The lift-and-fill facelift

Introduction

Rhytidectomy remains a mainstay in facial rejuvenation today, with a 75% increase in cases observed over the past 20 years. With the longevity of a well-performed facelift lasting up to 10 to 12 years, rhytidectomy continues to be the most effective method of achieving long-lasting results compared to its non-surgical alternatives.

It is now understood that volume deflation is one of the key components of the complex facial aging phenomenon. As a result, the focus of modern facelifting has shifted from isolated superficial musculo-aponeurotic system (SMAS) alternation to volume restoration and facial recontouring. While tissue mobilization and elevation remain a mainstay in facial rejuvenation, precise volume restoration has become a fundamental component and a powerful tool in the armamentarium of the aesthetic plastic surgeon. According to a 2015 American Society of Plastic Surgeons survey, over 85% of surgeons use fat grafting at the time of facelift, and significantly higher satisfaction rates have been demonstrated among patients who undergo lipofilling at the time of facelift compared with those undergoing a facelift alone.

The lift-and-fill facelift, which has revolutionized the plastic surgeon’s approach to aging of the face, merges two key concepts in facial rejuvenation: (1) effective tissue manipulation by means of surgical lifting and tightening in differential vectors according to original facial asymmetry and shape; and (2) volumetric rejuvenation to the face via selective fat compartment filling of deep malar and high malar locations and nasolabial fold to precisely control facial contouring.

Various SMAS manipulation techniques have been described. However, to date, a single technique has not been shown to be superior to another. Therefore, more emphasis is given to creation of smooth contour and highlights through deep and superficial volume augmentation and less to the exact method of tissue reposition.

Using a combination of standardized preoperative and topographic visual analysis to target fat grafting to specific areas that have undergone deflation, and doing so before SMAS alteration, allows for better control in facial recontouring and results in successful correction of the aging face.

In-depth understanding of the anatomy of distinct facial fat compartments and a systematic method to assess areas of fat atrophy and volume depletion, alongside recognition of vascular danger zones, are therefore essential to optimizing patient outcomes and maintaining safety during facelift procedures.

This chapter provides an outline for the basic principles that have set the standard for the modern facelift. Based on both existing literature and clinical experience this chapter provides overviews of the principles of the lift-and-fill facelift while still allowing the experienced clinician ample flexibility in treatment strategy. In addition to a detailed text, broad reference base, instructional videos, and anatomic illustrations, we provide two clinical patient scenarios that demonstrate the key concepts of the lift-and-fill facelift technique.

Basic science/disease process

Facial aging is a multifactorial process governed by both intrinsic (genetic) and extrinsic (environmental) factors that is the result of a complex interplay between the underlying craniofacial skeleton, mimetic musculature, compartmentalized facial fat, facial retaining ligaments, and the skin envelope.

An understanding of facial aging is fundamental to properly restoring natural, youthful and harmonious facial characteristics in facial rejuvenation procedures.

Collagen and elastin are the primary components of the skin. Toxic injury to these components, as well as atrophy of skin appendages and decreased extracellular matrix of the skin, contribute substantially to the process of aging through epidermal thinning, collagen loss and dermal elastosis over time.

With age, the facial skeleton undergoes clockwise rotation of the midface in relation to the cranial base. The maxilla increases in size and becomes posterior displaced, the orbital aperture enlarges, and the mandible decrease in size in both horizontal and vertical planes. Prior computed tomography (CT) studies have demonstrated that the relative prominence and position of facial soft tissues are substantially influenced by the morphologic changes of the facial bony skeleton, shifting the face’s overlying retaining ligaments and soft tissue, which in turn causes deflation of distinct facial fat compartments and gives the appearance of increased skin laxity and prominent folds in the nasolabial, periorbital, and jowl regions. These volumetric changes to both the facial bones and fat compartments further influence the facial mimetic muscles’ laxity and tension.

The concept of facial volume restoration has long been advocated as an important principle in facial rejuvenation with facial fat atrophy directly influencing both volume and shape of the aging face. The senior author (RJR) has extensively studied facial fat compartment anatomy and the role of facial fat atrophy in facial aging.

Once thought of as an anatomically continuous structure, the subcutaneous fat of the face has been shown to be highly compartmentalized in a multidimensional fashion.

Both volume deflation and distributional changes in these fat compartments contribute to the distinct morphology of the aging face, with volume deflation often preceding changes in volume distribution. Evidence for deflation as a primary component of facial aging has been clearly elucidated by Lambros, who has popularized the volumetric theory in his observations of midface and periorbital aging. In a photographic analysis of 130 subjects, he showed that the true descent of soft tissues might not be as profound as once thought, noting that the eyelid–cheek junction remained stable between the younger and older cohorts and therefore does not descend with age. Furthermore, skin landmarks such as moles and wrinkles in the periorbital and upper midface areas did not descend with time.

These findings further support fat compartment deflation as the main cause for undesirable and aged facial contour. The lift-and-fill facelift approach addresses volume deflation, the root cause of facial aging, allowing for less manipulation of the stable surface landmarks for a more natural facial appearance.

A series of dye-partition anatomic studies performed by Rohrich et al. elucidated the anatomy of superficial and deep facial fat compartments (see Fig. 9.9.1 ). They described the distinct fibrous septa separating the superficial and deep compartments extending from the fascial layer to the dermis. In 2014, in a cadaveric study comparing the adipocytes of the deep and superficial facial fat compartments, Wan et al . demonstrated a significant difference in size between the smaller adipocytes of the deep medial cheek compartment and those in the superficial nasolabial fat compartment, suggesting accelerated deflation in the deep compartments and further confirming the volumetric theory.

Another major force of facial aging is volume distribution and the formation of separations between the already defined fat compartments. In a youthful face the transition between subcutaneous compartments is smooth, whereas in aging individuals there are abrupt contour changes between regions.

Our understanding of the interplay between the deep and superficial fat compartments was further refined by introducing the concept of superficial fat “pseudoptosis”. Pseudoptosis results from the loss of support from deflation of deep compartments in conjunction with loss of support of the facial ligaments, resulting in anatomical descent of the superficial fat compartments and consecutive volume redistribution.

In a study comparing MRIs of older and younger faces, Gosain demonstrated relative descent in the position of the cheek fat. These findings were confirmed by Stuzin et al . who suggested that descent of the midfacial soft tissues, resulting clinically with soft tissue sagging described as radial expansion , is caused by age-related elastosis and attenuation of the fibrous attachments between the skin, fat, and deep fascia. In the senior author’s experience, facial fat atrophy in facial aging carries greater significance than soft tissue laxity and osseous changes. To demonstrate these findings, Rohrich et al . showed volume augmentation of the deep cheek fat compartments provided improved anterior cheek projection and reduced nasolabial crease. It is with these findings that facial fat grafting gained a high value in facial rejuvenation.

Age-associated soft tissue changes and loss of midface volume, particularly in the malar and submalar areas require both volume restoration, as well as repositioning of ptotic tissue and removal of redundant tissue. Anatomic studies have provided a topographic map of the superficial and deep facial fat compartments allowing an accurate and precise augmentation of deflated facial areas in conjunction with selective SMAS-shaping techniques. Based on these principles, the lift-and-fill facelift has revolutionized the approach to the aging face in aesthetic surgery.

The senior author routinely utilizes this powerful combination and selective fat compartment augmentation of the deep malar, nasolabial and oral commissures in every facelift.

Anatomy

In-depth understanding of the anatomy of the superficial and deep facial fat compartments is critical for precision in preoperative analysis and successful rejuvenation of the aging face. Fat compartments of the face are outlined in Table 9.9.1 and illustrated in Fig. 9.9.1 .

Retaining ligaments of the face

The fat compartments and retaining ligaments of the face are intimately related. Retaining ligaments are soft-tissue support structures of the face arising from the underlying facial skeleton or deep fascia and are important landmarks in identifying the danger zones of facelift dissection. The three major retaining ligaments of the face include the zygomatic ligament, the mandibular ligament, and the masseteric cutaneous ligaments ( Figs. 9.9.2 & 9.9.3 , Table 9.9.2 ).

Table 9.9.2

Retaining ligaments of the face

Ligament	Origin
Zygomatic ligament	Zygomatic eminence at the superior junction of the middle cheek and infraorbital fat
Mandibular ligament	Tubercle of the mandible at the cheek–chin junction
Masseteric cutaneous ligaments	Masseteric fascia

Patient selection, evaluation and planning

A wide variety of patients can be considered candidates for surgical facial rejuvenation procedures; however, a history of smoking, bleeding disorders, or surgical infections requires caution.

Optimal facial rejuvenation results require a multifaceted, patient-specific treatment plan that addresses skin, soft tissue support and fat atrophy. When tailoring a patient’s treatment, both facial volume and facial shape should be addressed. Symmetry assessment is a critical component of the preoperative evaluation. Described by Rohrich et al ., the individualized-component facelift takes into account regional asymmetries and applies the concepts of lifting and filling for facial rejuvenation. Fig. 9.9.4 demonstrates the technical sequence in the lift-and-fill facelift.

Differential fat augmentation is performed to treat volume asymmetry in conjunction with differential manipulations of the selective SMAS performed to each side to treat volume distributional asymmetry.

A preoperative discussion about the patient’s desired aesthetic goals and examination of photographs from the patient’s youth should be included as part of the preoperative planning in conjunction with a meticulous facial analysis. Indications for specific fat compartment augmentation are based on preoperative analysis of the topographic deflation. Accurate preoperative planning of selective fat compartment grafting is the first step in the lift-and-fill facelift. Three basic parameters should be addressed as part of facial analysis: midface width, facial length and facial fullness.