. Isolated
fat injections are also arguably of questionable benefit to the
patient troubled by significant facial sagging and skin redun-
dancy. Although aggressive filling of the sagging face with fat (or
Fig. 50.1 Simultaneous facelift and fat injections. All things being
otherwise equal, simultaneous facelift and fat grafting will produce
a better result than either technique performed alone. (a) This
49-year-old patient with both tissue ptosis and redundancy and
marked facial atrophy. (b) Same patient seen 1 year and 3 months after
high–superficial musculoaponeurotic system (SMAS) facelift, neck lift,
closed forehead lift, lower blepharoplasty, and panfacial fat injections.
Combined lifting and filling of her face produced a better outcome than
either technique could have alone. (Procedure performed by Timothy
Marten, MD, FACS. Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
689
filler) can produce improved contour and a smoother-appearing
skin surface, it generally results in an unusually large, overfilled
face that appears both unnatural and unfeminine. Such an over-
filled face is hard to correct in an attractive manner at a later date,
and it is both more logical and practical to perform fat injections
in conjunction with formal surgical lifts if needed, or as a second
stage after the facelift has been performed and ptotic tissue has
been repositioned and redundant tissue has been removed.
50.5 Where Should the Fat Be
Injected?
Areas in need of treatment will vary from patient to patient, and
planning fat injections requires looking at the face in a different
way and more as “sculptors” and less as “tailors,” as we have in
the past. Any area that is treatable with nonautologous inject-
able fillers is potentially treatable with fat injections including,
but not limited to, the temples, forehead, brow, glabella, radix,
upper orbit (´upper eyelidµ), lower orbit (´lower eyelidµ), cheeks,
midface, buccal recess, lips, perioral, nasolabial crease, genio-
mandibular groove, jawline, labiomental crease, submental
crease, and chin areas, and experience with fillers is a useful
point of reference for planning fat additions to the face.
Perhaps the best way to decide where fat is needed is for the
surgeon to study her or his facelift outcomes carefully and identify
areas where the procedure has fallen short. In most cases the
biggest shortcoming for the experienced surgeon will be evident
as the failure to replenish lost volume, and the areas in need of
treatment will be obvious.
Opportunities to see nonsmiling photographs of patients when
they were younger are highly valuable and are one of the best
ways to gain an appreciation of volume loss and its contribution
to changes that occur as the face ages. These photos are also very
helpful for educating patients as to how their face has changed
with age and for explaining the need for fat grafting during their
consultation.
In time, and after engaging thoughtfully in such study, one will
gain a deeper appreciation of facial atrophy and an increasing
desire to correct it (Fig. 50.2).
50.6 Sequencing Fat Injections with
Other Procedures
:hen fat grafting is best performed during facelift surgery is
scientifically unanswered, but as a practical matter it is most
expedient to inject fat at the beginning of the procedure before
the facelift itself has been started. The reasons for this include
the fact that it is easier to harvest the fat at the beginning of the
procedure, before the face has been prepped or draped and when
the patient is typically in a deeper plane of anesthesia. Also, in
the beginning of the procedure the tissue planes of the face have
not been opened, the face is not swollen, and preoperatively
made pen marks and facial landmarks are easier to identify. In
addition, surgical principles suggest that it is likely best to inject
the fat before the start of the facelift procedure to limit the time
the graft is out of the body. Perhaps the most important reason
Fig. 50.2 Patient before and after simultaneous facelift and fat injections. (a) Patient before procedure. She has had not prior surgery. (b) Shaded
areas showing were fat was placed: 3 mL in each upper orbit, 4 mL in each temple, 1 mL in each tear trough, 3 mL in each infraorbital area, 4 mL
in each cheek, 2 mL in each nasolabial crease, 1 mL in each stomal angle, 2 mL in each geniomandibular groove, 3 mL in each lip, and 2 mL in the
glabella. (c) Same patient 2 years and 4 months after high–superficial musculoaponeurotic system (SMAS) facelift, neck lift, lower blepharoplasty,
and 50 mL of fat injections. (Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
b
c
a

690
VIII Surgical Rejuvenation of the Face and Neck
to perform fat grafting first, however, is that the surgeon is more
technically and artistically energetic in the morning and will do
a better job than if it is performed at the end of a long facelift
procedure. If one waits until the end of a long facelift, fat grafting
will likely be performed with less patience and care.
50.7 Fat Injection Technique
The technique for facial fat grafting has been described previ-
ously, and Coleman’s principles are adhered to when fat injec-
tions are performed.
50.7.1 Logistics of Simultaneous Facelift
and Fat Injections
Fat injections are often discussed or viewed by many surgeons
as a simple procedure that can be performed in a few minutes
time. This is rarely the case, however, and such an attitude will
lead to frustration, disruption of workflow, and suboptimal
outcomes. Fat must be harvested in a specific, atraumatic, and
time-consuming manner if viable tissue is to be obtained that
can be expected to survive and ´takeµ at the facial recipient
site. It must then be processed and injected in a technically
demanding and time-consuming process that cannot be rushed.
It is also an artistically demanding activity that will require a
considerable amount of the surgeon’s intellectual, creative, and
physical energy. :hen anything other than small amounts is
being injected, the entire procedure can easily encompass an
hour or more, something that can significantly tax an already
overburdened surgical team engaged in a demanding operation
consisting of multiple procedures. Time must therefore be
planned carefully and appropriately.
50.7.2 Needed Equipment
Special instruments are required to harvest and inject fat (Fig.
50.3, Fig. 50.5), in addition to other specialized equipment to
process and organize it. Poor outcomes are typically obtained
if sharp hypodermic needles are used to harvest fat, if fat is
not processed, or if the fat is injected in a manner similar to
that used to inject nonautologous facial fillers. In addition, if
sharp hypodermic needles are used to inject fat (other than
for a true intradermal injection), there is the potential for
intravascular injection, fat embolization, and other serious
problems including tissue infarction, visual impairment and
blindness, and embolic stroke, and therefore their routine use
is not recommended.
Reusable cannulas (Fig. 50.3a) have been the standard for many
years and continue to be widely used by many surgeons. They
suffer the drawback that they are time-consuming to clean and
difficult to sterilize, and as such are not approved for use in some
countries. The smaller (and thus most useful) cannulas are also
very fragile and can break if not carefully used.
In many practices disposable, single-use cannulas are gradually
supplanting traditional reusable cannulas (Fig. 50.3b). These
cannulas come in a variety of diameters and lengths and do
not need to undergo time-consuming cleaning, processing, and
resterilization.
1ecessary equipment is listed in Table 50.1.
50.7.3 Choosing a Donor Site
Currently there is no scientific unanimity as to where the ´bestµ
fat for grafting should be obtained, and our scientific literature
on the subject has claimed various areas to be the most optimal
donor sites. As such, donor sites are typically chosen and marked
in conjunction with the patient in such a manner as to improve
her or his silhouette, although the ideal locations are arguably
those areas of diet- and exercise-resistant fat collections where
the fat is biologically programmed to be stubbornly persistent
throughout the patient’s life. For women these are typically the
Fig. 50.3 Fat injection cannulas. Special blunt-tipped cannulas are
required to perform fat injections properly, and poor outcomes are
typically obtained if sharp hypodermic needles are used. Sharp needle
injection also poses a serious risk of fat embolization, and related
problems. (a) Reusable fat injection cannulas. (b) Single-use disposable
fat-grafting instruments and supplies. High-quality single-use
disposable cannulas and supplies make fat grafting convenient and
preclude the need for time-consuming cleaning, reprocessing and
resterilization of reusable equipment. These are available in a variety of
diameters and lengths. (Not shown are single-use harvesting cannulas.)
Shown from left to right are disposable syringe caps to cap the ends of
syringes during centrifuging, 0.7-mm (20-gauge) 4-cm-long single-use
disposable injection cannula, 0.9-mm (18-gauge) 6-cm-long single-use
disposable injection cannula, single-use disposable Luer lock transfer
coupling for transferring fat from 10-mL syringes to 1-mL syringes.
(Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
691
hip, waist, flank, and outer thigh, and for men the ´love handleµ
and “spare tire” areas.
Although the lower abdomen might appear on casual consid-
eration to be the easiest and best place to harvest fat from, our
experience has shown otherwise, and we prefer to take fat from
the hip and lateral thigh when possible and if the patient agrees.
The reasons for this are several. First, although using the abdomen
as a donor site means that the patient does not need to be turned
and that only one area need be prepped and draped, abdominal fat
is usually harder to extract, and the fat obtained seems to be more
fragile and have a higher ´oilµ content upon centrifugation. In
addition, when anything more than a small amount is needed, the
abdominal area is far less forgiving than the hip or the outer thigh
due to the thinner, less elastic skin typically present, and postop
irregularities and contour problems are far more likely to arise and
to be seen. In fact, consideration should be giving to placing the
patient in a liposuction garment or abdominal binder if anything
more than a small harvest is made from the abdominal area.
Harvesting fat from the hip and outer thigh requires that the
patient be turned and that two areas be prepped, but the fat in these
areas is much easier to extract, and the tissue obtained typically is
more durable and nearly free of blood and ´oilµ following centrifuga-
tion. These areas also have thicker, more elastic skin, and it has been
our experience that postoperative problems and contour irregular-
ities almost never occur. Finally, overall, patients are typically more
pleased with the improvement in their figures when fat is removed
from their hips and outer thighs than from their abdomens.
In thin patients small harvests from multiple areas may be
required, including the inner thighs, inner knees, upper buttocks,
and anterior axilla, and the additional time this will add to the
procedure must be factored into the surgical plan. Preoperative
assessment of the patient’s fat stores will allow proper allocation
of time for the harvesting process and appropriate pricing of the
procedure. :e recommend that the harvest sites and site mark-
ings be photographed preoperatively on the day of surgery to
document what was agreed upon in the preoperative discussion
with the patient. This helps to avoid any dispute after surgery over
the preoperative condition of harvest sites.
50.7.4 Preoperative Marking of the Face
Fat injections cannot be placed arbitrarily, and a careful plan
must be marked preoperatively with the patient seated in an
upright position. It is not possible to mark the patient accurately
when supine and after anesthesia has begun. Marking requires
concentration on the surgeon’s part, will consume a significant
amount time, and is best carried out in a private area that is free
from distractions. Creating an initial plan on a life-sized laser
print of a photograph of the patient’s face in yellow ´highlight-
ingµ marker is helpful in organizing one’s thoughts and facilitates
discussions with the patient as to which areas will be treated. In
most cases marks are made in conjunction with the patient while
she or he holds a hand mirror. The goal is to create a topograph-
ical map of the deficient and atrophic areas of the face to guide
the surgeon during the procedure³essentially a reverse plan of
that used when liposuction is performed.
Because the face is undergoing a process of lipodystrophy³that
is, fat is deficient in some areas and excessive in others³marks
are also made where fat needs to be removed when indicated.
These areas can be marked in a different color or designated
by some other means. Once markings are complete, additional
photographs of the patient’s marked face are taken and printed
up for use during the procedure. These are also made part of the
patient’s medical record.
50.7.5 Informed Consent
Some surgeons print up and have the patient sign and date a laser
print copy of the image of the fat injection plan marked on the
patient’s face to avert any postoperative controversy as to what
the patient’s preoperative requests were and what was agreed on
and consented to. A companion strategy is to include language in
the informed consent document stating that the discussions and
designations regarding where fat is to be placed are necessarily
approximate and that the patient consents to placement of fat
during the procedure in any area that the surgeon feels, in her or
his sole judgment, is necessary to obtain the desired effect.
50.7.6 Anesthesia
Most modern facelifts are time-consuming and technically
demanding. The addition of fat injections to the procedure will
test the patience and composure of almost any surgeon, and it
is highly recommended that one enlist the services of an anes-
thesiologist or competent certified registered nurse anesthetist
(CR1A) when combined procedures are performed. This is
particularly important when the procedure is to be performed
upon a patient who is apprehensive or has a history of anesthetic
difficulties, hypertension, or other significant medical problems.
The majority of our facelifts are now performed under deep
sedation administered by an anesthesiologist using a laryngeal
mask airway (LMA). Use of an LMA allows the patient to be
heavily sedated without compromise of their airway, but the
patient need not receive muscle relaxants and can be allowed to
Table 50.1 Fat injection instrument set
Harvesting instruments
Number
Name
Diameter
Length
1
Multihole local anesthetic infiltrator
1.6 mm
15 cm
1
Carraway Harvester
2.4 mm
20 cm
1
Carraway Harvester
2.1 mm
15 cm
10-mL Luer lock syringes
Luer lock disposable syringe caps
Fat processing instruments
1
Luer-to-Luer transfer coupling
1
Syringe rack
1
Centrifuge
1-mL Luer lock syringes
Injection instruments, face
2
Injection cannula
0.7 mm
4 cm
2
Injection cannula
0.7 mm
5 cm
2
Injection cannula
0.9 mm
5 cm
1
Injection cannula
1.2 mm
6 cm

692
VIII Surgical Rejuvenation of the Face and Neck
breathe spontaneously. The heavily sedated patient is also easier
to harvest fat from, especially when fat must be harvested from
multiple sites, and treatment of multiple areas of the face with fat
is facilitated under these conditions. Any skillfully administered
anesthetic, however, is adequate for performing the procedure.
50.7.7 Harvesting Fat
Fat is harvested the day it is needed, not preharvested and
frozen and stored. There are several reasons for this. First, it is
a questionable practice to store harvested fat in casually labeled
syringes in a small, unmonitored refrigerator/freezer intended
for home or office use. These devices typically do not provide
round-the-clock monitoring of internal temperatures or have
backup power, and most surgeons do not have the means to
properly log in tissue to be stored and guarantee that cross-con-
tamination, inadvertent thawing and refreezing, or mislabeling
has not occurred. In addition, storage of fat in this manner could
be construed as ´tissue banking,µ a practice that only licensed
tissue banks are legally allowed to do in some states.
More to the point, however, the preponderance of scientific
information currently indicates that to be viable, fat must be
flash-frozen to very low temperatures much in the way that a
human egg cell would, and it is not viable when slow-frozen in a
typical food freezer and later thawed. Research and development
in fat banking is under way, however, and at some future date it is
likely surgeons will be able to store viable patient fat at a regional
blood bank, tissue bank, or special tissue storage center created
specifically for this purpose.
Fat should be harvested in a thoughtful and artistic manner
that improves the patient’s figure, and thus it must generally be
removed bilaterally and in a symmetrical fashion unless body
contours dictate otherwise. Patients must be advised that fat har-
vest does not constitute formal liposuction, however, and that the
small instruments used to harvest fat are not capable of making
large improvements in body contour.
It is prudent to examine the patient at the time of their consul-
tation, unless it is obvious that plentiful donor fat is present. Thin
patients with limited fat stores and patients who have undergone
prior body lifts, liposuction, cryolipolysis, or noninvasive fat reduc-
tion procedures have compromised donor fat and often present
significant challenges when harvesting fat, and considerable extra
time and effort will be required to obtain fat from them. Anesthesia
and operating room times³and the anesthesiologist’s, surgeon’s,
and facility’s fees³must be calculated accordingly.
Fat is harvested after anesthesia is initiated but before prep of
the face. In all but the unusual case a complete prep of the torso is
not necessary. Typically a limited prep of the marked area is made,
and a sterile field is established about the prepped area with
adhesive-edged blue paper drape towels (´sticky blue towelsµ).
The surgeon and the surgical assistant need not gown for this part
of the procedure, as sterile gloves are adequate in maintaining
sterile technique for this part of the procedure.
If fat is to be harvested from the hip, waist, and lateral thigh (as
we usually prefer), the patient is turned into a semilateral decubi-
tus position; prep, drape, and harvest performed; and the patient
then turned to the opposite side, where the harvest procedure is
repeated. If the patient is positioned carefully, this technique can
be used to harvest fat simultaneously from multiple sites, including
the inner knee, posterior inner thigh, outer thigh, upper buttocks,
hip, waist, and flank area (Fig. 50.4). Obtaining fat in this fashion
from multiple sites is particularly important in thin patients with
minimal fat stores. 1ote that if only 10 mL is harvested from each
area, a total of 60 mL can be obtained for each side.
Fig. 50.4 Positioning patient for fat harvest. If the patient is positioned carefully in a semilateral decubitus position, fat can be simultaneously
harvested from multiple sites, including the inner knee, inner and outer thighs, buttocks, hip, waist, and flank. Obtaining fat from multiple sites is
particularly important in thin patients with minimal fat stores. Following harvest from one side, the patient is turned to the other side, where a similar
harvest (as appropriate for contours present) is performed. (Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
693
Areas from which fat is to be harvested are conservatively infil-
trated with 0.1 lidocaine with 1:1,000,000 epinephrine solution
using a specially designed multiholed 1.6-mm and 20-cm-long
local anesthetic infiltration cannula (Fig. 50.5), and an adequate
time is allowed for a proper anesthetic and hemostatic effect.
Approximately 1 mL of this dilute local anesthetic solution is
injected for every 3 mL of anticipated fat removal. It is not necessary
or desirable to infiltrate in a tumescent fashion, as overwetting the
donor site will result in an overdilute harvest and more time spent
in the harvesting process. Local anesthetic should be injected, even
if deep sedation or general anesthetic is used, to limit the overall
amount of inhalation anesthetic and narcotics given.
Fat is then harvested with a special 2.1- to 2.4-mm Carraway
Harvester (Tulip Medical Products, San Diego, CA), TriPort (Tulip
Medical Products, San Diego, CA), Coleman (Mentor :orldwide, Santa
Barbara, CA), or other like harvesting cannula attached to a 10-mL
syringe, using gentle, gradually applied syringe suction to avoid
vacuum barotrauma to the fat tissue. These harvesting cannulas are
available as both reusable and disposable types. Fat harvested with
these cannulas will easily pass through 0.7-mm (20-gauge) injection
cannulas; the use of a smaller harvesting cannula is not necessary and
will needlessly slow down the harvesting process. In general, a 30 to
50 overharvest is made to be sure an adequate supply of processed
(centrifuged and separated) fat will be available for use on the face,
as centrifuging typically reduces the apparent harvest by 30 to 50.
Once fat harvest is complete, the stab incision used to obtain
the fat is closed with a simple interrupted suture of 6–0 nylon
or other suture of choice. The harvest site is then washed free of
prep solution and the sutured site dressed with a Tegaderm (3M,
St. Paul, M1) dressing.
50.7.8 Processing Harvested Fat
Harvested fat is generally not uniform in character and concen-
tration as extracted from donor sites, as each syringe will contain
a variable amount of fat, blood, local anesthetic, and ruptured fat
cells (´oilµ), and some type of processing is necessary to obtain
homogeneous material (uniform number of fat cells per unit
volume) for injection. Although fat can be separated from the oil
and water fractions using a ´tea strainerµ type sieve or by rolling
on Telfa (Medtronic, Dublin, Ireland) gauze, the majority of the
´stem cells,µ platelet-rich plasma (PRP), ´growth factors,µ ´cellular
messengers,µ and the platelet plug are likely lost when this is done.
In addition, it is now known that not all fat cells are the same, that
the high-density adipocytes are the most stem cell rich, and that
processing fat through a sieve or by rolling it on Telfa does not
provide a means of segregating and concentrating these.
Centrifugation, as advocated by Coleman, conversely allows sep-
aration of the ´oilµ (fat cells ruptured during the harvest process)
and ´waterµ (blood and local anesthetic) fractions from the fat
cells while simultaneously concentrating these other potentially
important components, and it has been our favored method of fat
processing for almost three decades. In addition, centrifugation
concentrates the high-density adipocytes and allows the surgeon
to use this ´superchargedµ fat, which is thought to be superior
in quality and higher in stem cells for grafting into critical areas
(such as the orbits and lips) or even the entire face if an adequate
overharvest of fat is made. Research efforts have been under
way for some time to develop low-cost devices for use in clinical
settings to process fat in a way that concentrates stem cells and
other potentially bioactive components or even allows them to be
separated. As these become available, the outcomes of fat injec-
tion procedures could be significantly enhanced, and many new
and interesting uses of autologous fat will likely become possible.
Controversy has existed for some time as to whether the forces
applied to the fat during centrifugation are harmful and decrease
eventual graft take. Available evidence seems to indicate that the spin
speeds and resultant applied forces in most countertop laboratory
centrifuges typically sold and used for processing fat are at or below
the threshold value for fat cell injury and do not harm harvested fat.
Before centrifugation is begun, a sterile, disposable plastic Luer
lock cap is placed on the end of the syringe tip to keep harvested fat
inside it, and the syringe plunger is removed from the syringe barrel.
Fig. 50.5 Fat-harvesting cannulae. (a) Special harvesting cannulas
are attached to 10-mL Luer lock syringes and are used to extract fat
atraumatically from donor sites using gentle hand-applied suction. Fat
harvested with these cannulas easily passes through injection cannulas
as small as 0.7 mm (20-gauge). Shown from top down: 10-mL Luer
lock syringe, 1.6-mm by 20-cm local anesthetic infiltration cannula,
2.4-mm Tulip TriPort” harvesting cannula (Tulip Medical Products,
San Diego, CA), and 2.4-mm Coleman harvesting cannula (Mentor
Worldwide, Santa Barbara, CA). (b) Close-up of instrument tips. Shown
from top down: 10-mL Luer lock syringe, infiltration cannula, Tulip
harvesting cannula, and Coleman harvesting cannula. (Copyright ©
Timothy Marten.)

694
VIII Surgical Rejuvenation of the Face and Neck
Capped syringe barrels containing unprocessed fat are then loaded
into the centrifuge rotor in a balanced fashion and spun for 1 to 3
minutes at 1,000 rpm. Most small, portable centrifuges available for
this purpose are inexpensive and have rotors that can be sterilized
so that the syringe barrels containing the fat remain sterile and can
be handled by the scrubbed surgical team on the sterile surgical field
after centrifugation is complete. Others centrifuges have sterilizable
tubes that fit into the rotor for this same purpose (Fig. 50.6).
Once centrifuged, syringe barrels containing centrifuged fat
are removed and will be seen to contain an upper ´oilµ (ruptured
fat cells), central fat (the material the surgeon seeks), and lower
´waterµ (blood and local anesthetic) components (Fig. 50.7).
The typically blood-tinged water (local anesthetic) component
is separated by simply removing the syringe tip cap and allowing it
to run out, and the cap is then replaced. Alternatively, the ´platelet
plugµ can be sequestered and mixed back with the fat, or it can be
injected separately into areas of the face, hands, and chest that have
sustained accelerated environmental damage. The oil fraction is
then poured off out of the top of the syringe. Telfa sponges can also
be placed inside the syringe barrel to wick up the small amount of
residual oil present after the majority of it has been poured off. If
fat overharvest is made, this wicking off of residual oil with Telfa
sponges need not be performed, and the top 1 or 2 mL of fat from
each syringe is simply discarded (or, if the patient is very thin,
injected back into the patient’s body at an appropriate site and
´bankedµ). A test tube–type rack to hold the syringes containing fat
greatly facilitates fat processing activities (Fig. 50.8). The rack also
conveniently holds 1-mL syringes, syringe components, and other
equipment used in the fat grafting procedure as shown.
50.7.9 Fat and Platelet-Rich Plasma
A number of surgeons have variously advocated mixing har-
vested fat with PRP, asserting that this enhances graft take
and improves overall outcomes. Mounting evidence suggests
that this is not true, however, and currently fat grafting is best
thought of and regarded as an artistic endeavor and art project,
not a technical exercise and science experiment.
50.7.10 Patients with Previous Filler Use
Patients who have previously received filler injections present a
specific challenge to the surgeon performing fat grafting and are
arguably suboptimal candidates for the procedure. Often more
Fig. 50.7 Centrifuged fat. After harvested fat is centrifuged, three
layers can be seen: an upper “oil” layer (ruptured fat cells), a middle
layer of intact fat cells, and a bottom (“water”) layer of blood and local
anesthetic. Unlike straining of fat through a “tea strainer” sieve or
rolling it on Telfa (Medtronic, Dublin, Ireland) gauze, centrifugation
is believed to allow separation of the oil and water fractions from
the fat cells with minimal loss of stem cells, platelet-rich plasma
(PRP), growth factors, and cellular messengers. Centrifugation also
allows high-density fat (bottom 2 mL of fat in center of syringe) with
increased stem cell activity, to be separated and preferentially used if
desired. (Copyright © Timothy Marten.)
Fig. 50.6 Centrifuging fat. Harvested fat is generally not uniform in
character as extracted from donor sites as each syringe will contain a
variable amount of fat, blood, local anesthetic, and ruptured fat cells
(“oil”) and some type of processing is necessary to obtain uniform
material for injection. Centrifugation allows separation of the “oil” and
“water” fractions from the fat cells. (a) Small, portable countertop
centrifuge (Tulip Medical Products, San Diego, CA). (b) Close-up view of
centrifuge rotor being loaded with unprocessed fat in 10-mL syringes.
Note that the syringe tip has been sealed with a disposable plastic cap.
The removable and sterilizable metal sleeves shown fit into the rotor to
keep syringe barrels containing fat sterile and allow them to be handled
on the sterile field after spinning. Other centrifuges are designed to
allow the entire rotor to be sterilized. (Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
695
filler is present than patients are aware of or admit to, and the
presence of filler hides the extent of the actual amount of atrophy
present. The presence of residual filler will also likely compromise
graft survival, make a uniform take less likely, and compromise
the ultimate outcome of the procedure. Experience has shown that
even fillers placed several years previously can make procedures
more difficult and the outcomes less predictable.
Filler patients constitute a ´moving targetµ and are as such dif-
ficult to assess and treat. Patients who have undergone HA-based
filler treatments are more likely to have suboptimal graft survival
and uneven take, and they may require multiple staged treatments.
HA-based fillers, when present, can be dissolved with hyaluroni-
dase such as Vitrase (Bausch  Lomb, Rochester, 1<) or Hylenex
recombinant (Halozyme Therapeutics, San Diego, CA), and it is
recommended that HA-based filler be removed a few days or more
before treatment. If filler is removed at the time of the procedure,
the patient does not have the opportunity to see what he or she
really looks like without the filler, and the extent of the problem is
not evident to the surgeon. :hen HA-based filler is dissolved with
hyaluronidase, the patient will also have residual inflammation
and is still likely to be a suboptimal candidate for fat grafting.
Patients presently using or having used non-HA-based fillers
such as calcium hydroxylapatite (CaHA; Radiesse, Merz, Frankfurt,
Germany), polymethylmethacrylate (PMMA), or silicone typically
present an even more perplexing problem. Present use of poly-L-
lactic acid (PLLA) or previous PLLA filler use can be particularly
problematic because of the chronic inflammation, internal fibro-
sis, and related tissue compromise this material can cause. Past
and present filler users should be informed that they are more
likely to have suboptimal fat graft survival and uneven fat take
and that they will likely need multiple staged fat graft treatments.
50.7.11 Injecting Fat
After centrifugation and the oil and water fractions have been
discarded (and high-density fat segregated, if desired), the fat
tissue so obtained is transferred into 1-mL Luer lock syringes
using a transfer coupling (Fig. 50.9) or other method, as proper
injection in very small aliquots as required cannot be made with
a 10-mL, a 5-mL, or even a 3-mL syringe.
1erve blocks are then performed on the face with 0.25 bupiv-
acaine with epinephrine 1:200,000 local anesthetic solution and
an adequate time allowed for a proper anesthetic and hemostatic
effect. It is typically not necessary to directly infiltrate areas to be
treated with local anesthetic if nerve blocks are performed cor-
rectly and sedation is administered, and fat is typically infiltrated
into “dry” recipient areas.
Once nerve blocks have been administered, 0.7-mm (20-gauge),
0.9-mm (19-gauge), and 1.2-mm (18-gauge) cannulas are used to
infiltrate fat into the face transcutaneously through small stab
incisions depending on the areas being treated.
Infiltration is made in multiple passes, in multiple planes as
appropriate for the area being treated, injecting on both the in
and the out strokes while moving the cannula rapidly back and
forth and feathering into adjacent areas. Injecting from at least
two separate injection sites allows ´crisscrossingµ of cannula
passes during graft placement and more smooth and uniform fat
infiltration, and it helps avert a ´row of cornµ effect that might
result if injection was made from only one site.
Determining How Much Fat to Inject
Unless one is willing to submit to a long process of trial and error,
deciding upon how much fat needs to be injected at a given site
requires empirical information provided by others who have
experience with the procedure, and one cannot simply rely
on what one sees in the operating room. In general, there is a
tendency to treat most areas too conservatively if amounts to
be administered are decided by intuition and observation alone,
and some ´overcorrectionµ is needed, as not all the graft will
survive. It is also the case that more fat will be needed than one
would use to fill a similar defect with nonautologous filler.
A prudent strategy for determining the amount of fat needed
for a given site is to rate the severity of the atrophy for each region
of the face based on what is seen in the preoperative photos, and
then to use empirical published data to chose the amount to be
administered to each area.
As a practical matter this amounts to simply rating or categorizing
the severity of atrophy at each proposed site of treatment as “small,”
´medium,µ or ´largeµ and then using data published regarding range
of amounts typically needed as a guide for treatment of each area. If
the defect is “small,” one would choose an amount from the low end of
the recommended range. If the defect is ´large,µ one would choose an
amount from the high end, and if ´mediumµ somewhere in between.
The authors’ recommended ranges for the technique described herein
appear in Table 50.2 for the regions shown in Fig. 50.10.
The insightful surgeon can see that these parameters must be
considered as guidelines and not absolutes, and that considerations
such as what equipment was used, how the fat was harvested, how it
was processed, how it was injected, and the condition of the tissues
receiving the fat will all influence amounts needed and eventual
outcomes. Patients who are smokers or previous smokers as well as
patients who have undergone previous noninvasive radiofrequency
and ultrasonic ´skin shrinkingµ procedures are likely to have com-
promised subdermal microcirculation and thus be less than optimal
Fig. 50.8 Syringe rack. A “test tube” rack to hold the syringes
containing fat greatly facilitates fat processing activities. On the left,
syringes containing unprocessed fat are present. In the center, syringes
containing centrifuged fat can be seen. The rack also conveniently
holds 1-mL syringes, syringe components, and other equipment used
in the fat grafting procedure. (Copyright © Timothy Marten.)

696
VIII Surgical Rejuvenation of the Face and Neck
candidates for fat grafting and need more fat than those who do not
have such a history. Similarly, patients who are longstanding filler
users, especially if they have used inflammatory fillers such as PLLA,
are likely to have internal facial fibrosis and inflammatory changes
that render them suboptimal candidates as well for fat grafting, and
as patients, they will require larger volumes of fat to obtain an equiv-
alent result. Patients undergoing concomitant facelifts will typically
require less fat than patients undergoing isolated fat grafting, as the
size of their skin envelope is being reduced. It is also the case that the
thoughtful injector must add a compensation for a large and small
face and adjust the amounts administered accordingly.
Ultimately however, the strategy just outlined, and in particular
the range of recommended volumes to administer, serves as a
time-tested starting point that will shorten the beginning injec-
tor’s learning curve and serve as a point of reference from which
surgeons develop their own ranges with experience and over time.
It should be understood that the volume ranges recommended
are not absolutes and are not a guarantee of success. 1onetheless,
this strategy has proven very useful in our own practices over
several decades of combined experience and is the strategy we
currently employ today. :ith it, surgeons currently seeking to
incorporate fat grafting into their facelift procedures have a signif-
icant head start over their predecessors, who had to develop these
guidelines largely through trial and error.
Technique of Injection
As the injection cannula is advanced and withdrawn, the surgeon
should feel for tissue resistance, and if resistance is felt injection
is made as the cannula is moved back and forth. Approximately
0.5 mL or less is injected per back-and-forth ´pass.µ This corre-
sponds to 20 to 40 passes for each 1-mL syringe of processed fat.
If tissue resistance is not felt as the injection cannula is advanced,
this indicates that a pass has already likely been made in that
area, and injection is not made, and the cannula is redirected to
an area where resistance is felt.
The goal is to inject the fat in a way that scatters it in the plane
and place of administration and optimizes its chance of developing
a blood supply and surviving, and the mental model should be one
of scattering tiny particles of fat into the recipient site in multiple
crisscrossing fine trails in multiple planes (as appropriate for the
area being treated) in such a way that each particle ideally sits in its
own compartment and has maximal contact with perfused tissue
and minimum contact with other injected fat cells to the extent pos-
sible. If fat is injected in the way in which an ordinary hypodermic
injection would be given, or if nonautologous fillers are typically
administered, fat cells will be bunched together, and only those on
the periphery of the injected area will have tissue contact and will
be likely to survive. The majority of the more centrally situated fat
particles will have contact only with each other and will be less
likely to survive, and this can lead to the formation of oil cysts and
contour irregularities. Put in more practical terms, the procedure
should be thought of as analogous to spray painting, not caulking.
At first the beginning injector will advance and withdraw the
injection cannula (back and forth movement) too slowly, but as
familiarity with the technique is acquired, the movements can and
should be made faster. Ultimately, all other things being equal, faster
movements are desirable, in that if the injection cannula is constantly
in motion, intravascular injection is less likely, and an accidental bolus
injection into one area is avoided. Rapid back and forth movements
ensure the smoothest and most uniform infiltration of fat.
How the syringe is held is also important in controlling the volume
expressed from the cannula with each pass and avoiding overinjec-
tion of a given area. If the syringe is held in the manner one would
typically use to give a filler injection, with the thumb on the end of
the syringe plunger, it is easy to inject too much fat unintentionally if
tissue resistance suddenly changes. More control can be generally be
maintained, and overinjection more easily avoided, if the syringe is
held with the end of the plunger in the palm of the hand (Fig. 50.11).
Although a bit of practice is required at first, with the syringe held
this way a slight closing of the hand results in only a small amount
of fat being expressed from the cannula, and overinjection of any one
area can more readily be avoided. Smaller cannulas now available
also help avoid bolus injection, as their small diameter physically
limits how rapidly fat can be extruded from the syringe.
Although cannula obstruction will be very uncommon if fat
is harvested and processed as described, if a cannula becomes
blocked, additional injection pressure should not be applied, as
this is the most common cause of a sudden and unintentional
bolus injection. It is better in such circumstances to simply
withdraw the blocked cannula, pass it to the surgical assistant,
and continue with a different one. The assistant can then clear the
obstruction while the surgeon continues to work. Typically, the
cause of the obstruction will be a particle of fat or subcutaneous
debris at the junction of the cannula and the inside of the cannula
Fig. 50.9 Transferring centrifuged fat to 1-mL syringes. Fat is transferred from 10-mL Luer lock syringes into 1-mL Luer lock syringes using a transfer
coupling after centrifugation and the oil and water fractions have been discarded. Proper injection in the very small quantities that are needed in
the face cannot be made with larger syringes. (a) 10-mL Luer lock syringe, 1-mL Luer lock syringe, and Luer-to-Luer transfer coupling. (b) Transfer
coupling in use. (Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
697
Table 50.2 Marten Clinic of Plastic Surgery facial fat grafting operating room reference guidelines
Region
in Fig.
50.10
Area
Cannula
Tissue plane
Amount, mL
(per side
except as
noted)
Special considerations
'iffiFuOWy
Size,
mm
Gauge Length,
cm
1
Temples
0.9
19
5
Subcutaneous
3–7
Larger cannula is less likely to perforate temporal veins.
If vein perforated, hold pressure on area for 3–5 min and
may then resume injections.
Intermediate
2
Supra-brow
0.7
20
5
Subcutaneous
1–3
Goal is to blend prominent brow with forehead.
Intermediate
3
Glabella
0.7
20
4
Subcutaneous
1–3* (total)
GF lines are not effectively treated with AFG unless
neurotoxin also used.
Intermediate
4
Radix
0.7
20
4
Preperiosteal
to skin
1-3* (total)
Can be continued on bridge of nose if inverted V or
rhinoplasty irregularities present (19).
Intermediate
5
Brow-supraorbital
(“upper eyelid”)
0.7
20
4
Preperiosteal/
sub–orbicularis
oculi
1–3
Conceptualize as lowering the supraorbital rim, not filling
the eyelid. Must protect ocular globe during fat infiltration.
Advanced
6
Infraorbital (“lower
eyelid”)
0.7
20
4
Preperiosteal/
sub–orbicularis
oculi
1–3
Important to inject perpendicularly from below rather
than parallel to defect. Must protect ocular globe during
fat infiltration.
Advanced
7
Nasojugal groove
(tear trough)
0.7
20
4
Preperiosteal/
sub–orbicularis
oculi
0.5–1.5
Important to inject perpendicularly from below rather
than parallel to defect.
Advanced
8
Midface
0.7
20
4
Preperiosteal
to skin
1–3
Overlaps infraorbital, tear trough, and cheek areas.
Beginner
9
Cheeks
0.7
20
5
Preperiosteal
to skin
3–7
Must consider shape of forehead, prominence of chin, and
width of mandible. If temples are hollow and not treated,
filling cheeks will look unnatural. Some of this fat will typically
be encountered during subsequent SMAS dissection.
Beginner
10
Lateral face/
preauricular
0.7
20
5
Subcutaneous
and sub-SMAS
1–3
Carefully placed in preparotid sub-SMAS location, this fat will
not be encountered during skin and SMAS flap dissections.
Intermediate
11
Buccal recess
0.7
20
4 or 5
Subcutaneous
1–3
Intermediate
12
Jawline
1.2
18
6
Preperiosteal/
submasseteric
3–9
Approached medial to lateral from puncture near
corner of mouth. Injection made on face of bone, not
subcutaneously, into muscle, or into parotid.
Intermediate
13
Nasolabial crease
(NLC)
0.7
20
4
Subcutaneous
0.5–1.5
Inject superficially if treating NLC, deep if treating maxillary
recession. Injecting larger volumes will not improve
results and can crease bizarre appearance. Overfilling NLC
area can result in reduced dental show when smiling.
Intermediate
14
Piriform
0.7
20
4
Preperiosteal
1–3* (total)
Project nasal tip. Overfilling can result in decreased upper
dental show when smiling.
Intermediate
Columellar–labial
junction
0.7
20
4
Preperiosteal
to skin
0.5–1.5
Improves columellar angle and projects tip of nose.
Intermediate
Upper lip
0.7
20
5
Submucosal
with emphasis
on vermilion–
cutaneous
junction
0.5–1.5
Injection should be made to create a central tubercle with
a sulcus on each side of it. Upper lip should be distinctively
smaller than lower lip (golden ratio). If upper lip the same size
as lower lip, mouth will appear contrived and unnatural.
Intermediate
Lower lip
0.7
20
5
Submucosal
beneath
vermilion
1–2.5
Injection should be made to create a central tubercle
with a sulcus on each side of it. Lower lip should be
distinctively larger than upper lip (golden ratio).
Intermediate
15
Labiomandibular
groove (“drool line”)
0.7
20
4
Mucosa to skin
0.5–2 (total) Goal is to fill and add structure to entire region, not to
spot-fill crease.
Intermediate
16
Labiomental sulcus
(“chin crease”)
0.7
20
4
Mucosa to skin
1–4 (total)
Adds vertical height to chin. Useful with chin implant to
avoid “implant look.”
Intermediate
17
Geniomandibular
groove (GMG)
0.7
20
4
Preperiosteal
to skin
1–3
Goal is to integrate chin and jawline to create smooth,
continuous aesthetic line.
Beginner
18
Chin
0.7
20
4
Preperiosteal
to skin
1–3
Exceeding 3 mL per side (6 mL total) can result in
excessive vertical height and globular appearance of chin.
Intermediate
19
Nasal dorsum
1–3* (total)
20
Forehead
0.7
20
5
Subcutaneous
2–4
Most often treating depression in midcentral area and
not entire forehead.
Intermediate
Abbreviation: SMAS, superficial musculoaponeurotic system.
*Important notes regarding recommended amounts:
1. Amounts listed in table are amounts administered per side, except where noted with asterisk and “(total).”
2. Amounts listed in table are for fat harvested with a 2.1- to 2.4-mm harvesting cannula centrifuged for 1–3 min at 1,000 rpm and administered to average-sized
female head in 0.5-mL aliquots as part of a facelift procedure. Larger amounts may be required for uncentrifuged or “tea-strained” fat, larger female faces; male
patients; and patients not undergoing facelift procedures.
3. A prudent and proven strategy for determining the amount of fat needed for a given site is to rate the severity of the defect based on what is seen in the preoperative
photos and then to use empirical data (as in this table) to choose the amount to be administered. As a practical matter, this amounts to simply rating the severity of
the problem at each proposed site of treatment as “small,” “medium,” or “large” and then using data in this table to determine the amount typically needed for
treatment of each area. If the defect is “small,” one would choose an amount from the low end of the recommended range. If the defect is “large,” one would
choose an amount from the high end, and if “medium” somewhere in between.

698
VIII Surgical Rejuvenation of the Face and Neck
hub, which is most easily cleared by removing the cannula from
the syringe and extracting the particle of fat or fragment tissue
debris from inside the hub with a fine forceps.
50.7.12 Planes of Fat Placement
Fat injections will necessarily be made in different planes,
depending on the areas being treated and the problem present. In
many areas where multiple tissue layers are present to inject in
and overlying skin is thick, injection can be made ´full-thicknessµ
at the treated site, from periosteum to the subdermal layer.
These areas typically include the geniomandibular groove (GMG,
prejowl groove), piriform, midface, cheek, and chin. In other
areas injections must necessarily be placed more specifically
if optimal results are to be obtained and if irregularities are to
be avoided, due to the anatomic characteristics of the treated
sites. These areas include the temples, which are injected sub-
cutaneously; the upper orbit, lower orbit, and tear trough, which
should be injected in a preperiosteal/sub–orbicularis oculi deep
plane; the lips, which should be injected predominantly in a
submucosal plane; and the jawline, which should be injected in
a preperiosteal/submasseteric plane. The easiest areas for the
beginning injector to treat are the areas in the full-thickness
category. In the beginning it is wise to ´stay deepµ and place the
majority of the graft in a predominantly preperiosteal plane.
Fig. 50.10 Anatomic regions typically addressed in treating facial areas. Red areas represent areas where fat is typically not injected. Additional and
more detailed information on the range of amounts of fat, injection cannula to be used, and other details for each region are given in Table 50.2. For
lip information see Fig. 50.23 and Fig. 50.24 and corresponding text. (Copyright © Timothy Marten.)
Fig. 50.11 Method of holding syringe to control volume released
during injection. If the syringe is held in the way one would typically
use to give an injection it is easy to infiltrate too much fat if tissue
resistance suddenly changes. More control can be maintained, and
over-injection better avoided, if the syringe is held with the end of the
plunger in the palm of the hand. Held in this manner a slight closing
of the hand results in a small amount of fat only being expressed.
(Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
699
Once familiarity with the technique has been obtained, areas in
the latter categories can then be treated. These areas will require
more careful and skilled placement of fat, however.
The ´lookµ the surgeon is after is also germane to depth of
fat placement. In general, if one is looking to enhance the facial
skeleton in the way one would with a facial implant, injections
should arguably be made more deeply. If one is seeking more of an
appearance of softness, at least some of the fat should be placed
superficially if the characteristics of the recipient site allow it.
50.7.13 Particulars of Sites of Treatment
Geniomandibular Groove Prejowl
Grafting of the prejowl/GMG area with fat has a high aesthetic
payoff and is a good area for the beginning injector to gain
experience with the technique (Fig. 50.12). Filling the GMG cre-
ates a strong, uninterrupted aesthetic line from the chin to the
posterior mandible that cannot be achieved by lifting the jowl
alone, and results in a highly desirable improvement on both the
male and female face. The effect is similar to the placement of a
Mittleman Pre -owl (Implantech Associates, Ventura, CA) implant
but is autologous and simpler to perform.
Injection of the GMG area is typically performed with a
4-cm-long, 0.7-mm (20-gauge) injection cannula from injection
sites on the mandibular border and the perioral area (Fig. 50.13),
and fat is placed in all tissue layers between the periosteum and
skin. Typically 1 to 3 mL of fat is placed in the GMG, depending
on the size of the depression and degree of atrophy present, but
occasionally more will be indicated. Another guideline for the
placement of fat in the GMG area is for the surgeon to imagine
filling the area in which one would place a pre--owl implant.
Cheek
Injecting the cheek with fat can enhance a patient’s facial shape
and proportion, increase cheek projection, and correct age-asso-
ciated loss of cheek volume. Often fat grafting can rival or even
exceed the kind of improvements obtained when Terino Malar,
Shell, and Binder Submalar (Implantech Associates, Ventura, CA)
and combined malar-submalar shell style cheek implants are
placed (Fig. 50.14). In some cases it can be argued that fat grafting
often results in a softer, more natural-appearing, integrated cheek
mass than cheek implants provide, and can produce a softer and
less harsh appearance (see case examples later in this chapter).
As the cheek atrophies, the lower eyelid fat bags become more
exposed and prominent (pseudoherniation). Removing lower
eyelid fat in such circumstances creates a hollow and elderly
appearance and a low lid–cheek junction. A better strategy for
many patients is to reconstitute the cheek with fat grafts, covering
up the pseudoherniated fat, raising the lid–cheek junction, and
creating a smooth and more youthful transition from the lower
eyelid to the cheek (Fig. 50.15).
Treatment of the cheek is usually performed using access inci-
sions on the cheek and the perioral areas (Fig. 50.16). A 5-cm-long
0.7-mm (20-gauge) cannula is used, and fat is placed in all tissue
layers between the periosteum and the skin. Typically 3 to 7 mL
of centrifuged fat is placed in the cheek area, depending on the
degree of atrophy present, but occasionally more will be indi-
cated. Often an asymmetrical placement of fat between the right
and left sides will also be required due to the common occurrence
of malar asymmetry, seen preoperatively in many patients.
Another guideline for the placement of fat in the cheek area is for
the surgeon to imagine filling the area in which one would place
a cheek implant. The cheek, like the geniomandibular groove, is a
good area for the beginning injector to treat.
Midface
The midface is a loosely defined triangular area bounded by the
infraorbital rim superiorly, the nasolabial fold medially, and the
zygomaticus major muscle laterally. For several decades the aging
change in this area has been characterized as one of descent and
referred to as “midface ptosis,” and as a result, a variety of failed
and/or largely abandoned procedures have been conceived over
the course of that time to ´liftµ what was thought to be the ´fallenµ
area. Often the early outcomes of these procedures looked satisfac-
tory, but surgeons and patients were confounded by the fact that
once healing was complete (and swelling had subsided), too often
no discernible difference from the preoperative condition was seen.
Fig. 50.12 Treatment of the geniomandibular groove (GMG) with fat injections. (a) Patient with deep GMG (prejowl sulcus) seen preoperatively. The
chin appears narrow and pointed, and there is poor continuity between the chin and jawline. (b) Same patient seen after facelift and injection of fat
to fill the GMG area. No chin implant was placed. The chin appears broader and more aesthetically integrated with the jawline. Fat was also used to
strengthen the posterior jawline, lower the mandibular angle, and fill the lips, nasolabial crease, cheeks, and infraorbital areas. (Procedure performed
by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
b
a

700
VIII Surgical Rejuvenation of the Face and Neck
In time, surgeons came to realize that the aging change in the
midface consisted largely of GHÁDWLRQ, not descent, and a rethink-
ing of how the midface should be best treated occurred. It is now
more widely recognized that one cannot lift an empty space but
instead must fill it, and fat injections have taken a starring role
in treatment of this aesthetically important area. Indeed, Tonnard
and Verpaele, who once advocated ´liftingµ the midface with a
medially placed minimal-access cranial suspension (MACS) suture,
have abandoned this suture placement and instead acknowledge
that the midface can be effectively and better rejuvenated by fat
injections alone.
Practically speaking, the midface is overlapped by the infraor-
bital region, the tear trough, and the cheek (see Fig. 50.10), and
when these adjacent areas are treated and feathered into each
other, specific filling of the midface may not be needed. Much
depends on how one defines each of these areas. Fat grafting
the midface when indicated can correct an atrophic and feeble
appearance that occurs as it shrinks with age by filling and
strengthening this aesthetically important area.
Fig. 50.13 Incision sites and plan for injecting fat into the prejowl or
geniomandibular groove (GMG) areas. Injection of these areas is per-
formed with a 4-cm-long 0.7-mm (20-gauge) cannula, and fat is placed
in all tissue layers between the periosteum and skin. Typically 1 to 3 mL
of centrifuged fat is placed on each side. Level of difficulty: beginner.
(Copyright © Timothy Marten.)
Fig. 50.14 Enhancing the cheeks with fat. Injecting the cheek with fat can enhance a patient’s facial shape and proportion, increase cheek projection,
and correct age-associated loss of cheek volume. (a) Patient with atrophic cheek and face before facelift and fat injections. (b) Same patient seen 1
year and 8 months after high–superficial musculoaponeurotic system (SMAS) facelift, forehead lift, neck lift, and panfacial fat injections. Fat grafting
often results in a softer, more natural-appearing, less harsh, and better integrated cheek mass than cheek implants provide. (Procedure performed
by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
Fig. 50.15 Enhancing the cheeks with fat and treating pseudoherniation of lower eyelid fat. As the cheek atrophies, the lower eyelid fat “bags”
become more exposed and prominent. Removing lower eyelid fat would create a hollow and elderly appearance. (a) Patient with atrophic cheek. The
lower lid fat is exposed and appears ostensibly as a “bag.” (b) Same patient seen after fat injections to the cheeks but no blepharoplasty. Protruding
lower eyelid fat has been disguised by building up and reconstituting the cheek. This produces a more youthful, fit, and attractive appearance than
removing lower lid fat would have. Note that the upper orbit has been replenished with fat injections as well. (Procedure performed by Timothy
Marten, MD, FACS. Copyright © Timothy Marten.)
b
a

50 Simultaneous Facelift and Facial Fat Grafting
701
Injection of the midface is typically performed with a 4-cm-long,
0.7-mm (20-gauge) cannula for stab incisions on the mid–inferior
medial cheek, and fat can be placed in all tissue layers between
the periosteum and skin. Typically 1 to 3 mL of centrifuged fat is
placed in each side, depending on degree of atrophy present, but
occasionally more or less will be indicated.
Chin
Injection of the chin with fat can correct age-associated loss of
chin volume, improve chin projection, and increase vertical chin
height, rivaling the kind of improvements obtained when small
chin implants are placed (Fig. 50.17).
Fat grafting of the chin can also correct an atrophic and feeble
appearance that occurs as the chin shrinks with age by broaden-
ing and strengthening it (Fig. 50.18) and filling in the labiomental
groove and the submental crease when indicated. The ability to
modify and fill the labiomental crease is a distinct advantage of fat
grafting over a chin implant. Typically, treatment of the chin must
be undertaken in conjunction with the GMG, and the two areas
will overlap each other in most cases.
Injection of the chin is typically performed with a 4-cm long,
0.7-mm (20-gauge) injection cannula from injection sites on the
mandibular border. Occasionally a third incision is used in the
midline of the lower lip (Fig. 50.19), and fat is placed in all tissue
layers between the periosteum and skin. Typically 1 to 3 mL of
centrifuged fat is placed in each side of the chin, depending on its
size and shape and degree of atrophy, but occasionally more or
less will be indicated. Another guideline for the placement of fat in
the chin area is for the surgeon to imagine filling the area in which
one would place an “extended anatomic” chin implant.
Despite the recommendations of some surgeons to the contrary,
fat injections to the chin are best used for small augmentations
only. If large changes in chin projection are attempted, a globular
and less sculptural appearance is usually obtained, and patients
in need of larger increases in chin projection are arguably better
treated with a chin implant or, most ideally, a chin implant and fat
injections combined.
Nasolabial Injection
One of the first areas most patients inquire about when consid-
ering fat injections, and most surgeons are typically eager to
treat, is the nasolabial crease. Nonetheless, one must be aware of
several misconceptions and certain limitations of the fat grafting
technique in regard to the treatment of this area. The first is that
treatment of the nasolabial creases with fat is generally not as
effective as treatment with nonautologous fillers. Fat is softer
and typically placed more deeply than nonautologous fillers, and
fat is better used to treat a volume deficiency in a region of the
Fig. 50.16 Incision sites and plan for injecting fat into the cheek area.
Fat grafting of the cheeks is typically performed with a 5-cm-long
0.7-mm (20-gauge) cannula, and fat is placed in all tissue layers
between the periosteum and skin in most cases. Typically 3 to 7 mL
of centrifuged fat is placed in each check. Level of difficulty: beginner.
(Copyright © Timothy Marten.)
Fig. 50.17 Using fat injections to project the chin. (a) Patient with underprojected chin seen before secondary facelift and fat injections. (b) Same
patient seen after secondary facelift with fat injections to the chin. No chin implant was placed. Injection of the chin with fat can enhance a patient’s
profile and approach the kind of improvements obtained when small chin implants are placed as shown. Fat was also placed in the upper and lower
orbits, cheeks, lips, and jawline areas. (Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

702
VIII Surgical Rejuvenation of the Face and Neck
face, as opposed to a more discrete line, wrinkle, or fold that is
subject to the repeated stress of facial muscle contraction and
facial movement. Patients undergoing fat injections solely for
treatment of their nasolabial folds will generally be disappointed
with the outcome. This is not the case, however, when a simul-
taneous facelift is performed and cheek and midface tissues
are repositioned and redundant cheek skin is excised. Fat is an
excellent adjunct in the treatment of the nasolabial fold in such
instances (Fig. 50.20). It is also not immediately and intuitively
obvious, but increasingly more widely appreciated by those
injecting nonautologous fillers into the face, that fiOOLQJ WKH XSSHU
PLGFKHHN SURGXFHV D SURfRXQGO\ EHQHfiFLDO H̵HFW RQ WKH QDVRODELDO
fold by integrating it with the rest of the face, and that treatment
of the fold is more effective when combined filling of both these
areas (nasolabial crease and cheek) is made. If the cheek is filled
as well as the crease, less fat is needed to improve the nasolabial
crease, and an overall better result will be obtained.
It is now generally accepted that the nasolabial crease is also
due, at least in part, to age-related loss of maxillary projection, and
the goal of injecting fat in the nasolabial areas should be thought
of at least in part as augmentation and restoration of maxillary/
midface projection rather than as simple filling of the soft tissue
Fig. 50.18 Using fat injections to strengthen the aging chin. (a) Preoperative view of patient with atrophic and feeble-appearing, deflated chin. (b)
Same patient seen after secondary facelift and fat injections to the chin, geniomandibular groove (GMG), and jawline areas. No chin implant was
placed. The atrophic and feeble appearance was corrected with fat injections by broadening and strengthening the chin. Treatment of the chin
along with the GMG and jawline areas enables strengthening of the entire lower facial contour. (Procedure performed by Timothy Marten, MD, FACS.
Copyright © Timothy Marten.)
Fig. 50.19 Incision sites and plan for injecting fat into the chin. Fat
grafting of the chin is typically performed with a 4-cm long 0.7-mm
(20-gauge) cannula, and fat is placed in all tissue layers between the
periosteum and skin. Typically 1 to 3 mL of centrifuged fat is placed
in each side of the chin. Level of difficulty: intermediate. (Copyright ©
Timothy Marten.)
Fig. 50.20 Combined lifting and filling of the nasolabial fold. (a) Patient with midface ptosis and heavy nasolabial fold. (b) Same patient seen after
high–superficial musculoaponeurotic system (SMAS) facelift and fat injections to the nasolabial creases. A combined lifting and filling provides a
better improvement than either procedure performed alone. (Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
b
a

50 Simultaneous Facelift and Facial Fat Grafting
703
crease. Accordingly, the surgeon’s effort, and how and where fat is
injected, will depend on the problem present. Injections should
be made more superficially and predominantly subcutaneously if
one is treating the nasolabial crease. Injections should be placed
more deeply and predominantly over the piriform in the upper
nasolabial area if one is treating age-associated maxillary reces-
sion. Many patients are best served by placement of fat in both
places.
A 4-cm long 0.7-mm (20-gauge) cannula is used, and fat is
placed in tissue layers between the periosteum and skin as appro-
priate for the problem present and, per the preceding discussion,
using access incisions in the perioral area (Fig. 50.21). Typically
0.5 to 1.5 mL of centrifuged fat is placed in the piriform/nasolabial
area, depending on the degree of the problem present, but occa-
sionally more or less will be indicated. Another guideline for the
placement of fat in the piriform area is for the surgeon to imagine
filling the area in which one would place a Peri-Pyriform implant.
Overfilling the nasolabial area is a common eventual outcome
of the frustration that arises when treating the nasolabial crease
with fat in isolation and in the same way one would inject non-
autologous fillers. Higher and higher volumes will be tried in a
futile effort to efface the crease, but an improved outcome will not
be obtained from injecting these larger amounts of fat. Instead,
the result is generally an abnormally heavy and objectionable-
appearing unaesthetic fullness of the midface. In addition, over-
filling the nasolabial area can produce changes in the posture of
patients’ mouth and the shape and size of their smile, and result
in a change in their ´look.µ For these reasons it is important to
advise patients accordingly, for the surgeon to set reasonable
goals, and to limit the amount of fat placed in the nasolabial area
to a reasonable amount.
Lips
There is perhaps no better example of the precedence of shape
and contour over a simple increase in volume than the lips. The
real measure of success in treating the lips is whether the treated
area has a healthy, fit, youthful, and sensual appearance³not
simply whether they are larger.
Despite the fact that patients and injectors are often erroneously
focused on the upper lip, the lower lip in the youthful mouth is
distinctly bigger than the upper lip, and in most cases the priority
in rejuvenation of the oral area is to restore lost lower lip volume.
This fact can easily be confirmed by having patients bring in
photos of themselves at a younger age, and a useful aesthetic goal
is to restore the relationship of the upper and lower lips to the
´golden proportionµ of approximately 1:1.6. Overfilling the upper
lip, or making the upper and lower lips the same size, will result
in unnatural ´clown mouth,µ ´Halloween wax lips,µ or having
been ´punched in the mouthµ appeaerance. In the aesthetic, nat-
ural-appearing mouth the lower lip is distinctly larger and fuller
that the upper lip, and this should be the goal when augmenting
the lips with fat (Fig. 50.22).
Treating the lips with fat has distinct advantages and disadvan-
tages that will both attract and repel surgeons and patients alike.
The advantages include that fat is autologous and arguably what was
present in youth, and if the procedure is successful and graft ´takeµ
is good, patients will be spared the inconvenience and discomfort
of having to undergo repeated filler treatments. Fat also produces a
Fig. 50.21 Incision sites and plan for injecting fat into the piriform
and nasolabial crease area. Fat grafting of the piriform and nasolabial
crease is typically performed with a 4-cm long 0.7-mm (20-gauge)
cannula. Fat is placed subcutaneously and superficially if treatment of
the nasolabial skin crease is the goal, and preperiosteally if improve-
ment in age-associated maxillary recession is desired. Fat is placed in
all tissue layers between the periosteum and skin if both problems are
present and are being treated. Typically 0.5 to 1.5 mL of centrifuged
fat is placed on each side. Level of difficulty: intermediate. (Copyright
© Timothy Marten.)
Fig. 50.22 Enhancement of lip volume with fat injections. Fat grafting the lips produces a soft, natural-appearing improvement in lip appearance
and slight undercorrection that is appropriate for the typical facelift patient in need of enhanced lip volume. Nonautologous fillers invite overcorrec-
tion and tend to produce a more stylized lip appearance. (a) Perioral area of a facelift patient seen before fat injections. Note that upper and lower
lips appear approximately the same size. (b) Same patient seen after facelift that included fat grafting of the lips. The lips are fuller and healthier-
appearing but soft and natural-looking. Note that the lower lip is distinctly larger than the upper lip and that fat has been placed to produce a natural,
sensual shape. (Copyright © Timothy Marten.)

704
VIII Surgical Rejuvenation of the Face and Neck
soft, natural-appearing improvement, and usually slight undercor-
rection, which we find to be most appropriate for the typical facelift
patient in need of some improvement around the mouth. In fact,
overcorrection of the lips with fat injections in our experience is
difficult unless a patient undergoes multiple treatments.
Fat injections to the lips have the distinct disadvantages that they
usually produce a ´monstrousµ amount of swelling that is slow to
resolve and that the ´takeµ of the graft varies from patient to patient,
and therefore so does the eventual outcome. Take can also be uneven,
in some cases leading to lumps and asymmetries that can be disturb-
ing to patients. Patients seeking a quick recovery, a specific lip size or
shape, or a full, stylized lip appearance are not optimal candidates for
the procedure. In particular, patients must be warned that it is gen-
erally not possible to create the highly stylized ´cover girlµ or ´stung
by a beeµ lip appearance seen in fashion magazines using fat. These
appearances are better obtained using nonautologous fillers, and
patients seeking such appearances should be advised accordingly.
Patients seeking nuanced changes in lip appearance are also not
good candidates for fat injections. These include patients seeking
corrections of small asymmetries, patients seeking accentuation
of the vermilion–cutaneous junction or requesting that specific
parts of their lip be ´lifted,µ ´rolled out,µ and the like. :hile fat can
be placed to achieve these appearances to some degree, it is rarely
dramatic or exact enough to satisfy most patients requesting
these sorts of improvements, and patients making these kinds of
requests are currently best treated with nonautologous fillers.
:hen the lips are to be treated, the prep of the face should
include the upper and lower gingivobuccal sulci, the buccal sur-
face of the anterior teeth, and the tongue if it rests in the surgical
field anterior to the incisors. Typically, the lips are treated after
all other areas have been fat-grafted but before the facelift is
begun, since treatment will require the surgeon to insert her or
his fingers inside the patient’s mouth. After injection is complete,
the surgeon can remove and replace her or his outer gloves, and
the anterior face and mouth can then be quickly reprepped.
A 5-cm long, 0.7-mm cannula is usually used to infiltrate fat
into the lips, but a slightly larger 0.9-mm cannula may be easier
for the beginning injector, as it is harder to perforate the mucosa
or vermilion accidentally with the larger instrument. Injection is
made from access incisions in the perioral region (Fig. 50.23), and
fat is placed submucosally beneath the vermilion and subdermally
in the white roll areas.
Typically the first few passes of the cannula are used to place
fat subcutaneously/submucosally directly under the vermilion–
cutaneous junction, then under the “red roll,” and then subdermally
under the ´white roll.µ Fat is then infiltrated submucosally beneath
the wet and dry lip vermilion in a way that optimizes lip shape (Fig.
50.22; Fig. 50.24). A total of 0.5 to 1.5 mL is usually placed in each side
of the upper lip and 1 to 2.5 mL in each side of the lower lip, for a total
of 1 to 5 mL per lip. Lesser amounts generally produce suboptimal
outcomes after initial swelling has abated. Larger amounts increase
swelling but generally do not result in an improved outcome.
A common error to be avoided when injecting fat (or nonautol-
ogous filler) into the lips is to fill the lips indiscriminately in such a
manner that a large but shapeless and unnatural-appearing ´sau-
sage lipµ is produced. To some extent the fat injection technique is
not prone to this, as lips treated with fat naturally tend to assume
the shape of the patient’s given lip envelope once swelling abates
and healing is complete. An attractive lip is generally one that is
not just big but has an aesthetically pleasing shape, and fat can
and should be injected in a way that creates these appearances.
The attractive lower lip typically has two tubercles³that is, two
areas of fullness laterally with a small central depression between
them. The attractive upper lip, by contrast, has three aesthetic
tubercles, one centrally and one on each side laterally, with slight
depressions between them (Fig. 50.24). Time taken to inject
fat to create these sorts of natural and aesthetic appearances is
well spent. In addition, depressions between lip tubercles can be
enhanced upon completion of injections by placing a finger and
thumb on the inside and outside of the lip and gently bidigitally
compressing areas between tubercles to enhance the sulci and to
optimize fat position and lip shape.
Perioral Area
with perioral wrinkles and ´pucker lines.µ Traditional resurfacing
by peel, laser, or dermabrasion typically provides an incomplete
solution for these patients in that these procedures address only
the skin itself and do nothing to replenish age-associated loss of
perioral subcutaneous fat. Patients may have smoother-appearing
skin in repose after these skin resurfacing treatments, but when
they speak or move their mouth, deep and objectionable lines
appear and perioral deflation and subcutaneous atrophy becomes
plainly evident. Typically these appearances spoil an otherwise
Fig. 50.23 Incision sites and plan for injecting fat into the upper and lower lip areas. Fat grafting of the lips is performed with a 5-cm 0.7-mm
(20-gauge) cannula, and fat is placed submucosally beneath the vermilion and subdermally in the “white roll” areas. (a) Typically, a total of 0.5 to 1.5
mL of centrifuged fat is placed in each side of the upper lip, and (b) 1 to 2.5 mL is placed in each side of the lower lip. Level of difficulty: intermediate.
(Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
705
excellent facelift result and stand as telltale evidence that the
patient is really older than she or he otherwise appears.
Fat injections provide a means by which this can be avoided
and fat normally situated between skin and orbicularis oris can
be replaced. A second likely benefit of perioral fat injections
rests in the ´stem cellµ effect the procedure provides. Experience
with combined dermabrasion or laser resurfacing and perioral
fat injections empirically suggests that healing and the overall
outcome are better when resurfacing procedures are combined
with fat injections, above and beyond the improvement gained by
simple volume addition (Fig. 50.25).
:hen injecting the perioral area, care must be taken not to
overfill the white upper lip in the name of wrinkle reduction, as
the patient’s upper lip can be lengthened, dental show can be
reduced, and an abnormal, convex, ´simianµ contour in profile can
result. A better strategy is to concentrate one’s efforts on and near
the ´white rollµ area, where the wrinkles are typically the deepest
and appear most objectionable (Fig. 50.25). Results are further
enhanced by injecting additional fat at the columellar–labial
angle, as this helps restore a youthful transition from the nose to
the lip and helps create a youthful concave upper lip shape.
Jawline
Fat grafting of the jawline area can enhance a patient’s facial shape
and produce the kind of improvements obtained when mandibular
border and ´Taylorµ-style mandibular angle implants (Implantech
Associates, Ventura, CA) are placed (Fig. 50.26; Fig. 50.27).
Fat injections along the mandible can also correct an atrophic
and feeble appearance that occurs as the mandibular border
shrinks with age by broadening and strengthening it. Typically,
treatment of the jawline must be undertaken in conjunction with
the GMG, and the two areas will overlap each other in most cases.
A 6-cm long 1.2-mm (18-gauge) cannula is usually used to
fat-graft the jawline, and fat is placed in a submasseteric/preperi-
osteal plane as appropriate for the problem present using access
incisions situated over the medial mandibular border and lateral
perioral areas (Fig. 50.28). Typically 3 to 6 mL of centrifuged fat
is placed on each side, but occasionally more or less will be indi-
cated. Another guideline for the placement of fat in the jawline
area is for the surgeon to imagine filling the area in which one
would place a Taylor lateral mandibular implant.
1ote that in treating the jawline fat is injected in a submasse-
teric/preperiosteal plane and not injected subcutaneously, into the
parotid, or into the masseter muscle. Note also that the cannula is
inserted in a manner in which it does not perforate the parotid or
masseter but is instead passed under them.
Although not intuitively obvious, strengthening a jawline and
posterior mandibular border when indicated makes the patient
appear more youthful, fit, and attractive and is an artistically pow-
erful adjunct to a facelift that helps avert the scrawny, deficient, and
fragile mandibular contour typically seen in the aging and elderly
face, which is usually made worse when a facelift is performed.
Fig. 50.24 Strategy for fat-grafting the lips. The natural and
attractive-appearing upper lip has one central tubercle and two lateral
tubercles with a sulcus between them. The lower lip should have a
central sulcus with a tubercle on each side of it. Fat should be injected
in a manner to duplicate these appearances and not simply to make the
mouth larger or to create “sausage-shaped” lips. To create a youthful
and sensual appearance, and to optimize treatment of perioral wrinkling,
fat must also be placed superficially under the vermilion–cutaneous
junction as shown. (Copyright © Timothy Marten.)
Fig. 50.25 Combined perioral resurfacing and fat injections. (a) Patient seen preoperatively with wrinkled, atrophic perioral area that lends an elderly,
unhealthy, and objectionable appearance to the face. Note the flat, unprojected appearance of mouth area. (b) Same patient seen 2 years and 7 months
after high–superficial musculoaponeurotic system (SMAS) facelift that included combined perioral fat injections and perioral dermabrasion. Both
atrophy and wrinkling have been improved, and the mouth has a more youthful, vibrant, and healthy appearance. The combined treatment produced a
better appearance than either procedure performed alone. (Procedure performed by Timothy J Marten, MD, FACS. Copyright © Timothy Marten.)
b
a

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VIII Surgical Rejuvenation of the Face and Neck
Fat-grafting the jawline is particularly useful in the secondary
facelift patient and in the patient with a ´long faceµ seeking facial
rejuvenation or improvement. Typically the secondary facelift
patient has experienced significant loss of jawline volume due
to loss or inappropriate surgical removal of facial fat, and this
is typically compounded by overzealous tightening of overlying
tissues. These appearances are readily reversed with jawline fat
grafting, and fat-grafting this area constitutes an important part
of many of our treatment plans for our secondary and tertiary
facelift patients.
Temple Area
Temporal hollowing is a consistent marker of the fourth decade
of life that is readily improved with fat injections (Fig. 50.29).
Even skillfully performed isolated eyelid surgery will result in
marginal improvement in overall orbital and upper facial appear-
ance if the outcomes of blepharoplasties are viewed against the
background of a hollow, elderly-appearing, atrophic, empty
temple. Fat-grafting the temple allows comprehensive improve-
ment of the entire upper orbital region, not just spot treatment
Fig. 50.28 Incision sites and plan for injecting fat into the posterior
jawline. Fat grafting of the jawline is usually performed with an 8-cm
1.2-mm (18-gauge) cannula, and fat is placed in a preperiosteal/sub–
masseteric muscle plane. Typically 3 to 6 mL of centrifuged fat is placed
in each side. Note that fat is not injected subcutaneously, into the
parotid, or into the masseter muscle. Level of difficulty: intermediate.
(Copyright © Timothy Marten.)
Fig. 50.27 Using fat injections to enhance mandibular contour and strengthen the jawline. (a) Patient seen before surgery with small mandible,
narrow intergonal distance, and lower facial disproportion. (b) Same patient after high–superficial musculoaponeurotic system (SMAS) facelift
and fat injections to the posterior jawline. No implants have been placed. Strengthening the jawline and posterior mandibular border results in a
more fit and proportionate appearance and helps avert the tight and deficient mandibular contour typically seen in the elderly face after a facelift
is performed. (Note: Fat has also been injected in the chin, geniomandibular grooves, buccal recess, and lip areas. Procedure performed by Timothy
Marten, MD, FACS. Copyright © Timothy Marten.)
Fig. 50.26 Using fat injections to enhance mandibular contour and strengthen the jawline. (a) Patient seen before surgery with a small mandible
having a narrow intergonial distance. A previous facelift performed by an unknown surgeon has tightened soft tissues over the jawline, resulting in a
harsh mandibular contour. (b) Same patient after fat injections to the jawline, geniomandibular groove, chin, lips, buccal recess, midface, and cheeks.
No implants have been placed and no secondary facelift was performed. Strengthening the jawline and posterior mandibular border results in a
more fit and proportionate appearance and helps avert the tight and deficient mandibular contour typically seen in many patients after a facelift is
performed. (Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
707
of the eyelid areas. Accordingly, it constitutes an important and
essential part of contemporary “blepharoplasty” procedures.
Fat-grafting the temples is also important to facial shaping
typically sought by surgeons with a sharp aesthetic eye in their
facelift procedures. The ideal youthful and attractive female
face has an inverted oval shape that with age typically changes
to a more rectangular, bottom-heavy one as the lower face, jowl,
and jawline sag. Temporal atrophy and hollowing contributes
further to this rectangularization and, when advanced, even a
´peanutµ-like facial shape. :hile a well-performed facelift will
correct the lower facial squareness, temporal filling by way of fat
grafting provides for a wider intertemporal distance and produces
an overall more inverted oval shape. In this way, temporal filling
accomplishes much more than simple filling of the temporal
hollow, or even than a more comprehensive rejuvenation of the
eyelids and orbital area³it can provide a more youthful, feminine,
and beautiful-appearing facial shape.
The temple areas are usually grafted in a subcutaneous plane
from small stab incisions just within the temporal hairline (Fig.
50.30). Typically 3 to 7 mL of centrifuged fat is placed in the temple
area, but occasionally more or less will be indicated. In most cases
a slightly bigger and blunter, 0.9-mm, 6-cm long injection cannula
is superior to sharper and smaller-diameter types preferred else-
where. Using slightly larger cannulas helps minimize perforation
of temporal veins predictably present in the temporal area, and
allows fat to be placed over and around them to conceal them.
The injection cannula is not inserted specifically above or below
the temporal veins but rather is allowed to pass into the plane of
least resistance in the temporal area. Should a temporal vein be
inadvertently penetrated during injection despite these precau-
tions and swelling from the leakage of venous blood noted, it is
a simple matter to hold pressure on the temporal area for a few
moments with a surgical sponge. Typically after applying uniform
and continuous pressure for a few minutes, bleeding stops and
treatment of the area can be completed.
Buccal Recess Area
Buccal atrophy is frequently present in the fourth decade of life
and beyond in patients and can be readily improved with fat
grafting, as can buccal hollowing due to previous overzealous
excision of buccal fat or resulting from ill-conceived facial lipo-
suction of the buccal area (Fig. 50.31).
Injection of the buccal recess is typically performed with a 4- or
5-cm-long 0.7-mm (20-gauge) injection cannula from injection
sites on the medial midcheek (Fig. 50.32), and fat is placed in
both subcutaneous and sub-SMAS planes. Typically 1 to 3 mL of
centrifuged fat is placed in each side, depending on the degree of
atrophy present, but occasionally more or less will be indicated.
Upper Orbit/“Upper Eyelid” Area
:hether a hollow upper orbit is the result of illness, aging,
or an overzealous surgical procedure, filling it can produce a
remarkable rejuvenation of the upper eyelid and eliminate an
unnaturally hollow and elderly appearance, sometimes referred
to by patients as ´nursing homeµ or ´owlµ eyes (Fig. 50.33).
Fig. 50.29 Filling of the temple hollow with fat. Temporal hollowing is a consistent marker of the fourth decade of life that is readily improved with
fat injections. (a) Patient aged 45 before surgery. (b) Same patient 2 years and 4 months after high–superficial musculoaponeurotic system (SMAS)
facelift and fat injection to the temple region (Note: Fat has also been injected in the upper and lower orbital areas. Procedure performed by Timothy
Marten, MD, FACS. Copyright © Timothy Marten.)
Fig. 50.30 Incision sites and plan for injecting fat into the temple areas.
Injection of the temples is performed with a 5-cm long 0.9-mm (19-gauge)
cannula, and fat is placed in a subcutaneous plane. Typically 3 to 7 mL of
centrifuged fat is placed on each side. Level of difficulty: intermediate.
(Copyright © Timothy Marten.)

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VIII Surgical Rejuvenation of the Face and Neck
:hat layers into which fat should be placed in the upper orbit
(´upper eyelidµ) is a subject of some debate, and subcutaneous,
sub–orbicularis oculi, and even subseptal (intraorbital) locations
have all been advocated and safely and effectively used by various
surgeons. For the beginning injector, it is safest to avoid the sub-
septal area due to the small but not insignificant risk of intraorbital
and retrobulbar bleeding and other possible problems. It is also
wise to avoid a purely subcutaneous injection in this area, due to
the extremely thin skin present, and to limit initial injections to a
preperiosteal/sub–orbicularis oculi location.
A common misconception in treating the hollow upper orbit is
that the fat is needed and should be injected in the preseptal portion
of the eyelid itself. The hollow upper eyelid is more properly and
practically restored by placing fat in a preorbital position along the
inferior margin of the supraorbital rim however, and the process
is best conceptualized as one of lowering the inferior margin of the
supraorbital rim and filling the upper orbital area to lower skin
that has retracted up into the orbit down onto the preseptal eyelid
to create a full and appropriately creased upper eyelid. Once one
accepts that improvement is obtained by injection of the orbit,
and not the eyelid itself, it becomes apparent that larger volumes
than might otherwise be expected are required. Smaller injection
cannulas now available have made injecting the upper orbit easier
and more predictable than in the past, as they can be advanced
more smoothly and accurately through tissues and allow the
deposition of very tiny aliquots of fat per pass, and it is highly
recommended that small cannulas be used to treat this area.
Currently a 4-cm long 0.7-mm (20-gauge) cannula is preferred,
and in general 1 to 3 mL of centrifuged fat must be placed in each
upper orbit to achieve the improvement typically required, but on
occasion more or less may be indicated.
:hen fat-grafting the upper orbit, it should always be remem-
bered that one is working in very close proximity to the eye, and
although the injection cannulas are blunt-tipped, they are small
and easily capable of perforating the ocular globe. In light of this,
several important technical considerations should be observed.
First, injection sites should be placed in such a way that the
injection cannula will be passed parallel to the globe and the
supraorbital rim, not perpendicular to them (Fig. 50.34).
Directing the cannula toward the globe when injecting the upper
orbit is potentially dangerous and should be avoided. Second, the
index finger of the surgeon’s nondominant (noninjecting) hand
should always be held firmly on the inferior margin of the supraor-
bital rim as cannulas are passed into tissues and injection is made,
and this finger should always be kept between the tip of the can-
nula and the globe (Fig. 50.35). The idea is to position the finger
so that the cannula will hit it instead of penetrating the globe if
inadvertently misdirected. Having one’s finger in this position also
gives important feedback to the injector as to where the tip of the
cannula is and helps one place fat as accurately as possible. Finally,
a shorter, 4-cm long cannula is easier to control and keep in the
correct plane on the inferior margin of the supraorbital rim and
should be used in preference to longer instruments.
Fat-grafting the upper orbit and ´eyelidµ is advanced in dif-
ficulty, and this area should be treated only by a surgeon who
has gained experience treating more forgiving areas. Once that
experience is obtained, fat-grafting the upper orbit can be one of
the most artistically rewarding uses of autologous fat and is likely
to become a routine part of rejuvenating the upper eyelid in the
future.
Fig. 50.31 Correction of buccal atrophy and overexcision of buccal fat. Buccal fat excision is often erroneously recommended as a way of creating
a “high cheekbone” and more angular facial appearance. In reality, it often produces an ill, haggard, gaunt, and unfeminine appearance, especially
when performed aggressively. (a) Patient with buccal hollowing following buccal fat excision by an unknown surgeon. (b) Same patient 11 months
after fat injections to the buccal area. (Note: Fat has also been placed in the infraorbital, midface, cheek, preoral, and jawline areas. Procedure
performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
Fig. 50.32 Incision sites and plan for injecting fat into the buccal
hollows. Fat grafting of the buccal hollow is typically performed
with a 4- or 5-cm 0.7-mm (20-gauge) cannula, and fat is placed
subcutaneously and in sub–superficial musculoaponeurotic system
(SMAS), or buccal space, locations in most cases. Typically 1 to 3 mL of
centrifuged fat is placed in each side. Level of difficulty: intermediate.
(Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
709
Lower Orbit/“Lower Eyelid” Area
Injecting the infraorbital (´lower eyelidµ) area is in some ways
analogous to injecting the upper orbit in that there are similar
misconceptions as to where the fat should be placed, similar tech-
nical considerations for which tissue layers fat should be injected
into, and similar concerns regarding injury to the ocular globe. In
addition, and as with injecting the upper orbit, the artistic payoff
is high if the procedure is carried out correctly (Fig. 50.36).
Injecting the infraorbital area allows correction of age-related
atrophy and hollowness, which lends the face and ill or haggard
appearance; ´shortensµ the apparent length of the lower eyelid;
and produces a youthful, attractive and highly desirable smooth
transition from the lower eyelid to the cheek that is generally
unobtainable by traditional lower eyelid surgery, fat transpositions,
´septal resetsµ midface lifts, free fat grafts, and other such means.
As is the case in treating the upper orbit, fat need not and should
not be injected in the pretarsal lower eyelid. Fat should be injected
deep in a submuscular (orbicularis oculi)/preperiosteal plane, and
the technical goal of the procedure should be thought of as raising
up and anteriorly projecting the infraorbital rim rather that filling
the lid itself. And as in the upper orbit, volumes required to obtain
corrections in the lower orbit are typically more than one might
intuitively expect, and 1 to 3 mL is usually necessary to produce
the desired effect, although sometimes more or less will be
indicated. In contrast to the upper orbit, however, experience has
shown that fat is best and most easily injected, and a “banana” or
´sausage rollµ (unaesthetic bulge) is less likely to occur, if injection
is made from injection sites on the midcheek perpendicular to the
infra-orbital rim (Fig. 50.37a). :hen fat is injected in this manner,
lumps and irregularities are also less common.
Fat should not be injected parallel to the lid–cheek junction in the
infraorbital area (Fig. 50.37b). It is our observation that surgeons
injecting fat parallel to the infraorbital rim have more trouble
getting fat into the proper plane and location and have more
problems with irregularities, lumps and bumps, sausage- and
banana-shaped bulges, and other untoward results.
As is the case in injecting the upper orbit, when injecting the
lower orbit, the index finger of the surgeon’s nondominant (non-
injecting) hand should be placed firmly on the infraorbital rim to
protect the ocular globe while injections are made, and this finger
Fig. 50.34 Incision sites and plan for injecting fat into the upper orbital
(“upper eyelid”) area. Injection of the upper orbital area is performed
with a 4-cm long 0.7-mm cannula, and fat is placed in a sub–orbicularis
oculi/preperiosteal plane. Typically 1 to 3 mL of centrifuged fat is
placed in each upper orbit, but occasionally more is indicated. Level of
difficulty: advanced. (Copyright © Timothy Marten.)
Fig. 50.35 Protecting the globe when injecting fat into the upper
orbital (“upper eyelid”) area. To protect the ocular globe when
injecting fat into the upper orbit, the index finger of the surgeon’s
nondominant (noninjecting) hand should always be held firmly on
the inferior margin of the supraorbital rim as cannulas are passed into
tissues and injection is made. (Copyright © Timothy Marten.)
Fig. 50.33 Correcting upper orbital hollowing. (a) Patient with hollow upper eyelid, an unnaturally hollow and elderly ocular “owl eye” or “nursing
home” appearance following blepharoplasty performed by an unknown surgeon. (b) Same patient seen after fat injections to the upper orbit.
Although the upper lid has been incompletely filled and restored, a healthier, more youthful appearance can be seen. (Procedure performed by
Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

710
VIII Surgical Rejuvenation of the Face and Neck
should always be kept between the tip of the cannula and the globe
(Fig. 50.38). The idea is to position the fingertip so that the cannula
hits it instead of penetrating the globe if inadvertently misdirected.
Having one’s fingertip in this position also gives important feedback
to the injector as to where the tip of the cannula is and helps one
place fat as accurately as possible. As is the case when injecting the
upper orbit, a shorter, 4–cm long cannula is easier to control and
keep in the correct plane on the infraorbital rim and should be used
in preference to longer instruments.
As the injection cannula is advanced perpendicular to the orbit
and toward the fingertip in a sub–orbicularis oculi/preperiosteal
plane through infraorbital tissues, the origin of the zygomaticocu-
taneous and orbicularis retaining ligaments can be felt along the
infraorbital rim and the cannula tip allowed to penetrate them.
Typically after multiple back-and-forth cannula movements used
in the placement of fat in this manner, no resistance will be felt
along the course of the ligaments, and it is assumed that the multi-
ple passes used to place the graft have effectively partially released
them, further improving the overall outcome. Another guideline
for the placement of fat in the infraorbital area is for the surgeon
to imagine filling the area in which one might place an infraorbital
implant, as the goal of treatment is essentially the same.
It is wise to avoid any subcutaneous injection in the infraorbital
area due to the extremely thin skin present and the likelihood of
creating visible lumps and irregularities, and to limit injections
to a preperiosteal/sub–orbicularis oculi plane until considerable
experience has been obtained.
Tear Trough
:here the infraorbital area ends and the ´tear troughµ and cheek
areas begin is hard to define, and in reality the treatment of the
infraorbital, cheek, and ´tear troughµ areas must be undertaken
concurrently and in most situations the treated areas will over-
lap each other to a certain extent. In addition, it must always be
remembered that the ultimate goal of the procedure is creating
youthful and attractive contour, not simply filling a specific area.
Fat-grafting the tear trough (Fig. 50.39) is simpler and faster
to perform than fat transposition and septal reset, and we have
largely abandoned the latter procedures. Unlike septal reset and fat
transpositioning, fat grafting allows comprehensive rejuvenation
Fig. 50.37 Correct (a) and incorrect (b) plan for injecting fat into infraorbital (“lower eyelid”) area. Fat grafting of the infra-orbital area is typically
performed with a 4-cm long 0.7-mm (20-gauge) cannula, and fat is placed deep in a sub–orbicularis oculi/preperisoteal plane. More superficial
injections should be avoided. Typically 1 to 3 mL of centrifuged fat is placed on each side, but occasionally more or less is indicated. A smoother
effect is obtained, and a “banana” or “sausage” (unaesthetic bulge) is less likely, when fat is injected perpendicular (a) rather than parallel (b) to the
infraorbital rim. Level of difficulty: advanced. (Copyright © Timothy Marten.)
Fig. 50.36 Filling the hollow lower orbit with fat. (a) Patient with hollow lower eyelid, an unnaturally hollow and elderly infraorbital appearance. The
lower eyelid appears long, and there is a distinct line of demarcation between the lower eyelid and the cheek. (b) Same patient seen after facelift and
fat injections to the infraorbital area. There is a smooth transition from the lower eyelid to the cheek, and the patient has a more healthy, youthful,
and attractive appearance. (Note: The upper orbit, radix, cheek, and nasolabial crease have also been treated with fat injections, and the patient has
undergone ptosis correction. Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
b
a

50 Simultaneous Facelift and Facial Fat Grafting
711
of the entire orbital region, not just spot-filling of the tear trough.
:hen fat grafting is performed, one can fill not only the tear
trough but also the infraorbital region, the cheek and midface,
the upper orbit, the temple, and the radix and glabella while also
comprehensively rejuvenating the entire orbital region. This is
aesthetically far superior to the limited fill of the tear trough only.
Fat grafting of the ´tear troughµ area is performed through
perialar stab incisions on the medial midface with a 4-cm 0.7-mm
(20-gauge) injection cannula, and fat is placed deep in a preperi-
osteal/sub–orbicularis oculi plane, as it is when the infraorbital
area is treated. Typically 0.5 to 1.5 mL of centrifuged fat is placed
on each side, depending on how far inferiorly and laterally the tear
trough extends onto the cheek. A smoother effect is obtained, and
an unaesthetic ´sausageµ roll or ´bananaµ bulge is less likely, when
fat is injected perpendicular rather than parallel to the defect
(Fig. 50.40). Another guideline for the placement of fat in the tear
trough area is for the surgeon to imagine filling the area in which
one might place a tear trough implant, as the goal of treatment is
essentially the same.
50.7.14 Secondary Facelift Patient
Secondary facelift patients who have not had facial fat lost with age
replaced at their primary procedure(s), or who have had cervicofa-
cial fat inappropriately removed during their previous procedures,
typically present cases in which all sites previous discussed likely
need and warrant treatment. For these patients the fat injections
are often more important than the secondary facelift itself, which
is performed largely to improve scars and hairline displacement,
earlobe irregularities, and the like. In the majority of secondary
facelift cases, fat grafting typically provides the lion’s share of the
improvement and is capable of truly transforming the patient in a
way that traditional ´liftingµ alone cannot (Fig. 50.41).
The secondary facelift patient stands as compelling evidence that
correction of facial atrophy requires the addition of volume to the
face, not a subtraction, lifting, or tightening, and thus requires a
rethinking of the traditionally taught approach to rejuvenation of
the face. Unlike problems corrected by a ´liftµ of the face, correction
of atrophy requires the surgeon to employ techniques that ´fillµ and
´sculptµ the face and to think in three, instead of just two, dimen-
sions. Fat grafting, when properly performed in these patients,
produces soft and natural contours and affords the opportunity to
correct problems traditional surgery cannot (Table 50.2).
50.8 Final Touches
Fat injections are continued until the preoperatively determined
volume of fat has been added to each target area. Typically a
one- to threefold “overcorrection” must be made, as compared
with volumes one would use if nonautologous fillers are used,
but typically the patient does not look overfilled on the operating
table and before swelling sets in. In all, the process is time-
consuming and technically and artistically demanding, and its
difficulty should not be underestimated. That said, because of
Fig. 50.38 Protecting the globe when injecting fat into the lower
orbital (“lower eyelid”) area. To protect the ocular globe when
injecting fat into the lower orbit, the index finger of the surgeon’s
nondominant (noninjecting) hand should always be held firmly on
the inferior margin of the infraorbital rim as cannulas are passed into
tissues and injection is made. (Copyright © Timothy Marten.)
Fig. 50.39 Filling the “tear trough” with fat. (a) Patient with hollow nasojugal groove (“tear trough”), an unnaturally hollow and elderly infraorbital
appearance. (b) Same patient seen after fat injections. (Procedure performed by Timothy J Marten, MD, FACS. Copyright © Timothy Marten.)

712
VIII Surgical Rejuvenation of the Face and Neck
its aesthetic importance and because it provides comprehensive
treatment of the aging change of the face, it is likely to also
become an enjoyable one for the surgeon who adopts it, and one
that will yield great benefits to patients so treated.
After fat has been infiltrated, treated areas are palpated to
ensure that the fat has been distributed smoothly in the target
tissue and that any lumps or irregularities are gently pressed
out. The lip and cheek areas can be bidigitally palpated, and if
the orbits have been treated, the ocular globe should be gently
depressed and irregularities checked for in the infraorbital area.
50.8.1 Microliposuction
:hen indicated, fat is extracted from areas where excess
fat is present with a blunt-tipped 0.9- or 1.2-mm infiltration
cannula attached to a 3-mL Luer lock syringe using a syringe
´microliposuctionµ technique (Fig. 50.42).
The amount of fat extracted can be gauged by expressing the
contents of the syringe onto a gauze sponge and allowing the
blood and fluid to separate from the fat that has been removed
(Fig. 50.42b).
Fig. 50.41 Secondary facelift and simultaneous fat injections. (a) Preoperative view of patient who has had a previous facelift and related procedures
performed by an unknown surgeon. Although her facelift was ostensibly well performed, untreated panfacial atrophy can be seen. A secondary
facelift alone would likely result only in an unnatural tight and windswept appearance. (b) Same patient 13 months after combined secondary facelift
and fat injections. Although the facelift allowed scars to be moved to more concealed locations and for correction of earlobe irregularities, the
replenishment of lost facial volume with fat injections was far more important to the overall outcome of the procedure. Note panfacial filling of the
temples, upper and lower orbits, cheeks, midface, buccal recess, lips and perioral area, labiomandibular creases (“drool lines”), chin, geniomandibular
grooves, and over and along the jawline. A soft, healthy, youthful, and sensual appearance can be seen, unobtainable with facelift alone. (Procedure
performed by Timothy J Marten, MD, FACS. Copyright © Timothy Marten.)
Fig. 50.40 (a) Correct and (b) incorrect plans for injecting fat into the nasojugal (tear trough) areas. Fat grafting of the nasojugal tear trough area
is typically performed with a 4-cm 0.7-mm (20-gauge) injection cannula, and fat is placed deep in a preperiosteal/sub–orbicularis oculi plane.
Typically 0.5 to 1.5 mL of centrifuged fat is placed on each side, depending on how far inferiorly and laterally the tear trough extends onto the cheek.
A smoother effect is obtained, and a sausage roll (unaesthetic bulge) less likely, when fat is injected perpendicular (a) rather than parallel (b) to the
defect. Level of difficulty: advanced. (Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
713
50.8.2 Documenting What Was Done
A nonscrubbed member of the operating room team should keep
a detailed record of areas treated and amounts of fat injected
in each, and a fat injection data sheet is useful for this purpose
(Fig. 50.43).
Typically a mark is entered on the record by the circulator for
each 1-mL syringe injected. In the absence of a circulating nurse,
a copy of this record can also be sterilized and a temporary tally of
the fat injected kept by a scrubbed member of the operating room
team using a sterile surgical marker. The information recorded can
later then be transcribed to the patient’s official fat injection treat-
ment record after the procedure has been completed. Alternatively,
amounts injected can be recorded by a nonscrubbed team member
on a life-sized laser print of a photograph of the patient’s face.
50.8.3 Learning the Procedure
The first step in learning the fat injection technique and adding it
to one’s facelift procedure is appreciating atrophy as a significant
part of the aging process and learning to recognize it. This is more
easily said than done and will take some time to master. Then
one needs to learn the basics of the fat injection technique and
obtain the needed equipment to perform the procedure prop-
erly. Once problems have been identified, needed equipment to
perform the procedure obtained, and the basics of the technique
mastered, one must analyze the patient’s problems carefully and
budget the appropriate amount of time needed to carry out the
procedure in a technically and artistically appropriate fashion. It
is wise to make small additions of fat at first to ´safeµ areas such
as the GMG and the cheeks so as to gain familiarity with the tech-
nique. Less forgiving areas such as the upper and lower ´eyelidsµ
(orbits) and tear troughs should initially be avoided. Starting out
conservatively in this manner will mean that problems, should
they occur, will be minor and easily managed. Finally, treated
patients should be followed up carefully, outcomes critically
evaluated, and ways sought of improving one’s technique and
making the next case better (Table 50.3).
50.8.4 Completion of Concurrently
Planned Procedures
Upon completion of the fat injections, face, neck, and forehead
lifts, upper blepharoplasty, lower blepharoplasty, perioral resur-
facing, and other planned procedures are performed, as indi-
cated. Because the majority of fat is needed and will be injected
in the anterior face and other areas that do not overlap the areas
dissected in these other procedures, performing them after fat is
injected does not interfere with their execution or compromise
the final outcome of the procedure. Fat placed in areas that are
dissected as part of the facelift will be seen to stick where it has
been injected and not be disrupted, partly because if properly
infiltrated, the tissue has been saturated with fat and has not
been injected in boluses of clumps, and partly due to “tissue
glueµ naturally secreted in response to the infiltration process.
50.8.5 Dressings
After all planned procedures have been completed and all inci-
sions closed, the patient’s hair is washed with shampoo, rinsed,
and conditioned. 1o dressing is required or applied. Patients are
typically discharged with a hat, scarf, and sunglasses. Drain res-
ervoirs are attached to a lanyard placed around the patient’s neck.
50.9 Postoperative Care
Most patients having combined face lifts and fat grafting are dis-
charged to aftercare specialists the first night after surgery with spe-
cific written instructions as to how they are to care for the patients.
Fig. 50.42 Microliposuction technique. The face undergoes a process of lipodystrophy over time and the aging change consists of not only atrophy
but also lipodystrophy and excess fat accumulation in some areas. Fat can be extracted from areas where excess is present using a “microliposuction”
technique, applying suction to an infiltration cannula with a 3-mL syringe. (a) Fat being extracted from the jowl using a 1.2-mm injection cannula
attached to a 3-mL syringe. This technique provides a simple way for removing small quantities of fat in a precision fashion. (b) The amount of fat
extracted can be determined by emptying the contents of the syringe onto a gauze sponge and allowing the fat to separate. On the right is the fat
extracted from the patient’s jowl area. On the left is fat extracted from the nasolabial fold. (Copyright © Timothy Marten.)

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VIII Surgical Rejuvenation of the Face and Neck
Fig. 50.43 Fat injection data sheet. Using a fat injection data sheet simplifies the documentation of what was done and provides a clear and easily
accessible record of the patient’s treatment. (Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
715
Patients are asked to rest quietly and apply cool compresses to their
eyes and other treated areas for 15 to 20 minutes of every hour they
are awake for the first 3 days after surgery, or use a commercially
available thermostatically regulated water-cooled mask. For most
patients, edema peaks at about this time. Patients are advised not to
place ice or ice-cold compresses on their face, as this is likely to be
injurious to grafted fat and to compromise outcomes.
All patients are provided oral analgesics, sleeping pills, and
antiemetics and are instructed to sleep flat on their backs without
a pillow. A small cylindrical neck roll is permitted if the patient
requests it. This posture assures an open cervicomental angle and
averts neck flexion, dangerous folding of the neck skin flap, and
obstruction of regional lymphatics that inevitably occurs if the
patient is allowed to “elevate their head on pillows” as is commonly
recommended. In addition, swelling will drain to the back of the
head instead of the anterior neck and submental region in this posi-
tion, where it is not harmful, is less noticeable, and is more rapidly
transmitted away from the head and neck area to the torso when the
patient sits upright.
Patients are advised to take a soft, easy chew and digest diet
after surgery and encouraged to feed frequently on liquid and
light-carbohydrates foodstuffs for 2 weeks. Poor dietary intake,
or intentional dieting after fat grafting procedures, is likely to put
metabolic strain on grafted fat and compromise outcomes. Patients
are asked to abstain from the intake of alcohol for 2 weeks after sur-
gery and until they are no longer taking pain pills (acetaminophen
included) or sleeping medication. Showering and shampooing are
not harmful and are permitted even when drains are in place.
50.10 Recovery and Healing
:hen patients return to work and their social lives will depend
upon how aggressively their procedure was performed (how
much fat was injected and where), their tolerance for surgery, their
capacity for healing, the type of work they do, the activities they
enjoy, and how they feel overall about their appearance. Patients
are asked to set aside 2 to 3 weeks to recover from surgery, and
additional time off is recommended before an important business
presentation, family gathering, vacation, or like event.
If patients are doing well and not experiencing problems, they
are allowed to travel and return to light office work and casual
social activity 9 to 10 days after surgery. It is often wise that they
begin with a limited workday at first and adjust their schedules
thereafter. If a patient’s job entails more strenuous activity or
physical labor, a longer period of convalescence will likely be
required. Patients are advised not to drive for the first 10 days
after surgery and until they are feeling well, their vision is clear,
and they are off pain medications.
Patients are advised to avoid all strenuous activity during the
first 2 weeks after surgery, including heavy lifting, stooping, strain-
ing, and bending forward, and are informed that aerobic activities
and exercise can result in internal bleeding and hematoma forma-
tion. Two weeks after surgery, patients are allowed to begin light
exercise and gradually work up to their presurgical level of activity.
Four to six weeks after surgery they are allowed to engage in more
vigorous activities, including most sports, as tolerated.
Patients are informed that they will often take 2 to 3 months
to have a natural appearance in a photograph or to be seen at an
important function. They are also advised to expect some firm-
ness in the face and submental areas for 6 to 9 months.
Patients will often mistakenly interpret the resolution of swell-
ing and the return of some facial wrinkles as poor graft survival
and will often comment once healing is complete that ´the fat went
away.µ Such comments arise out of the joy most patients experience
when they first see their faces surreally full and smooth after the
procedure, the fact that volume addition to the face often produces
subtle three-dimensional changes, and because most patients
simply forget the extent to which a lack of volume was present in
treated areas on their preoperative faces. The treating physician
can also sometimes initially experience similar disappointment for
similar reasons, and it can take time to train one’s eye to recognize
improvements made. The key to assessing outcomes is to take well-
matched photographs in multiple views and to learn to recognize
improvements made. Reviewing preoperative photographs with
the patient after surgery is an excellent way to assure them that a
beneficial improvement has been obtained and that the procedure
was productive and worthwhile. Ultimately the surgeon with a
well-developed aesthetic eye seeks a nuanced improvement over
multiple areas, not an overly stylized and immediately recogniz-
able filling of one or two regions. Indeed, many of the patient
examples included in this chapter are arguably overfilled and
somewhat stylized outcomes, but these typically need to be shown
to the surgeon learning the procedure to see and appreciate what
is possible. Once the effects of treating each area are understood,
a more nuanced approach to treating one’s patients can be taken.
50.11 Retreatment
Most of the change in facial contour seen on the patient’s face 4 to
6 months after the procedure is likely to consist of living fat and
constitute a persistent improvement, and patients can be informed
that ´what they see is what they getµ at that point, as swelling and
induration have largely resolved at that time. Four to six months
after surgery is also the time at which most surgeons performing
fat injections feel that facial edema, induration, and inflammation
have resolved sufficiently to the point where retreatment can be
considered should it be indicated and the patient request it. Since
there is a limit to the amount of fat that can be properly infiltrated
into the thin, atrophic face, the need for secondary fat grafting
should not be viewed as a failure of the primary procedure; it is
simply an inherent limitation of the technique. If the patient has
achieved improvement with the primary treatment, a secondary
procedure will typically be equally or more beneficial and often
can be far less comprehensive than the first.
Table 50.3 Learning the fat injection procedure
• Acknowledge atrophy as part of the aging deformity.
• Learn the basics of the fat injection technique and obtain the needed
equipment to perform the procedure properly.
• Make the needed commitment of time to perform the procedure.
• Don’t underestimate the technical and artistic difficulty of the
procedure.
• Make small additions at first to gain familiarity with the technique.
• Critically analyze outcomes.
• Improve.

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VIII Surgical Rejuvenation of the Face and Neck
50.12 Complications
:e have seen no major complications attributable to fat injec-
tions while performing the procedure simultaneously with
facelifts over the past 25 years, including infection and emboliza-
tion, tissue infarction, or blindness. These devastating problems
have been reported, however, and are known to occur when fat
injections are performed. Clinical experience has shown that
embolization is extremely uncommon when fat is injected with
a blunt cannula and in accord with currently recommended
technique, but more cases might be seen as more surgeons
perform the procedure. Embolization and the majority of related
complications, including blindness, have been reported with
sharp needle injection, and these and other complications of fat
injections have been discussed in detail by Coleman and others.
´Complicationsµ of simultaneous facelift and fat injections
attributable to the fat injection procedure fall largely under the
heading of aesthetic problems and include lumps, ´oil cysts,µ
asymmetries, undercorrection, overcorrection, and donor site
irregularities. These are more accurately considered inherent
risks of the procedure, however, in that even if the procedure is
technically performed properly and with care, variations in ´takeµ
that can occur with any graft, which are beyond the surgeon’s
control, can cause them. This is particularly true in the case of a
fat graft, as fat has shown itself to be comparatively fragile tissue.
Certain patients seem to be at higher risk for problems and com-
plications as a result of compromised condition of fat donor and
recipient sites. These patients include smokers and former smokers,
patients who have undergone previous radiotherapy, and patients
who have undergone radiofrequency or ultrasound skin-shrinking
treatments. Unlike laser resurfacing procedures, where energy
is dispersed on the skin surface, these latter procedures disperse
energy in the deep dermis and subcutaneous areas, which can
cause damage to tissue microcirculation, which appears to com-
promise graft take. Compromise of a similar sort seems to also be
present in patients who have had large volumes of inflammatory
fillers, such as poly-L-lactic acid (PLLA) or calcium hydroxylapatite
(CaHA) microspheres, and in patients who have had hyaluronic
acid–based fillers present for a long time. Simply dissolving
hyaluronic acid–based fillers enzymatically with hyaluronidase
when present does not seem to eliminate this problem, as residual
inflammation seems to be present still, which in turn can result in
suboptimal graft take. All such patients should be approached with
caution, and it is prudent that they be informed that they are likely
to be at an increased risk of problems and complications.
Patients who have undergone previous liposuction, especially
laser or ultrasound procedures, will typically be more difficult to
harvest from. In addition, the fat harvested will typically have an
increased oil (ruptured fat cell) fraction and will be more likely to
have fibrotic tissue fragments that clog injection cannulas.
Most ´complicationsµ will be small and easily managed if fat
injections are performed properly and conservative additions are
made. “Oil cysts” can usually be simply aspirated or unroofed.
Lumps have been exceedingly rare in our own practices but are
now being increasingly seen in patients who have been treated by
other physicians. These can usually be treated by microliposuc-
tion, direct excision, or overgrafting with more fat. Asymmetries
and undercorrections are generally treatable by additional fat
injections, and donor site irregularities are generally treatable
with touch-up liposuction and/or fat grafts.
Overcorrection is uncommon in single-stage treatments and is
typically seen only when patients undergo multiple fat injection
procedures. In fact, when a patient returns after a single-session
fat-grafting procedure with an overfilled appearance, one should
be suspicious that the patient has received filler injections from
another physician or other injector. This is particularly the case if a
Tyndall effect (fullness and bluish discoloration in the tear trough
and infraorbital area) is present, if ridges are seen in the nasolabial
creases, or if excess fullness seems to be present in untreated or
lightly fat-grafted areas. In such cases, it is prudent to consider
hyaluronidase administration even if the patient denies having
filler recently placed before the problem is treated as one due to
excess fat, as our experience has frequently shown that in many
cases this will resolve the problem. It should be remembered,
however, that fullness due to PLLA, calcium hydroxylapatite
(CaHA), polymethyl methacrylate (PMMA), silicone, or permanent
filler injections will not respond to hyaluronidase treatment.
:hen overcorrection occurs, improvement can usually be obtained
by judicious extraction of fat from overcorrected areas. Other than in
the orbital area, when overcorrection occurs, improvement can be
made by judicious removal of fat from overcorrected areas using a
microliposuction technique (see Fig. 50.42) using a 0.9- or 1.2-mm
injection cannula attached to a 3-mL syringe. Irregularities or
overfilling of the orbital areas often require opening the eyelid and
removing the offending fat under direct vision, however, and small
lumps and bumps on the lips are readily treated by direct excision
using a radially situated incision made in a vermilion wrinkle.
The best way to treat complications is to avoid them altogether,
and the surgeons with the fewest are likely to be the ones who
take the time to learn to perform the procedure properly, obtain
the needed equipment necessary to do so, and introduce it into
their practice gradually and in a conservative manner.
50.13 Some Concerns and Questions
50.13.1 Doesn’t the Fat Go Away?
Although many surgeons recognize volume loss as part of the
aging process, they cling to the excuse that ´the fat doesn’t lastµ
as a way of not having to learn and perform the fat injection pro-
cedure. This assertion has now been proved to be meritless and
is no longer a valid justification for denying the patient the many
important benefits fat grafting has to offer (Fig. 50.1, Fig. 50.2,
Fig. 50.41, Fig. 50.44, and case examples). Unlike temporary fillers,
fat is living autologous tissue that neovascularizes and establishes
itself as part of the face. It is analogous to hair transplantation and
other grafts performed by plastic surgeons. Furthermore, if the
grafts did not persist, there would not be overcorrected patients.
50.13.2 Isn’t the Fat Lumpy?
Asserting that fat grafts are ´lumpyµ has also been a common
excuse surgeons have used not to learn or perform the procedure,
and this too has now been proven to be false and no longer remains
a valid excuse to deny the patient the many important benefits of
fat grafting. If proper technique and equipment are used, lumps
and irregularities will be far less common than problems and
complications seen after almost every other aesthetic surgery
procedure we perform. Unlike fillers, fat actually integrates with
the tissues it is infiltrated into, and there is a natural smoothing

50 Simultaneous Facelift and Facial Fat Grafting
717
effect, since fat must be scattered in the tissue to survive. If fat is
injected in clumps, the central fat typically undergoes necrosis
and does not survive. Fat grafting has been our secret weapon for
obtaining faces smoother than can ever be obtained by facelifting
alone (Fig. 50.1, Fig. 50.45). That is not to say that irregularities
are not possible. Fat must be injected with meticulous care in the
appropriate planes for the areas treated if contour irregularities are
to be avoided. Simply put, this means injecting deep in any thin-
skinned area until considerable experience has been obtained.
50.13.3 :KDW ,V WKe (̵eFW RI :eigKW
Gain or Loss?
A large weight gain will compromise almost any plastic surgery
procedure, and that is arguably the case with fat grafting as
well. Despite this, a number of anecdotal case reports have been
endlessly recycled at meetings and conferences and among plas-
tic surgeons regarding patients with large lips, overfull cheeks,
and so on as a result of large weight gains after fat grafting. The
reality is that such large weight gains would spoil the result of
almost any aesthetic surgery procedure, and thus any argument
to this effect constitutes false logic and a hypocritical double
standard.
Fat grafting in a child or younger patient does hold the potential
for a change in graft volume with age and weight gain, but most
patients in the typical facelift age group have reached a stable
weight that fluctuates only modestly during the rest of their lives.
Therefore the concern about areas treated with fat becoming
objectionably large with weight gain is essentially overwrought
and again falls into the category of excuse-making by surgeons
Fig. 50.44 Does the fat last? This patient is seen (a) before and (b) 3 years and 7 months after a facelift and fat grafting in which 58 mL of fat was placed.
It can be easily seen that the infraorbital, cheek, midface, buccal recess, nasolabial fold, lips, stomal angle, chin, geniomandibular groove, and jawline
areas are all distinctly fuller almost 4 years after these procedures and that the fat has persisted in each area treated. (Copyright © Timothy Marten.)
Fig. 50.45 Is the fat lumpy? (a) A 55-year-old patient seen before facelift and fat grafting. She has tissue ptosis, skin redundancy, and facial atrophy.
(b) Same patient seen 1 year and 4 months after high–superficial musculoaponeurotic system (SMAS) facelift, neck lift, forehead lift, lower blepharo-
canthoplasty, and panfacial fat injections. If proper technique is used, lumps and irregularities will be far less common than complications seen after
almost every other aesthetic surgery procedure. Practically speaking, fat grafting is the surgeon’s “secret weapon” for obtaining faces smoother than
can ever be obtained by facelifting alone. (Procedure performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)
b
b
a
a

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VIII Surgical Rejuvenation of the Face and Neck
not interested in learning or taking the time to perform the pro-
cedure. :eight gain may actually afford the facelift patient some
benefits in that if weight is gained and the grafts are seen to grow,
growth is experienced in areas where the increase in volume
maintains facial proportion. :ithout fat grafts, weight gain tends
to occur in areas that create a disproportionate, unattractive, and
objectionable appearance, such as the jowl and the neck. After
fat grafting, weight gain occurs in all areas, and the face remains
proportionate and appears more attractive. The face may become
bigger, but it remains proportionate and attractive.
50.14 Results/Case Examples
50.14.1 Patient Example 1
The woman in Fig. 50.46 presented at age 45 with overall facial
laxity and panfacial atrophy. She had not had any previous plastic
surgery. She underwent a high-SMAS facelift, neck lift, closed fore-
head lift, and lower eyelid lift combined with transfer of 50 mL of fat
to the temples, cheeks, lips, nasolabial fold, GMG, stomal angles, and
upper and lower orbital areas (Fig. 50.2). Two years and 4 months
Fig. 50.46 Patient Example 1. (a,b,c) Before-surgery views of a woman, aged 45. Note overall facial laxity and panfacial atrophy. The patient has had
no previous plastic surgery. (d,e,f) Same patient, 2 years and 4 months after high–SMAS facelift, neck lift, closed forehead lift, lower eyelid lift, and
fat transfer to the temples, cheeks, lips, nasolabial, geniomandibular groove, stomal angles, and upper and lower areas (see Fig. 50.2 for a diagram
of fat placement). A total of 50 mL of fat has been placed. Note soft, natural facial contours and the absence of a tight, pulled, or “facelifted” appear-
ance. Facial atrophy has also been simultaneously corrected and the patient has a healthier, more youthful, and more feminine appearance. The
combined facelift and fat injection procedures have produced a result that could not be obtained by either procedure alone. (All surgical procedures
performed by Timothy Marten, MD, FACS. Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
719
postoperatively, she shows soft, natural facial contours without a
telltale tight or pulled appearance. She looks healthier, younger, and
more feminine thanks to the correction of her facial atrophy.
50.14.2 Patient Example 2
The 68-year-old man in Fig. 50.47 presented with sagging
cheeks, cheek folds, and jowls and loss of volume in the cheeks,
infraorbital, perioral, and GMG areas. He underwent a high-
SMAS facelift, neck lift, closed forehead lift, upper and lower
eyelid lifts, and earlobe reduction, and he received a total of 28
mL of facial fat injections. He is shown 1 year and 9 months after
his procedure. These combined procedures restored a younger,
healthier, and more virile appearance.
50.14.3 Patient Example 3
Although the face of the 53-year-old woman in Fig. 50.48 might
appear full at first glance, she shows regional atrophy in her tem-
ples, cheeks, infraorbital and perioral regions, GMG, chin, and
Fig. 50.47 Patient Example 2. (a,b,c) Before-surgery view of a man, aged 68. The patient has sagging cheeks, deep cheek folds, and jowls. Loss of
facial volume is also evident in the cheeks, infraorbital, perioral, and geniomandibular groove areas. (d,e,f) Same patient, 1 year and 9 months after
high–SMAS facelift, neck lift, closed forehead lift, upper and lower eyelid lifts, partial facial fat injections, and earlobe reduction. A total of 28 mL of
fat was placed. Note restoration of youthful and masculine facial shape without a tight or pulled appearance. Facial atrophy has also been simultane-
ously corrected and the patient has a healthier, more youthful, and masculine appearance. The combined facelift and fat injection procedures have
produced a result that could arguably not have been obtained by either procedure alone. (All surgical procedures performed by Timothy Marten, MD,
FACS. Copyright © Timothy Marten.)

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VIII Surgical Rejuvenation of the Face and Neck
jawline with sagging jowls. Previous upper and lower eyelifts
have been performed by an unknown surgeon. She underwent
a high-SMAS facelift, neck lift, temple lift, canthopexy, and mole
removal, combined with 66 mL of fat placed in her temples,
cheeks, infraorbital, nasolabial, perioral, GMG, chin, and jawline.
She is shown 1 year and 5 months after her procedure. The addi-
tion of fat to her face made it younger and more fit and attractive.
50.14.4 Patient Example 4
This 62-year-old woman had undergone facelift, neck lift,
blepharoplasties, and other procedures performed by
unknown surgeons, but her face still showed sagging in the
neck and jowls as well as atrophy in the cheeks, temples, chin,
and jawline along with the orbital, perioral, and GMG areas.
Fig. 50.48 Patient Example 3. (a,b,c) Before-surgery view of a woman, aged 53. Although the patient’s face appears full at first glance, a careful
examination shows regional atrophy to be present in the temples, cheeks, infraorbital, perioral, geniomandibular groove, chin, and jawline areas.
The patient has had prior upper and lower eyelifts performed by an unknown surgeon. (d,e,f) Same patient, 1 year and 5 months after high–SMAS
facelift, neck lift, temple lift, canthopexy, and fat transfer to the temples, cheeks, infraorbital, nasolabial, perioral, geniomandibular groove, chin,
and jawline areas. A total of 66 mL of fat was placed simultaneously with the facelift and related procedures. Note soft, natural facial contours and
the absence of a tight, pulled, or “facelifted” appearance. Facial shape has been significantly improved, and the patient now has a more youthful
appearance. Although fat has been added to the patient’s face, it has a more trim, fit, and feminine appearance. Note also that lips are fuller but
natural-appearing. The combined facelift and fat injection procedures have produced a result that could arguably not have been obtained by either
procedure alone. An unwanted mole has been removed from the left upper lip. (All surgical procedures performed by Timothy Marten, MD, FACS.
Copyright © Timothy Marten.)

50 Simultaneous Facelift and Facial Fat Grafting
721
She underwent a high-SMAS facelift, neck lift, small-inci-
sion forehead lift, and earlobe reduction; she received 70
mL of fat placed in the temples, glabella, radix, upper and
lower orbital regions, cheeks, midface, lips, stomal angle,
chin, and jawlines as well as the orbital, perioral, and GMG
regions; and she also underwent trichloroacetic acid (TCA)
Fig. 50.49 Patient Example 4. (a,b,c) Before-surgery view of a woman, aged 62, who had had previous facelift, neck lift, blepharoplasties,
and other procedures performed by an unknown surgeon. Note residual facial sagging and neck and jowl fullness. Although the patient’s face
appears full at first glance, a careful examination shows atrophy to be present in the temples, cheeks, and orbital, perioral, geniomandibular
groove, chin, and jawline areas. (d,e,f) Same patient, 12 months after high–SMAS facelift, neck lift, small-incision forehead lift, trichloroacetic
acid lower eyelid peel, earlobe reduction, perioral dermabrasion, and fat grafting of the temples, glabella, radix, upper orbital, lower orbital,
cheek, midface, nasolabial, perioral, lip, geniomandibular groove, stomal angle, chin, and jawline areas. A total of 70 mL of fat was placed
simultaneously with the facelift and related procedures. Note restoration of youthful and feminine facial shape without a tight or pulled
appearance. Facial atrophy has also been simultaneously improved. Temple hollowing has been corrected, orbital atrophy corrected, an
improved transition from the lower eyelid to the cheek is evident, the cheek and midface can be seen to be fuller, and the chin flows smoothly
and aesthetically into a smooth jawline. Although fat has been added to the patient’s face, it has a more trim, fit, feminine, and photogenic
appearance. Note also that lips are fuller but natural-appearing. The combined facelift and fat grafting procedures have produced a result that
arguably could not have been obtained by either procedure alone. (All surgical procedures performed by Timothy Marten, MD, FACS. Copyright
© Timothy Marten.)

722
VIII Surgical Rejuvenation of the Face and Neck
peel in the lower eyelid and dermabrasion in the perioral
regions. She is shown 12 months following her procedure.
These combined procedures restored a younger, healthier,
and more youthful appearance with a smooth aesthetic tran-
sition from the lower eyelid to the cheek and from the chin
to the jawline.
50.14.5 Patient Example 5
The 75-year-old woman in Fig. 50.50 had previously undergone
multiple facelifts and other cosmetic procedures, including laser
resurfacing that was performed by unknown plastic surgeons,
yet cheek laxity and uncorrected panfacial atrophy left her with a
Fig. 50.50 Patient Example 5. (a,b,c) Preoperative views of a woman, aged 75, who had had multiple prior facelifts and related procedures, including
previous laser resurfacing, performed by unknown plastic surgeons. Note marked cheek laxity despite prior surgeries, and fragile, elderly appearance
due to uncorrected panfacial atrophy. Another facelift would predictably produce a gaunt, haggard, or even ill appearance. (d,e,f) Same patient,
1 year 7 months after high–SMAS facelift, neck lift, forehead lift, upper and lower eyelid lifts, canthopexy, and fat transfer to the temples, cheeks,
midface, upper and lower eyelids, lips, nasolabial creases, stomal angles, geniomandibular grooves, chin, and jawline. A total of 90 mL of fat was
placed simultaneously with the facelift and related procedures. No skin resurfacing, facial implants, or other ancillary procedures were performed.
In these situations fat injections are arguably more important to the overall outcome than the facelift itself. Facial contour has been significantly
enhanced and facial volume restored. The patient has a healthy, fit, and feminine appearance that could not have been obtained by either procedure
performed alone. (Previous procedures performed by an unknown surgeon. Secondary surgical procedures performed by Timothy Marten, MD, FACS.
Copyright © Timothy Marten.)