Lily Daniali, MD

It sounds like you are noticing some lateralization of the implant when you lay down. Naturally the chest wall is sloped downwards as the chest wall ribcage curves backwards. When a person lays down our chest wall becomes like a slide and the implant at times will want to lateralize. First of all what you are describing is normal and seems very subtle. With more extreme changes, there may be more significant lateralization of the implant. This is why the implant fitting tightly into the breast pocket and careful dissection of the space is so critical. If the pocket is too big the implant can lateralize. Occasionally patients need the lateral pocket tightened up + consideration for a wider implant but that is only if the implant is narrow for the chest. If the implant fits your chest width and it continues to lateralize you may need the pocket tightened with a procedure called a capsulorraphy with possible internal mesh reinforcement such as Galaflex or durasorb. Again what you are describing is subtle and I would not worry at this point. Your post-op swelling is coming down so you may be noticing small motion in the pocket more. Small implant motion is very normal and actually a good thing to keep the pocket soft and non constricted. At this point in your recovery it is important to wear a supportive compression bra while you are healing and to follow your activity restrictions.

There are two purposes of fat transfer in face lifting: adding volume & tissue regeneration.
Fat transfer that is structural is used to add volume to cheeks and specifically is used to address some of the subtle hollows that happen with age. Areas of shadowing at the lid cheek junction or the jowl sulcus. Nanofat is fat at has been lysed until it is really a cellular signaling soup for regeneration of the tissues. It can help by adding luminosity and improves textural issues. I often pair it with a laser resurfacing when possible (though you do have more darkly pigmented skin and have to approach laser resurfacing very carefully). In reviewing your photos I would recommend that consider a deep plane face and necklift with someone who is skilled in understanding the anatomy and maneuvers for correction. It will help reposition your tissues and provide you with the contours you desire. The fat transfer provides an enhancement of the result, but it will not need to be a high volume of fat. Patients like yourself require 8 - 12 ccs of fat injected very strategically for the whole face. But it does have a big impact & it takes a lot of skill from the surgeon to do it properly.

What a great question! In order to fully understand the answer to this question we need to first go over the layers of tissue in the face:
- Layer 1: Skin
- Layer 2: Subcutaneous Fat
- Layer 3: Superficial musculoaponeurotic system (SMAS): fascial layer that lays on top of your facial muscles above nerves & other critical structures
- Deep to SMAS: facial nerve, facial muscles, parotid & submandibular glands
There is a misconception that facelift surgeons are using the skin to tighten and give the desired result. The truth is that face lifting techniques have evolved tremendously over the last decade, and there is a growing understanding of the most durable approaches for facelift longevity. We never want to use the skin to lift the midface and provide shape to the neck. All of the work is done in the deeper anatomical layers. The skin and subcutaneous layers are draped over the deeper work on the SMAS. That is one of the secrets to beautiful, imperceptible scars. The SMAS layer is elevated off the deeper structures with great care and it is then repositioned in a more elevated position. This is the deep plane facelift. The SMAS is dissected into the neck (here it turns into the platysmal muscle) and after many technical maneuvers are performed deep to the SMAS to debunk glands and to retighten the platysmal muscles corset, the SMAS is laterally repositioned to provide a beautiful angle of the jawline lift and tightening.

We never use the facial muscles for the facelift tightening. In general all of the facial muscles and there nerves of the face are carefully protected during the dissection and left alone. The only muscle used for tightening is the platysmal muscle in the neck. The platysmal is a very think muscle that lays along each side of the neck. Sometimes it meets in the midline neck and sometimes it doesn’t based on a person’s anatomy and aging. It is really important as a facelift surgeon to carefully dissect out the platysmal and not to shred it as it is key for the necklift shaping. If the platysmal is damaged from previous surgical manipulation or non-surgical damaging procedures then unfortunately the longevity of the necklift correction can be compromised. If this is the case, I would recommend finding a facelift surgeon who is skilled in revisionary procedures for correction.

First of all you have beautiful skin and excellent skin quality. You stated that you have hereditary heavy cheeks, and you are starting to see deepening of your NL folds. It is possible that your use of fillers in your cheeks is heading to worsening of the weight in your cheeks. HA fillers are like sponges and can hold on to fluid while also migrating through the soft tissues. You may consider having your fillers dissolved to see if that unweights your cheeks. Deep plane face lifting approaches are very powerful and allow for direct contouring of the soft tissues, tightening of the fascial system of the face and neck. You are a younger patient, and it is a personal decision if you are ready for this approach this early on. I would counsel considering investing first in non-surgical tightening with Sofwave to stimulate collagen and elastin after dissolving out your fillers. If you still want more at that point, you can feel comfortable pursuing facelifting procedures with an experienced surgeon in these techniques. Many facelift surgeon will want the fillers dissolved out before surgery too. You may be surprised how much slimmer your face is after removing fillers that may be causing cheek distortion.

The deep plane facelift can have amazing results, but it is not always the right thing for everyone. I would recommend having a consultation to really understand what areas of your face are most concerning to you. If you are looking to have a more defined neck line, a deep necklift would be a powerful technique to achieve that. I have done necklift procedures without a combined facelift in younger patients without major facial laxity with life changing results. You do have beautiful skin quality and your upper face would likely respond well to non-surgical procedures that stimulate collagen deposition such as Sofwave. Sofwave uses high frequency ultrasound that is preserves facial fat. The last thing you want is to destroy your facial fat with rounds of deep radiofrequency microneedling. At times someone that is young would benefit from a facelift, and that is a determination that has to be made in person. I have to feel your skin and tissues to see the level of laxity and also to understand what your specific goals are. The best plan is one in which the surgeon and the patient really get to connect, educate one another, and formulate a plan that is right for you. Warm regards, Lily Daniali, MD FACS