This article outlines Dr. Kai Kaye & Dr. Gabriela Casabona’s algorithmic, area-based approach which takes the type of fat, layers needing restoration, and overall desired effect or patient expectations into account. The approach encompasses six main areas of treatment:
Figure 1 (A) Temples Before, (B) after. Injected with microfat, intramuscular and prefascial, 12 cc per side
Area 1: Temples
Deflation of the temples (one of the first areas to age), due to a loss of volume in the fat compartments, leads the brow and the lateral region of the face to lower as well as develop a hollow appearance to the temples themselves.
Our goal is to restore volume, to re-contour the affected area, as well as restore projection and provide support to the outer brow and cheek.
To achieve rejuvenation of the skin we apply the following;
- Type of fat: microfat and nanofat
- Layer injected: micro fat to the deep layer of the posterior temple (behind hairline), the deep compartments and intramuscular in the anterior temple. Nanofat to the superficial compartments.
- Aesthetic effect: lifting and revolumising of the lateral brow, lifting of the lower lateral temple/lateral orbital region.
Area 2: Midface/malar (cheek - side of the head)
Deflation of the midface/malar areas occurs quite early in the ageing process. Volume loss, in combination with the progressive loss of bony support by the inferior orbital rim, leads quickly to a lack of support of the lower eyelid. Often even young patients complain about having a ‘tired’ look. Revolumizing the periocular fat pad and restoring support for the lower eyelid is one of the main goals, as well as recontouring of the zygomatic bone to augment projection and achieve lifting to the lateral face.
- Type of fat: microfat
- Layer injected: deep compartments of the anterior & lateral cheek, and periocular fat pad.
- Aesthetic effect: better contour of the cheek/malar and smooth transition into the lower face, less sunken and deflated lower eyelid with revolumization to give a more ‘rested’ look.
Area 3: Mandible/gonial angle
The mandibles not only define the framework of a masculine look in men but also provide strut-like tension support for the overlying facial skin in both sexes. An under-projecting mandible reduces this support and leads to the early formation of jowls. This loss of projection can begin in either sex as early as age 25, therefore it is considered as a preventative anti-aging procedure from this time.
Figure 2 (A) Perioral before, and (B) after. SNIF intradermal nanofat injection perioral 5 cc total, microfat upper/lower lips 2 ml each, 2 cc marionette fold, 3 cc nasolabial groove per side
- Type of fat: microfat
- Layer injected: deep to on top of the bone.
- Aesthetic effect: improved jaw definition and contour. Better posterior projection of the gonial angle and anterior projection of chin to augment projection of the mandible, thus enhancing the cervicomental angle of the neck, and providing a lifting effect to the anterior neck.
Area 4: Brow/Periorbital
The brow and periorbital area form an aesthetic unit that should be addressed simultaneously, as their visual connection defines the frame of any beautiful eye.
Progressive descent of the brow caused by forehead skin laxity, in combination with deflation of the ROOF, during the ageing process leads to a heavy upper-eyelid and patients often complain about looking ‘sad’. Atrophy of the superficial portion of the area underlying the lid crease leads to an augmentation of visible upper eyelid height (doll eye effect). Age-related atrophy of the periocular fat pad augments the visible lower lid length and deepens the lid-cheek junction, and subsequent exposure of the underlying structures like fat compartments and canthal ligaments results in the skeletonization of the infraorbital area.
Revoluminisation of lateral eyebrow fullness and reprojection of the eyebrow shape are key goals when treating this area; as well as the reduction of upper-lid height, correction of lower lid skeletonization, and treatment of dark circles.
- Type of fat: microfat and nanofat
- Layer injected: brow and deep forehead layers; microfat on the periosteum, upper eyelid, microfat in lid crease area and nanofat in the superficial upper eyelid crease. Lower eyelid; microfat under the orbicularis oculi muscle and nanofat over the orbicularis oculi to achieve dermal rejuvenation via an SVF effect.
- Aesthetic effect: better contour of the brow, restoration of lateral fullness with brow elevation, correction of the skeletonisation effect, eyelid height, lid/cheek junction and dark circles.
Area 5: Perioral/lips
In much the same way as the periorbital area should not be addressed separately from the brow; the perioral area forms an equally strong aesthetic unit with the lips. Structures like the philtrum, the white roll and the vermillion support the lip and define its youthful shape.
Figure 3 (A) Panfacial before, and (B) after. Microfat chin 7 cc total, mandibular 8 cc, gonial angle 6 cc, upper/lower lips 2 cc each, philtrum/supraoral 6 cc, malar 6 cc ,infraorbital 2 cc, lat brow 2 cc, temples 6 cc per side
From the mid-twenties onwards the maxillary bone begins to lose projection. With further advance of the ageing process, the deep sub-muscular fat compartments also lose volume resulting in a loss of support for the anatomic structures mentioned above.
The lip becomes straighter, losing the cupid bow shape, and becomes inverted. In cases with severe deflation and loss of volume in the subcutaneous layer, the patient often complains about the ‘bar code’ lines on the upper lip. The restoration of support and recreation of a youthful shape is the principal goal in this area, as well as conservative volume restoration and correction of dermal wrinkles.
- Type of fat: microfat and nanofat
- Layer injected: micro fat to the perioral/philtrum deep compartments and intramuscular lips. Nanofat to the white roll, upper lip superficial sub-dermal layers.
- Aesthetic effect: better contour of the lip and proportions, lip eversion, smoother skin and reduced wrinkles around the mouth.
Area 6: Piriformis fossa/nasolabial/deep cheeks
The nasolabial fold (the creases running from either side of the nose to the lips) was one of the first regions for volume restoration with injectable fillers.
Figure 4 (A) Panfacial transgender before, and (B) after. Microfat forehead 7 cc, chin 4 cc total, mandibular 10 cc, upper/lower lips 2 cc each, philtrum/supraoral 4 cc, malar 8 cc ,infraorbital 3 cc, lat brow 4 cc, temples 8 cc per side
At the time, the anatomy of the deep and superficial fat compartments of the face was not yet fully explored, and so treatments with injectables concentrated on linear filling along this fold. The formation of this fold and its subsequent deepening during the ageing process is the result of a loss of soft tissue volume and bone projection not only along the line itself, but in all adjacent areas. It should, therefore, all be treated as a unit.
The widening of the piriform fossa (part of the pharynx area) due to bone resorption of the maxillae (bone either side of, above and below the nose) leads to an inwards rotation and depression of the soft tissues on both sides of the nose, as well as a loss of support of the upper lip and nasal base. Subsequently, the support to the lateral deep cheek compartments is diminished, leading to the deflation of the deep cheek fat compartments and a downwards/inwards sagging cheek, thus further enhancing the development of the fold.
Patients often complain of a ‘sad’ or ‘aged’ look, and the goal in this area is the restoration of a smooth transition between the cheek and the perioral area.
- Type of fat: microfat
- Layer injected: piriform fossa, deep cheek fat compartments periosteal - deep, spina nasalis/philtrum periosteal/ submuscular under orbicularis oris
- Aesthetic effect: Smooth transition between perioral area and cheek with volumization. Re-projection and eversion of the lip with correction of gummy smile, plus enhanced support of the nasal base.
Figure 5 (A) Cheek/malar before, and (B) after. Microfat forehead 10 cc, mandibular 5cc, chin 4 cc, upper/lower lips 2 cc each, philtrum/supraoral 4 cc, malar 6 cc, infraorbital 3 cc, lateral brow 2 cc, temples 8 cc per side
Application / Safety
As the success of any fat grafting procedure depends on a variety of factors, especially on the careful handling and even distribution of the fat aliquots, the surgeon should gather enough experience with single zone, small volume approaches before performing large volume, pan-facial single treatments to avoid the multiplicator effect for complications.
Figure 6 (A) Periorbital before, and (B) after. Microfat, 4 cc infraorbital, 3 cc lateral brow
To avoid intravascular injections, the injection should be performed with a retrograde movement of the cannula, and the injector should avoid placing a degree of pressure on the plunger. Vascular anatomy should be visualised prior to injections, and injection pathways should be perpendicular to large vessels, not parallel, to minimise the possibility of vascular canulization. In areas with large diameter vessels at the surface, digital compression of the main vessel minimises flow and vessel diameter.
The overall goal of pan-facial rejuvenation using a combination of micro and nanofat in a holistic, anatomy-based approach is not only to restore a youthfully shaped face but also to create beauty through enhanced proportions and recreate the natural glow we find in younger skin, resulting in a true three-dimensional regeneration concept.
Figures 1–6 © Dr Kaye, Ocean Clinic, Marbella.
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