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    Fat grafting and the facelift

    Just as in the world of entertainment, many of the top plastic surgery strategies work best as a combo. Think of them as Captain & Tennille, Simon & Garfunkel or Sonny & Cher.

    Scratch that. When it comes to SMAS flap procedures and fat grafting, University of British Columbia plastic surgeon Richard Warren, M.D., says we need to think bigger and bolder. Batman & Robin? Close but not quite. There’s no sidekick here.

    In fact, the two strategies are more akin to two superheroes on the same team, he told an audience at The Aesthetic Meeting yesterday in Las Vegas during a panel on repositioning facial fat. Like, say, Superman and Batman. “Ideally,” he says, “you’d like to have both on your side for most facial rejuvenation cases.”

    His colleagues on stage didn’t offer up-to-the-moment Hollywood metaphors, but they agreed that fat grafting has revolutionized the art of SMAS flap procedures, which in turn revolutionized facelifts themselves.

    In fact, for patients undergoing a second facelift, “fat grafting is more important to rejuvenating the patient than the facelift itself,” says Timothy Marten, M.D., FACS, a plastic surgeon in San Francisco. “They’re synergistic tools.”

    Where should plastic surgeons begin when they add fat grafting to an SMAS flap procedure? Alex Verpaele, M.D., a plastic surgeon based in Belgium and The Netherlands, suggests that they start by examining the patient’s face in order to “analyze what has brought this patient to this situation.” At Dr. Verpaele’s practice, he asks patients to provide photos of themselves when they were decades younger. “Facial fat repositioning and/or replenishment are guided by the patient’s appearance in youth,” says Dr. Verpaele.

    The University of British Columbia’s Dr. Warren says fat grafting is especially useful in hollowed areas. “For the deflated face, fat grafting has been a major game changer; the biggest game changer in my career,” he says. “We can put fat virtually anywhere in the face, but it’s dependent on facial shape and contour.”

    San Francisco’s Dr. Marten agreed. “Lifting doesn’t treat atrophy. That’s been the missing link.” Now, he says, fat grafting allows the plastic surgeon to produce a softer, natural appearance without tension deformity. The combo SMAS/fat grafting treatment also extends the lifetime of facelifts by several times, he says.

    Additionally, the panel agreed that you should perform fat grafting before the SMAS flap procedure because you’ll be more artistic and more energetic.

    And, Dr. Verpaele says, it’s important to set expectations for patients regarding the possible need for more fat grafting. “I tell all my patients that they have a 20% chance they will come back for a refill procedure after four months,” he says. “That’s not a big problem. You go back in and do a refill under local.”

    If you want to see more mid-face improvement from the SMAS flap procedure, Dr. Marten recommends a procedure he’s developed called the “high SMAS facelift.” Via a flap at the zygomatic arch instead of below, it’s a “simultaneous single flap repositioning of mid-face, cheek and jowl fat,” he says. 

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