Volumetric Facelif twith Intra - and Post-Operative MidfaceVolume Replacement‘‘The Four-DimensionalFacelif t ’’Benjamin A. Bassichis, MD, FACS*

With the millennium came an ideological shift inthe approach to facial rejuvenation from predomi-nantly subtractive surgical methods to additivevolume restoration techniques.1 Earlier faceliftprocedures focused on tightening lax skin, withoutattention to volume, often leading to a pulled post-surgical visage.2 More recently, the effects offacial volume loss have been recognized asa central contributor to the aging process. Intoday’s approach to facial rejuvenation, a faceliftis not just a facelift but rather is a surgical make-over to restore youthful facial contour. Surgicaland aesthetic studies have demonstrated theneed to address the midface volume deficit whenperforming standard facelift techniques.Combining surgical facelift techniques withvolume restoration produces a three-dimensionalaesthetic improvement. In fact, nearly 95% of theauthor’s patients undergoing facial rejuvenationsurgeries receive volume correction at the time ofsurgery. Although the method of volume replace-ment can be debated and is highly operatordependant, it should be understood that thisthree-dimensional restoration does not adequatelyaddress the dynamic aspect of aging. The

continued treatment of the facelift patients withappropriately applied filler materials for yearsfollowing surgery ensures more persistent naturalresults over time,3 hence the concept of ‘‘thefour-dimensional facelift.’’ In this article, the authoroutlines his methodology from initial consultation,to the surgical and nonsurgical procedures, tothe years of volume maintenance. The conceptsof progressive treatment of facial maturation overtime, of commitment, and of long-term patientcare are incorporated into the author’s surgicalapproach to the aging face to achieve enduring,natural results (Fig. 1).

UNDERSTANDING FACIAL ANDMIDFACIAL AGINGDuring the aging process, the face loses fat andvolume, and the skin loses collagen and elasticity.4

Accentuated by full cheeks and voluptuous curvesin youth, the aging face becomes framed by bonycontours wrapped with thin skin, appearingdeflated and aged. Understanding the dynamicfacial maturation process is crucial to attain-ing optimal results with facial rejuvenation

Advanced Facial Plastic Surgery Center, 14755 Preston Road, Suite 110, Dallas, TX 75254, USA* Corresponding author. Advanced Facial Plastic Surgery Center, 14755 Preston Road, Suite 110, Dallas, TX75254.E-mail address: drbassichis@advancedfacialplastic.com

KEYWORDS! Facelift ! Facial fillers ! Facial aging! Midface volume restoration ! Fat grafting! Surgical technique ! Cosmetic rejuvenation! Rhytidectomy

Facial Plast Surg Clin N Am 17 (2009) 539–547doi:10.1016/j.fsc.2009.06.0041064-7406/09/$ – see front matter ª 2009 Elsevier Inc. All rights reserved. fa

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procedures.1 The significant contribution of volumeloss to aging features has recalibrated the mannerin which the maturing face is treated. Now it isrecognized that to correct the signs of facial aging,not only the skin but the facial soft tissues,

the subcutaneous muscle–aponeurotic system(SMAS), fat, and even facial bones need to beaddressed.The aesthetics of the youthful face consist of

healthy fullness, smooth contours, symmetry,

Fig.1. (A and B) A 57-year-old woman shown (left) before and (right) 9 months after a facelift, fractionated CO2laser resurfacing, and intraoperative filler treatments to the midface including the tear trough and mouth.

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and proper proportions. The youthful midface ischaracterized by voluminous cheeks with anuninterrupted distribution of soft tissue overlyingthe malar bone and invisible transitions to neigh-boring facial regions. Although skin laxity yieldsaging effects that are most prominent along thelower face and neck, volume atrophy is mostevident with midfacial aging. Here, tissue involu-tion creates hollow infraorbital depressions andshadowing evident as dark infraorbital circles,where thinned lower eyelid skin permits visualiza-tion of the underlying blood vessels and muscula-ture. The formerly seamless contour of soft tissuebetween the eyelid skin and cheek of the youthfulface is interrupted by malar tissue loss withsubsequent ptosis of the skin and supportingstructures. Inferior migration of the malar fatpad results in a flattened, hollowed midfacewith pseudoherniation of lower eyelid fat padsand tear trough deformity. Concomitant atrophyof soft tissue, facial bones, and musculatureevokes a skeletonized manifestation of the agingface.5

The modern approach to surgical rejuvenationof the face seeks to restore lost facial volumeand contour to reinstate youthful facial aesthetics.Cosmetic rejuvenation of the lower face can beaccomplished effectively with facelift surgery, butsignificantly improved aesthetic outcomes arepossible when midface volume restoration isachieved and maintained over time. Even aftersuccessful facelift surgery with or without volumereplacement, this loss of volume and volume shiftcontinue to contribute significantly to the ever-progressive process of facial maturation.

MIDFACE VOLUME REPLACEMENT: A DISCUSSIONOF SELECT OPTIONSCombining facelift surgery with midface volumereplacement can yield dramatic yet natural-look-ing improvements. The goals of midface rejuvena-tion in conjunction with a facelift involvereestablishing malar volume and smoothing thetransition between the eyelids and cheeks. Effec-tive restoration of volume can be difficult toaccomplish in a predictable long-term manner,however. The plethora of options for midfacevolume restoration range from surgical tech-niques, including SMAS plication or midface lifts;procedures using various permutations of autolo-gous materials, including dermis, fascia, or muscleas well as fat grafting; and alloplastic options,including malar implants, thread lifts, and inject-able facial filler materials.

Surgical procedures to restore midface volumeinclude SMAS resection, plication, or rotation;

however, these results have demonstratedminimal improvement of the naso- andmentolabialfolds and negligible improvement in tear troughcontour.6 Overall, none of the myriad surgicalapproaches to the midface has been universallysuccessful.

Currently, one of the more commonly used tech-niques for intraoperative midface volumeenhancement during facelift surgery is autologousfat transfer. Although recent improvements inpreparation, harvesting, and injection techniquesallow longer-lasting and more predictableresults,7–10 potential issues include the need formultiple procedures, a high resorption rate, poten-tial contour irregularities, and patient dissatisfac-tion. Complications that arise after fat grafting,such as lumps and bulges, overcorrection, andasymmetry, can be difficult to manage.5 Fatgrafted to the delicate tear trough and lower lidareas can be visible and palpable and can possiblyworsen the contour abnormalities it was intendedto correct. Used in conjunction with a facelift, fatgrafting can replenish hollow cheeks, but careshould be taken to avoid overcorrecting the mid-face, which can appear unnaturally heavy afterexcessive fat transfer.11 In a slender patient whohas a low body mass index, finding an adequatesupply of donor fat can be a challenge, as is theincreased propensity for fat reabsorpsion in thesepatients. In addition, weight loss or gain can alterthe outcome of fat grafting. A weight loss of 10pounds or more can result in concomitant loss ofthe cosmetic result achieved by the fat transferprocedure. In the reverse circumstance, the resul-tant fatty hypertrophy from weight gain may causeundesirable fullness or contour irregularities to thegrafted material.12 In addition, even where thestatic result may be successful, with facial anima-tion such as smiling, the enhanced malar softtissue sometimes gathers abnormally by the eye,yielding an unaesthetic appearance.

Malar implants are limited in their ability to fillthe inferior orbital rim and buccal hollows andmay create a relative exaggeration of these defi-cits. In addition, the isolated use of malarimplants in an older, volume-depleted patientcan accentuate a skeletonized appearance ofthe face.5 Smaller implants often are preferableto replace atrophic volume loss. Medium to largeimplants should be reserved for the patient whodesires not only to replace lost volume butalso to augment a previously unsatisfactoryaesthetic.13 Overall, enthusiasm for cheekimplants seems to be diminishing in favor ofsoft tissue–based treatments, which offer moreplasticity and more natural-appearing movementthan static implants.

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Minimally invasive facial traction techniques,such as thread lifts, should be viewed withcaution14 because of untoward complicationssuch as visible threads apparent through the skinsurface and an often unnatural-appearingoutcome.Injectable dermal fillers are an internationally

popular option for volume restoration throughoutthe face.11 A broad spectrum of alloplastic inject-able materials suitable for facial revolumizationhas been approved by the Food and DrugAdministration (FDA). Because of their longevity,efficacy, safety, and reversibility, the authorprimarily uses hyaluronic acid (HA) products (Re-stylane and Restylane Perlane, MedicisAesthetics, Scottsdale, Arizona; Juvederm Ultraand Juvederm Ultra Plus, Allergan, Irvine, Califor-nia) in his practice. Other FDA-approved prod-ucts, including poly-L-lactic acid (Sculptra,Dermik, Sanofi-Aventis, Bridgewater, NewJersey), collagen-based products (Cosmodermand Cosmoplast, Allergan, Irvine, California; Evo-lence, ColbarLife Sciences, Herzliya, Israel), andcalcium hydroxyapatite (Radiesse, BioFormMedical, San Mateo, California), provide varyingdegrees of longevity; however, only HA productsclaim reversibility through a simple injection ofhyaluronidase (Amphadase, Amphastar Pharma-ceuticals, Rancho Cucamonga, California;Vitrase, Ista Pharmaceuticals, Irvine, California).Also, the availability of both small- and large-particle HA products permits customization forthe most effective treatments. For difficult to treatareas such as tear trough or brow, small-particleHA injections produce unsurpassed aestheticresults with experienced injection.There are permanent injectable filler materials

that can be used in an off-label capacity forcorrection of midface volume, such as polymethyl-methacrylate (Artefill, Artes, San Diego, California)or silicone (Silikon 1000, Alcon, Fort Worth, Texas;Adaptosil 5000, Bausch Lomb, Rochester, NewYork). However, it should be cautioned thatpermanent products can yield permanent prob-lems. Because of the need for exquisitely sensitivetechnique, the possibility of significant complica-tions or corrections, and uncertain long-term risks,these permanent products are not used widely formidface revolumization, either independently or inconjunction with facelift surgery.

PREOPERATIVE EVALUATIONInitial Contact and Consultation

For every potential facelift patient, the first impres-sion of one’s practice begins during the initial tele-phone call or Internet inquiry. Almost independent

of the quality of the surgeon’s surgical skills,pleasant employees who are able to answer allpatient questions effectively and knowledgeablyare vital in determining whether a patient decidesto establish a consultation for elective cosmeticsurgery. Staff members should convey confidenceand enthusiasm about their physician and medicalteam. Personnel with poor attitudes and an insuffi-cient knowledge base may dissuade a potentialsurgical candidate.Developing patient rapport and trust is the most

important initial step in any medical consultation.To build a patient–physician relationship, thepatient must feel confident in the physician’s abil-ities and judgment. For patients, this confidencecan be accomplished by openly and empatheti-cally listening to the patient’s concerns. Under-standing each patient’s motivation for desiringelective physical change to the face is also crucial.Patients who want to ‘‘look as young as they feel’’or who are motivated to undergo surgery toenhance their own self-esteem often benefit fromsurgery. Patients interested in appearing refreshedto compete effectively in the job market also aresuccessful candidates. Excluding individuals whohave unrealistic expectations of surgery, thosewho have permutations of body dysmorphic disor-ders, who may be pressured to have surgery froma relative or spouse, who are unstable mentally oremotionally, or who believe that the surgery willsolve a failing marriage or life problems is neces-sary to avoid a postoperative patient who eitheris unhappy or who never will be satisfied with theoutcome, no matter what the result. Listening toone’s own intuition regarding these red flags isas important as listening to the patient. As one ofthe author’s respected mentors wisely stated,‘‘You’ll never regret a surgery you didn’t do.’’During a patient’s initial consultation in the

author’s practice, the patient first has a privatediscussion with an aesthetic coordinator (eitheran aesthetician or patient coordinator) to elucidatethe patient’s desired aesthetic goals. Theaesthetic coordinator distills the patient’s informa-tion to facilitate a more productive, efficientconsultation with the surgeon. In addition, theaesthetic coordinator explains the spectrum ofother cosmetic services available in the practiceand reviews before and after photographs withthe patient to illustrate the surgeon’s surgical styleand to generate realistic expectations.Armed with a synopsis of the patient’s goals, the

physician’s facelift consultation can focus onestablishing rapport and efficiently determininga treatment plan. In the author’s practice, noconsultation regarding full-face rejuvenationwould be complete without a discussion of volume

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restoration. Each patient is educated regarding thenecessity of long-term midface volume restorationto refresh and maintain a youthful, natural appear-ance. Many patients ask about longer-lasting orpermanent options for volume, but, dependingon body type, alloplastic products offer manyadvantages, most significantly reversibility andplasticity. For midface restoration in the author’spractice, all FDA-approved fillers are offered inaddition to fat-grafting techniques, to achievenatural full-face rejuvenation. During the patient’sconsultation, concepts of conservative lowereyelid fat removal and the need for long-termperpetuation of cheek volume are discussed. Theauthor’s philosophy regarding the importance ofmaintaining midface volume in a manner thatchanges dynamically as the face changes overtime is central to his successful facelift outcomes.Patients understand that the midfacial volumerestoration they receive at the time of facelift isnot permanent, and therefore patients are notdisappointed when the volume eventually dissi-pates. Because maintenance of volume is socrucial, the author personally performs allcosmetic injectable treatments, thereby devel-oping strong, long-term relationships with hispatients for optimal facial health.

Photographic Documentation

Digital photographs are taken of each faceliftcandidate including full-face frontal, left and rightoblique, and right and left lateral views with atten-tion to consistent lighting and patient positioning.Additional close-up views of the anterior neckand each ear, focusing on the pre- and post-auricular hairlines, are helpful in preoperativeplanning for facelift surgery. Computer imagealterations are performed to illustrate potentialfacelift results. These images are reviewed care-fully with the patient to confirm that they representrealistic, but not guaranteed, outcome scenarios.

OPERATIVE TECHNIQUEOperative and Injection Techniques

In the operating room, the primary or revision face-lift portion of the procedure of the procedure iscompleted. Although there are many permutationsof facelift procedures, the author performs anextended sub-SMAS procedure to achievesuccessful lift while minimizing facial nerveconcerns. This sub-SMAS technique allowssome additional fullness resulting from the slightmedial dog-ear in the SMAS. The mid-face portionof the SMAS is elevated with a superior vector, andthe jaw line and neck region of the SMAS are repo-sitioned posterolaterally behind the ear. After the

facelift closure is sutured carefully, the facial fillersand/or fat are injected into areas requiring volumerestoration. Areas to consider include cheeks/mid-face, nasojugal folds, tear troughs, naso- andmentolabial folds, lips, and any additional areasthat are aesthetically depleted. In the midfaceregion, one to two syringes per side of large-particle HA filler are placed deeply in the subcuta-neous tissues and along the supraperiosteal plane.After injection, the HA product can be modulatedmanually to achieve the desired contour. Teartroughs can be rejuvenated successfully withcareful injection of a small-particle HA filler placedjust beneath the dermis. When treating superficialand delicate areas such as the tear trough, conser-vative dermal product placement is crucial,because superficial injection can be visiblethrough the skin, worsening the patient’s appear-ance.1 In the lower face, including the naso- andmentolabial folds, two to three syringes of small-particle filler are injected as cosmetically indicated(Fig. 2 A and B).

Two factors paramount to successful filler injec-tions are treating to complete correction and fillerplacement in the dermis. Except for the periorbitaland tear trough areas, where prudent undercor-rection is the rule, both the patient and the surgeonare more likely to be satisfied with the treatmentoutcomes when complete correction is achieved.Anecdotally, experienced injectors have recog-nized that if complete correction is accomplishedinitially, the correction persists longer.1 Aftercompleting the filler injections, standard post-facelift pressure dressings are applied using fluffs,Kerlex rolls, and Coban dressings.

Maintenance of Results

During the initial consultation for full-face rejuvena-tion, patients are educated regarding the need forcontinued volume replacement to maintain results.To optimize the longevity of the filler injections, theinitial re-treatment should be performed between4.5 and 9 months after surgery.15 Additional follow-up treatments are scheduled yearly or as neededto maintain the most ideal, customized result.

DISCUSSION: FACELIFT WITHMIDFACE VOLUMEAlthough previous facelift techniques focused ontightening loose skin and resuspending de-scended structures, most of these techniquesdid not address the loss of midfacial volume. Forsome patients, loss of youthful facial fullness canbe the most significant sign of aging. In approach-ing full-face rejuvenation effectively, a combinationof traction and volume can achieve the mostnatural-appearing results.

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Fig. 2. (A) A 52-year-old woman shown (left) before and (right) 9 months after a facelift, fractionated CO2 laserresurfacing, and intraoperative filler treatments to the midface, including the tear trough, lips, and nasolabialfolds. (B) A 46-year-old woman shown before and 12 months after a facelift, browlift, upper and lower blepha-roplasty, and intraoperative filler treatments to the midface including the tear trough and nasolabial and perioralareas.

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Natural-looking and dynamic restoration ofvolume can be a challenging prospect. The unre-lenting atrophy of facial volume occurs atmultiple levels, in various tissue types, and withvariable velocities. As such, there currently is

no single, one-time technology to address thischanging system effectively in a fully predictablefashion. Injectable facial fillers provide thenatural-appearing volume to address facialatrophy and use the potential downside of

Fig. 2. (continued)

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impermanence to an advantage, permittingcustomized, adaptive results. Studies also haveshown that injected HA fillers can stimulatedermal fibroblasts to produce collagen,

yielding potential long-term volume results overtime.16

Although numerous variations of facelift tech-niques are possible, the author has chosen to

Fig. 3. A 62-year-old woman shown (left) before and (right) 5 months after a secondary facelift and intraoperativeHA filler treatments to the midface including the tear trough, nasolabial and perioral areas (A, B).

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focus this article on the vital concept of combinedfacelift plus midface volume restoration rather thana debate about facelift surgical technique. In theearlier phase of his practice, when volume playeda small role during surgical procedures, to thepresent, when 95%of full-face rejuvenation proce-dures receive concomitant volume replacement,the author has noted a definite evolution in faceliftparadigm culminating in this combined approach.This described technique has shown significantvolumetric improvement and offers less risk forcomplications, especially those involving facialnerves. The simultaneous addition of volumesometimes is even more significant at the time ofrevision surgery or secondary facelifts, becauseadditional contour abnormalities may requirecorrection during these procedures (Fig. 3).

In addition, the temporal component of thismethod addresses the dynamic nature of facialmaturation and allows a healthy, long-termcommitment to facial rejuvenation. Albert Einsteintheorized that time was the fourth dimension17;hence, the concept of integrating time intoa three-dimensional facial restoration yields the‘‘four-dimensional facelift.’’

Although the search for the perfect long-lastingand dynamic midfacial rejuvenation continues,the present understanding of facial aging and thecurrent state of technology make the approachdescribed herein a contemporary and effectiveoption for full-face rejuvenation.

SUMMARYThe twenty-first century approach to the surgicaltreatment of facial aging is customized to matcheach patient’s aesthetic needs and desires. Thesignificant contribution of volume loss to agingfeatures has recalibrated the manner in which thematuring face is treated. Modern facial plasticsurgery has come a long way from themore limitedtraction-centered approach, to achieve dynamic,volumetric, natural-looking outcomes that are trulyrejuvenating. Viewed as a ‘‘four-dimensional’’process, the continued treatment of faceliftpatients with appropriately applied filler materialsfor years after the surgical procedure can achievemore persistent, natural-looking outcomes.

ACKNOWLEDGMENTSThis manuscript is dedicated to Dr William

Bassichis and Dr Joseph Mantel. Thank you toDr Michelle Mantel Bassichis for her assistancewith this project.

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