Is fat grafting necessary with my SMAS facelift and upper eyelid surgery?

Question

I have hollows under my eyes but am concerned after having read that there is a possibility of lumpiness. Should I ask for fillers to be used instead?

Paul Lanfranchi, DO, FAOCOO · Answer

First and foremost, it is very important to realize and understand that the lower eye (and upper cheek) area is quite delicate.  It is an area that should be respected by the surgeon (or injector).  In our practice it is unfortunately very common to see patients who had excessive filler placed under their eyes by other practitioners.  Both artificial filler and fat can create "lumps" that are often difficult to treat.  The goal should be to treat conservatively even if a second treatment is necessary in the future.

Alejandro J. Quiroz, MD · Answer

Thank you for your question. Is important to have at least a picture to give you a more valuable and precise answer but if you have a high SMAS technique the surgery will give you volume in the cheek and under eye area no under your eye. I will go for a physical consultation

Jeff T. Healy, MD · Answer

One of the signs of aging is loss of volume in our faces.  Restoring that volume makes us look younger and more refreshed.  When undergoing a facial rejuvenation procedure, your results may be enhanced if volume is added.  The most common ways to restore volume to the face are using fat or using fillers.  Both ways can be very effective if done properly by a highly skilled surgeon.  The benefits of fat are: it's your own tissue, more permanent results and maybe some contouring improvement at the donor site.  The disadvantages of fat are: possible lumpiness, under or over correction, difficult to reverse if results not ideal and possible problems with donor site.The benefits of fillers are: no need for donor site, consistency of product and ability to reverse if results not ideal.  The disadvantages of fillers are:  temporary results, possible lumpiness, under or over correction and possible allergic reactions.Discuss with your surgeon which option they think is best for you and agree on the method you are most comfortable with.

Kevin Sadati, DO · Answer

Structural fat grafting with PRP, sometimes referred to as micro fat grafting with PRP can provide fullness to hollowed upper or lower eyelids and can fill lines and wrinkles on the face.  In the hands of an experienced facial plastic surgeon you can be expect a smooth and natural results.  It can be performed in conjunction with SMAS facelift. 
There are several different types of facelift techniques that are currently performed by facelift surgeons. The most important factor is that the technique that is used by a facial surgeon will create a youthful, natural with long lasting result. An ideal facelift result includes in part not having anyone assume you have had a face lift procedure.  I think a patient that desires improved appearance but wants a natural, non-operated result will have to communicate this to his or her prospective surgeon but also seek out an experienced facelift surgeon that prefers to achieve these types of results.  Experience is the key in facial rejuvenation. Vectors of facial tightening vary from patient to patient. For a 45- 50-year-old patient, I would not apply the same vector and tension that I normally apply to a 70-year-old face. In addition, direction of vectors must be modified during secondary or tertiary facelift to avoid artificial look.  I have performed well over 3,500 face and neck lifts and published a specific technique that describe the rotational angles and amount of tension that must be applied during SMAS plication to avoid over or under tightening.  A well-performed neck lift during facial rejuvenation is the paramount in a youthful-appearing face. I apply gradual tension on my SMAS as follow: starting at temple area there is only 20-30% tension on muscle plication, once at the jawlines the muscle is tightened 100%. This prevent pulled looked at the corner of mouth. In neck area the muscle must be tighten with greater tension than 100%, depending on the neck laxity.  Look at the doctor’s before and after pictures, a talented and experienced facelift surgeon will have a smooth and well-contoured neck that enhances the facelift results.  The face ages through a combination of changes including volume loss, skin changes, and soft tissue drooping.  When facial rejuvenation is desired all of these changes must be addressed.  Therefore, fat grafting, a facelift, and skin resurfacing frequently must be combined to accomplish a natural result.

Amir Nakhdjevani, MBBS, MRCS, FRCS(Plast) · Answer

Thank you for your question.  I believe filler is a really good temporary solution for hollow eyes.  If performed correctly the results can be really beneficial.  Fat Grafting is good if the fat survives however sometimes it can die therefore a few tries maybe needed.  Please have a consultation with a board certified plastic surgeon.  All The Best

Sean Fisher, MD · Answer

fat grafting is very commonly performed by many facelift surgeons in combination with face/neck lifts. Most surgeons will likely tell you that our preference is to use fat as opposed to an absorbable HA filler. These products are temporary and are not without their own risks. Different types of fat (micro & nanofat) can be used depending on the area being addressed and the depth that this is being injected. typically, more refined fat is used in the under eye area to prevent issues with contour irregularities or lumps. If you are having a lower blepharoplasty in combination with your other facial procedures, fat repositioning can also be considered as a way to smooth this lid-cheek junction while avoiding fat grafting and filler. 
Sean Fisher MDAesthetic Plastic Surgeon Seattle, WA

Terry Maffi, MD · Answer

I routinely incorporate fat grafting into the majority of my facelift and lower eyelid surgeries. Opting for fat grafting proves to be a superior choice when addressing multiple areas concurrently, surpassing the efficacy of fillers.
Additionally, I employ fat grafting specifically to the lower eyelids as a standalone procedure to rectify hollowness. While there is a minimal risk of lumpiness, referred to as fat necrosis, characterized by small portions of fat undergoing cell death and forming tiny scar tissue nodules, such occurrences are infrequent. It's essential to note that fat necrosis is entirely manageable through techniques such as massaging and, when necessary, steroid injections.

Francis R. Palmer, III, MD (retired) · Answer

Hi, I have performed many SMAS facelifts for over 30 years and have performed many minimally, invasive SMAS facelifts.  As discussed below fat is far less reliable at providing consistent volume than an off the shelf dermal filler or silastic facial implant (for the cheeks, chin, lips).
 Following my beauty principles, women look the most feminine, youthful and attractive with heart shaped faces.  Heart shaped faces have cheeks that are full and round in the front.  Cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement will create full, round cheeks that will feminize the entire face.
 A weak chin creates an imbalance making the nose appear larger, the mid face top heavy and the lower face look short that de-emphasizes the lips and allows early formation of a double chin.  Chin augmentation using a chin implant will add projection to the chin creating harmony and balance to the lower face.  I have found placement of a silastic chin implant, through a small curved incision under the chin (also allows excess skin removal) to be very safe, quick and highly effective.
 If you have "jowls” these are sagging facial tissues and the main indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.
My most popular SMAS facelift is the minimally invasive, short incision SMAS facelift that has all the benefits of more invasive facelifts (traditional, mid-face, deep plane, cheek lift and subperiosteal facelifts) but with these added benefits:
very small incisions and no incisions extend or are placed within the hair.
minimal tissue dissection = less bruising and swelling = rapid recovery ( several days instead of weeks or months with the more invasive type facelifts mentioned)
can be performed in 90 minutes or less, with or without general anesthesia
proper SMAS Imbrication technique
no incisions within the hair = no hair loss
excess fat can be removed from the face and neck
excess skin removed from the face and neck
cheeks, chin and jaw line can be augmented with dermal fillers (I prefer Restylane Lyft) or facial implants
most patients fly back home to parts all over the world in as little as 3 days post-op
I combine facial shaping with every facelift procedure.  When jowls are present, these should be done in concert and not alone or separately in order to create a naturally, more attractive face.
I have performed many facial shaping procedures using dermal fillers, facial implants (cheek, chin), liposuction and/or facelifts for over 30 years.  In my experience and despite its recent increase in popularity, fat transfer (fat injection) offers "far" less of a reliable and predictable volume for facial shaping than an off the shelf dermal filler or silastic facial implant.  For that reason, I do not use fat to shape the cheeks, chin, lips or jaw line.  Tissue physiology is quite simple.  Tissue requires a blood supply in and out as well as lymphatic connections to remain viable and alive.  Once fat is removed from the body all of these things have been disrupted.  Just because the removed fat is mixed with PRP or something else doesn't make the blood and lymphatics magically re-appear.  The fat at that point is not living tissue which means that it's prone to being dissolved by the body (most likely in an uneven and unpredictable manner).  Injecting fat back into the face does not create the required elements to make the fat living tissue once again.  So the argument that fat is alive and viable in the face once it's been removed and re-injected makes no sense to me as a physician and surgeon.
 The other issue that I have with fat transfer is the lack of precision.  Fat is thick by nature which means it's not the same consistency as an off the shelf dermal filler.  Fat injections use an increased volume injected in an attempt to compensate for the volume loss that "will" happen.  This means a lack of specific shape and volume that simply can not begin to compare with the specificity of using a silastic facial implant of a "known" shape and volume.  In that regard fat offers too much of an unknown to make it a reliable and predictable method for facial shaping.  There's a significant difference between a 3mm and 5mm thick cheek implant.  You can imagine the magnitude of difference there is between retaining 60% of 25cc's of fat versus 35%.  In my humble opinion, I just don’t see how fat could possibly be used to precisely shape facial features?
Hope this helps.

Is fat grafting necessary with my SMAS facelift and upper eyelid surgery?

Answers (8)

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