Combining the Midface Lift and Fat Transfer to Maximize Aesthetic Results
Allison T. Pontius, MD
Edwin F. Williams III, MD, FACS
Allison T. Pontius, MD: Private Practice, Plastic Surgery Associates of New York ,
59 East 79th Street , New York , NY 10021 .
Edwin F. Williams III MD, FACS : Director, Williams Center for Excellence, Latham, New York 12110; and Chief of Facial Plastic Surgery, Albany Medical Center, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Albany, New York 12208.
Corresponding Author: Allison T. Pontius, MD. Plastic Surgery Associates of New York , 59 East 79th Street , New York , NY 10021 . Phone (212) 288-0450, Fax (212) 288-4208. E-mail: email@example.com .
Request for reprints: Edwin F. Williams, III , MD , FACS. Williams’ Center for Excellence, 1072 Troy Schenectady Road , Latham , NY 12110 .
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Objective: To evaluate the aesthetic results in our initial group of patients treated with a combination of a midface lift and fat transfer as compared to a randomly selected group of patients who underwent a midface lift without concurrent fat transfer by the senior author (EFW).
Setting: Private, ambulatory surgical center
Design: A comparative study between patients who did or did not receive fat transfer in addition to a midface lift to determine if the addition of fat transfer to the midface lift resulted in an improved aesthetic outcome.
Patients: A total of 40 patients with complete photographic and chart records and a minimum of 6 months of follow-up were included in the study. Group 1 consisted of 30 patients randomly selected (from over 650 potential patients) who underwent a midface lift without fat transfer to serve as a control group. Group 2 consisted of our initial 10 patients who underwent fat transfer in addition to a midface lift at the same setting.
Main Outcome Measures: The degree of aesthetic improvement in 4 facial zones were assessed by 3 independent, blinded evaluators. Zone I represents the tear trough and infraorbital rim, zone II the malar eminence, zone III the submalar region and zone IV the nasolabial crease. Each zone was given a rating from 0 to 2 (0 for no improvement, 1 for mild improvement and 2 for marked improvement). The two groups were compared with four Chi-Square tests of independence.
Results: Four Chi-Square tests of independence were conducted to compare the findings between group 1 and group 2. The first Chi-Square (tear trough/infraorbital rim) test revealed a significant difference on Tear Trough Ratings by Group, c 2 (2) = 73.59, p < .01. Group 1 participants were more likely to receive a No Improvement Rating than those in Group 2 (25.56% and 0% respectively). Additionally, participants in Group 2 were more likely to receive a Marked Improvement Rating than those in Group 1 (66.67% and 0% respectively). The second Chi-Square (malar eminence) did not reveal a significant difference on Malar Eminence Ratings by Group, c 2 (2) = 3.10, ns. The third Chi-Square test (submalar region) failed to reveal a significant difference on Submalar Region by Group, c 2 (2) = 4.01, ns. The final Chi-Square test (nasolabial crease) revealed a significant difference on Nasolabial Ratings by Group, c 2 (2) = 14.28, p < .01.
Conclusion: Our findings revealed a statistically significant difference between Group 1 (no fat transfer) and Group 2 (fat transfer) in the tear trough region (p<0.01) and the nasolabial crease (p<0.01). The fat transfer technique is a safe and effective means to provide more complete facial rejuvenation especially in the regions of the tear trough and nasolabial crease.
The aged face is the consequence of several concurrent factors, including skin laxity, soft tissue ptosis and volume loss. Improving the condition of the skin is most commonly obtained with resurfacing procedures, laser and light therapy, daily skin care and UV protection. Correction of soft tissue ptosis is usually surgically treated with a brow lift, midface lift and lower face rhytidectomy. Correction of volume loss can be obtained with injectable facial fillers, most notably by autogenous fat transfer procedures. Ideally, all of these elements should be treated in order to provide complete facial rejuvenation.
The authors have written extensively on the importance of addressing the midface in facial rejuvenation procedures [1-2], however, despite repositioning of the ptotic soft tissues of the midface, facial rejuvenation may remain incomplete due to the persistent loss of volume seen in these patients. Despite excellent surgical results obtained from the midface lift we found that our rejuvenation procedures needed to evolve to include the correction of facial volume loss. In 2004 we began introducing fat transfer to patients undergoing a midface lift to improve our aesthetic results. We specifically utilized fat transfer in patients undergoing a midface lift because the key areas of volume loss are centered around the midface: the tear trough and infraorbital complex, the malar eminence, the submalar region and the nasolabial crease. We have found that these areas are where volume loss is most prominent. Additional areas where volume loss is present in some patients include: the temporal fossa, the jawline, the glabella, the lateral brow and the perioral region. This report documents our aesthetic findings in the initial group of patients treated with a combination of a midface lift and fat transfer as compared to a randomly selected group of patients who underwent a midface lift without concurrent fat transfer.
All patients underwent either a midface lift alone or in conjunction with fat transfer performed by the senior surgeon (EFW). A total of forty patients with complete photographic and chart records and a minimum of six-months follow-up were included in the study. Group 1 consisted of 30 patients randomly selected (from over 650 potential patients) who underwent a midface lift without fat transfer. Group 2 consisted of our initial 10 patients who underwent a midface lift with fat transfer
The degree of aesthetic improvement of the 4 zones was assessed by 3 independent, blinded evaluators. Zone I represents the tear trough and infraorbital rim, zone II the malar eminence, zone III the submalar region and zone IV the nasolabial crease. Each zone was given a rating from 0 to 2 (0 for no improvement, 1 for mild improvement and 2 for marked improvement). The two groups were compared with four Chi-Square tests of independence.
The patient is placed under monitored anesthesia care with intravenous sedation or general anesthesia. When fat transfer is performed as the sole procedure, oral sedation is an option, however, because the patients in this study are undergoing a concomitant midface lift general anesthesia or MAC anesthesia is necessary. Prior to any surgical manipulations or infiltration of local anesthesia, the areas of planned injection are delineated with a surgical marking pen and the estimated amount of fat needed is determined. Typically, for the four areas examined in this study a total of 40cc of aspirated fat is sufficient. Next, the fat harvest sites are delineated with the surgical marking pen. We have found that the ideal place for fat aspiration is the inner thighs, however we commonly also access the outer thighs and the abdomen. In thin patients, we access any areas of fat accumulation, including the flanks and lateral buttocks. Once the entry sites for aspiration are determined, a single stab incision is made with a No. 11 blade. A long liposuction aspiration cannula is attached to a 20 cc syringe filled with the tumescent solution (1cc 1% lidocaine with 1:100,000 epinephrine, 4cc 1% plain lidocaine, and 15cc of saline). The long cannula is placed through the stab incision and directed out from the injection site in a fan-like pattern. A first pass is performed as a tunneling maneuver and the second pass is when the tumescent solution is infiltrated. This is repeated in the other fat aspiration sites. Typically, a total of 4-20cc syringes are used to infiltrate the abdomen (2 per side, from periumbilical stab incisions), and 2-20cc syringes of tumescent solution is used per inner or outer thigh. The total amount of tumescent solution utilized in a case is dependant on the number of aspiration sites; however, the total amount of lidocaine infiltrated is always carefully recorded. Ten minutes is allowed to elapse for maximal vasoconstrictive effect of the epinephrine. Next, the same liposuction aspiration cannula is affixed onto a 10ml Luer lock syringe. The non-dominant hand is used to elevate the skin and superficial fat away from the aspiration cannula and the dominant hand is used to perform manual aspiration of the fat (Figure 1). A vigorous forward and backward movement of the cannula is used for optimal aspiration. When aspirating in the abdominal area, one must be careful to stay in a relatively superficial plane as to avoid any trauma to the underlying rectus muscle or untoward peritoneal entry, especially in patients with a previous history of abdominal surgery. The non-dominant (or “smart” hand) can be used to guide the aspiration cannula in the proper plane. Following aspiration of the fat in multiple 10cc syringes, the stab incisions are closed with a single 5-0 fast absorbing gut suture. If the abdominal area was accessed, an abdominal binder is placed. The inner and/or outer thighs are wrapped with a 6-inch Ace wrap.
The plungers on the 10cc syringes filled with aspirated fat are removed and a metal stopper is placed on the ends of the syringes. The syringes are then passed off the table to the circulating nurse who places them into the centrifuge. The centrifuge must always be “counterbalanced”, i.e. an even number of syringes should be placed in centrifuge directly across from each other. The fat is centrifuged for 3-5 minutes at 3500 rpm. At the conclusion of the centrifugation the fat has separated into three distinct layers: the top layer consists of oil from ruptured adipocytes, the central area is the usable fat and the bottom layer contains lidocaine, saline and blood (serous fluid) (Figure 2). The stoppers are then removed from the syringes to allow drainage of the serous fluid. The oil layer is then partially removed by carefully pouring it out from the top of the syringe. The remaining oil layer is removed by placing moist 4×4 gauze sponges (opened up lengthwise) into the tops of the syringes to wick out the remaining oil layer. Once the usable fat is isolated in the syringes they are placed in a refrigerator until the conclusion of the midface procedure.
Fat Transfer Procedure
The details of our surgical approach to the midface are detailed extensively elsewhere . Once the midface lift portion of the procedure is concluding, the surgical technician transfers the fat from the 10cc syringes into individual 1cc syringes using a Luer lock transfer device. Either a straight or slightly curved 16-gauge blunt cannula is placed on the 1cc syringes, depending on the anatomical site being injected. Attention is then turned to the previously marked out areas on the face: the tear trough, the malar eminence, the submalar region, and the nasolabial crease. An 18-gauge NoKor needle is used to create small stab incisions at the sites of entry. Beginning with the tear trough, the stab incision is made just inferior to the infraorbital rim and lateral to the infraorbital nerve. The 16-gauge blunt cannula is used to inject fat along the tear trough using multiple passes and laying down a minimal amount of fat (ideally about 0.03cc per pass). The fat is injected at many different angles, however at this location the fat is injected only in the deep plane just superior to the periosteum. Next, attention is turned to the malar eminence. Injection at this site is focused on injecting into and along the zygomaticus major, zygomaticus minor and levator labii superioris muscles and into the malar fat pad (Figure 3). The entry incision is made with the NoKor needle at the inferior region of the muscles. A similar technique of inserting the blunt cannula and inject a small amount of fat upon withdrawal is performed. Multiple passes with the cannula and injection into multiple tissue levels is performed. The submalar region is addressed next with injections targeting the buccinator and risorius muscles. Finally, the nasolabial creases are addressed by making the entry stab incision at the inferiormost point of the nasolabial crease. The same technique is utilized here except that the injection is performed solely into the subcutaneous tissue layer and not into a specific muscle. After the conclusion of fat injections the face is cleansed with saline and a small amount of antibiotic ointment is placed on each of the stab incisions and a typical facelift/brow lift pressure dressing is placed (solely for the midface lift). The injected areas are aggressively iced for the 1st 48 hours in order to decrease edema and ecchymoses.
The most common complication, or sequela, from the fat transfer was prolonged post-operative edema. The edema is thought to be due to the multiple tunneling performed with the fat transfer as well as from the concurrent midface lift. The second most common complication were ecchymoses from the stab incisions used to pass the injection cannula through the skin and from the multiple tunnels created to lay down the fat. Other reported complications of fat transfer include: undercorrection, overcorrection, tissue irregularities and asymmetries, migration of the placement of the fat and hematoma.
Four Chi-Square tests of independence were conducted to compare the findings between group 1 and group 2.
The first Chi-Square test revealed a significant difference on Tear Trough Ratings by Group, c 2 (2) = 73.59, p < .01 (Table 1). Group 1 participants were more likely to receive a No Improvement Rating than those in Group 2 (25.56% and 0% respectively). Additionally, participants in Group 2 were more likely to receive a Marked Improvement Rating than those in Group 1 (66.67% and 0% respectively).
The second Chi-Square did not reveal a significant difference on Malar Eminence Ratings by Group, c 2 (2) = 3.10, ns (Table 2). One cell had an expected frequency less than five. The results from this test may not be valid because the small expected frequency can increase the risk of a committing a Type II error.
The third Chi-Square test failed to reveal a significant difference on Submalar Region by Group, c 2 (2) = 4.01, ns (Table 3). Two cells had an expected frequency less than five, thereby increasing the probability of committing a Type II error.
The final Chi-Square test revealed a significant difference on Nasolabial Ratings by Group, c 2 (2) = 14.28, p < .01 (Table 4). Overall, both Group 1 and Group 2 participants were more likely to receive a Mild Improvement Rating than a No Improvement Rating. However, participants in Group 2 had a higher proportion of Mild Improvement Ratings than their Group 1 counterparts. There were no participants in either group who received a Marked Improvement Rating.
The use of fat to fill facial defects has been in practice since 1893 when Neuber used pieces of fat to reconstruct facial scars due to tuberculosis . Since that time multiple reports have verified that fat can be transplanted and survive in various areas of the body [4-8]. In 1926, Miller described the infiltration of fat via a cannula . Although he described good results, the technique did not obtain much notoriety at the time. The breakthrough in fat transplantation occurred with the development of liposuction in the 1970’s  and its widespread use in the 1980’s. Illouz was a pioneer of liposuction and he also studied the effects of fat transplantation to the face [11-13]. In 1988 he studied the long-term results of facial fat injection in 167 cases . Despite finding somewhat disappointing results in the long-term correction of facial wrinkles, he remained optimistic in the possibility of fat-cell survival and encouraged further research in this area. In 1985 Fournier first began extracting fat via a syringe and needle and confirmed the integrity of the fat harvested by syringe aspiration . In the 1990’s Coleman contributed significantly to our current techniques and understanding of fat transfer by emphasizing the need for gentle removal and handling of fat and the injection of very small volumes of fat per pass combined with multiple passes in order to improve fat vascularization and therefore aesthetic outcome and longevity of results [15-16]. In 1999 Amar described “FAMI” (Fat Autograft Muscle Injection) in which fat is harvested via syringe aspiration, refined via centrifugation and injected into the muscles of facial expression with specific anatomically-curved cannulae .
In this study we attempted to determine the aesthetic benefit of combining our extended-minimal incision midface lift with fat transfer by having 3 independent evaluators rate the aesthetic improvement on a 3-point scale. We compared the results of the study group with a control group of 30 randomly selected patients who had previously undergone a midface lift alone. We only studied patients with a minimum of 6-months of chart documentation and photographic follow-up. We concentrated on 4 areas of the face in which we saw shortcomings with the midface lift alone: the tear trough/infraorbital complex, the malar eminence, the submalar region, and the nasolabial crease. The 10 patients presented in Group 2 represent the initial group of patients in which we combined a midface lift with fat transfer. Obviously while beginning to incorporate the fat transfer procedure into our operation for the midface lift we remained conservative with this initial group of patients. Fat volumes injected in these patients were somewhat modest (average 21.5cc per patient) and all patients underwent only one fat transfer procedure at the time of their midface lift.
Our findings demonstrate that there was a statistically significant difference between Group 1 (no fat transfer) and Group 2 (fat transfer) in the tear trough region (p<0.01) and the nasolabial fold (p<0.01). The most impressive results were seen in the tear trough/infraorbital region where the majority of patients in group 2 (66.67%) had a marked improvement rating. No patients in group 1 received a marked improvement rating (0%) in this area. The tear trough demonstrated excellent aesthetic improvement and long-term correction as noted at 6-months. In the tear-trough region the injection is performed in a deeper plane, just superficial to the periosteum in an area of minimal mobility which may account for the more dramatic results seen in this area as compared to the other studied areas.
In the nasolabial fold, we also found a statistically significant difference between groups (p<0.01). Patients in Group 2 received a higher proportion of mild improvement ratings than group 1; however no patient in either group received a marked improvement rating. The nasolabial crease continues to be a challenging area to correct long-term. Most commonly the initial correction observed with fat transfer is only a mild improvement by the 6-month follow-up. This may in part be due to the mobility of the region and the more superficial plane of injection.
In the malar and submalar regions there were no statistically significant differences between groups, however, because the values in these groups were not normally distributed around the expected frequency a Type II error may have occurred. In other words, there may in fact be a clinical difference that is not statistically discernable. Regardless, possible reasons for the minimal improvements noted in the malar and submalar region may be related to the midface lift itself. We perform a subperiosteal midface lift which elevates the origin of the zygomaticus major muscle off of the underlying bone. This creates a potential space in the subperiosteal plane that is much easier to enter when injecting fat than is the belly of the zygomaticus muscles themselves. Additionally, the midface structures are suture suspended to the temporalis fascia, therefore one must also be extremely cautious not to break these sutures when injecting the midface. The edema and occasional bleeding incurred during the midface lift also may be playing a role in fat resorption and obscuring tissue planes of injection.
Potential alterations in technique that may yield more significant results in the malar and submalar regions may include staggering the midface lift and fat injection procedures to eliminate the effects of tissue edema seen immediately following the midface lift and to provide more static planes of injection. Additionally, a second fat transfer procedure may be indicated in certain patients at 3-6 months to restore complete correction.
In our practice the evolution of the midface lift now includes the addition of fat transfer to the operation. Our study is in support of the use of fat transfer to correct the tear-trough deformity and the nasolabial crease at the time of the midface lift. Many patients who undergo a midface lift have a significant tear trough deformity and infraorbital skeletonization (either from previous blepharoplasty or aging) that can be emphasized with a midface lift alone. By combining fat transfer to the tear-trough and infraorbital rim with the midface lift we are able to create a youthful, convex contour between the lower-lid and the cheek which provides superior aesthetic results and long-term correction (Figure 4). In addition, the nasolabial crease can be improved with fat transfer. In our initial group of patients this resulted in modest long-term improvement, however, as our fat transfer technique is evolving we are anticipating even more impressive results in the future.
The authors would like to thank Alain Polynice, M.D. and Rami Batniji, M.D. for their enthusiastic participation in this endeavor.
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