Fat strip grafting?

Hello Doctor Yang,
I am new to this forum but have been reading the posts here for months. I am 35 yrs old and I was a smoker for 20 years and quit about 10 months ago, and was under extreme stress for the last two years…I feel that these two factors really aged my face. I am scheduled for a short scar face lift to address my slightly sagging midface with fat graft to address the hollowness in my tear troughs in about 3 weeks. My surgeon has recommended a fat strip transfer? He will remove a strip of fat from my abdomen and “place” it in the area that appears hollow under my eyes by way of a small incision inside of my lower eyelid with dissolvable stitches. I have not been able to find much information on this procedure and as the date of my surgery approaches, I am becoming more and more nervous. I do think I trust my surgeon….He specializes in face lift surgery,has a very long list of credentials, the pictures he has of his previous facelifts are beautiful and I have only had positive experiences in my visits,but he has said that this is not a procedure that he does very often.I am also having this done in office under a local and am very curious and nervous about how this procedure will be performed.
Thank you for reading,
Starla Valen

Hi Starla,

In general, a short scar facelift will tighten the jawline. For a local anesthetic procedure, not much can be done to perform a thorough releases of a cheek fat pad to elevate the sagging midface to achieve a long lasting result. Even the deep plane facelifts which completely release the cheek fat before elevating them can look really good initially but still sag after a year or two (Hamra.) An endoscopic midfacelift is reported to last 5-7 years, which is the longest.

A typically recommended procedure these days for a woman in her 30′s-40′s with early signs of facial aging is an endoscopic midfacelift with or without a simultaneous endoscopic browlift. These incisions are all in the hairline and are well hidden. I don’t know if you were offered this as an alternative to your recommended procedures.

The typical short scar facelift, S-lift, or mini-facelifts mainly lift the jawline but do not do much for the cheeks or any significant neck improvement when performed as an isolated procedure (without liposuction of the neck or platysmaplasty.) These types of facelifts can be typically performed under local anesthesia.

One exception is a European modification of the S-lift called the MACS lift. This can be modified into an extended MACS lift which can somewhat addresses the midface, but definitely is not in the same leagus as a deep plane facelift or endoscopic subperiosteal midfacelift. I don’t know if this is the type of short scar facelift your surgeon is referring to. If so, you may get some improvement of the sagging midface if you get the extended version. Here is a prior post that I wrote about the MACS lift: http://messageboards.makemeheal.com/vie … hp?t=65970 There are picture examples of a MACS lifts in this post, and you can decide for yourself how much of the cheek is lifted up, and how much the nasolabial folds (smile lines) are improved.

Many people choose to have a facelift as an alternative to fillers to improve their smile lines, because when they lift their cheeks up their smile lines look better. Also, because people think that a facelift typically lasts 5-10 years that they may be able to avoid fillers during this time. Unfortunately this is not the case. The cheeks/midface is one of the hardest things to lift up and keep in the lifted position. A smooth jawline can easily last 5-10 years, the cheeks are another story. For these patients they end up being disappointed when they still want fillers after their facelift, because their cheeks were not lifted as much as their surgeon may have showed them.

Fat strip grafiting to the lower eyelids
I do know about fat strip grafting, but mainly to the upper eyelid hollowing. I have not heard of using a strip of fat for the lower eyelid hollowing. A more common and more accepted method of fat grafting this area is with fat transfer (micro-fat grafting of gently liposuctioned and purified fat which is injected evenly with specially designed blunt tipped needles (cannulas.) I use the fat transfer method for lower eyelid hollowing. I think that if you ask 100 plastic surgeons about the best way to filling the lower eyelid hollows effectively least 95 out of 100 would know about fat grafting with liposuctioned fat, the other 5 may not have a good solution for this problem, and fewer would know about the strip fat grafting.

Why use a strip of fat instead of liposuctioned fat?
The reason that I use a solid piece of fat for the upper eyelids is to take advantage of the higher fat survival rate as compared to liposuctioned fat. My one concern would be lumpiness of the fat, or the piece of fat showing through the skin, because the fat has a certain shape and may not be able to blend smoothly into the surrounding area. I don’t know how he does the procedure, so maybe there is a way, I just don’t know about it.

Maybe this is how he does it?
In some recent private email discussions about fat repositioning lower eyelid surgery for tear trough hollowing under the eyes, I discussed the problem of not having enough fat to tuck under the tear trough area. Not knowing exactly how your surgeon sews this fat into place, I could imagine this procedure being similar to a fat repositioning lower eyelid surgery, but instead of using lower eyelid fat, a strip of fat from the abdomen would be used. This would allow for more fullness where the tear trough hollow. Also if this were placed under the “periosteum” in a deeper location on the bone as in a fat repositioning procedure, it would be less likely to be lumpy since it is under a tough layer of tissue which should keep the fat compressed and prevent lumpiness.

Very interesting. Thanks for letting me know about this procedure. I think that the fat grafting will likely make a nice improvement to your lower eyelid region. But my concern is what you expectations for improvement for the midface/cheeks are with the short scar facelift.

Upper cheek and lower eyelid fat transfer
For people who are “aging prematurely” from stress and smoking, I wonder if you are lacking overall volume to your lower eyelids and upper cheeks. One way to figure this out on your own, is to find your high school and college pictures. Find the ones where you are not smiling. Compare these to your current pictures and see if you feel that your face has deflated. If so, another option is fat transfer to the upper cheeks with blending of the fat into the hollowing of the lower eyelids. This would be a no incision procedure, and would not address your eyebrows if your eyebrows have truly dropped (check your eyebrows and how much eyelid is showing on your high school and college pictures, too.)

Conflict of interest
It sounds like you have already chosen your surgeon. I just wanted to let you know of other possible options for the same areas you are concerned about, in case your surgeon did not discuss them as a possible options for you. These are just his opinions and if you saw 10 different surgeonsyou may get 10 different answers. Each surgeon thinks their method is best, even though each one has a different approach. It is up to you to figure out if this particular surgeon can deliver on your expectation for improvement. The surgeon that you consult with is not obligate to tell you, “This is how I do my facelifts, but my worthy competitor down the block offers a different procedure which may give you better results based on your expectations.” No, each surgeon would prefer that you choose him or her over anyone else, since this is obviously a very competitive field with lots of money involved. Most surgeons will not openly recommend other competitors unless they don’t offer the procedure themselves. People somehow think that because we are doctors we always have the patient’s best interest in mind. If this is the case, if a surgeon knows that another surgeon would do a better job then he could, shouldn’t he instead recommend the other surgeon over himself? But, the reality is that the surgeon has to support his staff, pay rent and malpractice insurance, and feed his family or if they don’t have a family, their flashy lifestyle. This is why I titled this paragraph, conflict of interest. If a doctor owned his own pharmacy and could profit more by perscribing drug A over B, despite drug B being more less expensive and more effective. When this doctor recommends Drug A, this is called a conflict of interest since this recommendation also directly benefits the doctor when his pharmacy make more profit on Drug A over drug B.

What’s the catch?
This is for anyone else reading this post. Whenever you are considering a new procedure, you have to ask yourself, “What’s the catch?” There are no perfect procedures, so it is important that you would be able to deal with the “catch” part. If you can deal with the Risks, complications, and after effects of the procedure, then this is probably a good procedure for you, more so than the Benefits part of the procedure.

I hope this makes sense.


Dr. Yang