The minute you are born, you begin to age. The normal physiologic changes that occur as you grow older result in the loss of volume called involution, or the progressive degeneration of your skin. Aging is an inevitable process although a substantial component of how we look when we are older is how we treated our bodies when we were younger. Medical research confirms that there are two distinct types of aging: Intrinsic or Internal aging, caused by the genes you inherit, and Extrinsic or External aging caused by environmental factors. Intrinsic aging is a natural aging process where the collagen production within your skin slows and synthesizes less elastin fibers. Your skin is composed of two types of important skin fibers: collagen and elastin. Collagen fibers are found in the reticular dermis and they are defined as the structural fibers of your skin. Collagen fibers do not extend since one of their main functions is to resist stretching and provide structure. Elastin fibers are found in the papillary dermis and elastin is a protein in connective tissue that is elastic, allowing your skin to resume its shape after it contracts. The single most important cause of age related skin wrinkles and sagging is the loss of skin elastin fibers because they are responsible for providing your skin its resiliency and flexibility.
Extrinsic aging is what you do to your skin because it is the part of the aging process that you control. A number of extrinsic factors often act together with the normal aging process to prematurely age your skin including gravity, repetitive facial expressions, disease, weight fluctuations, sleep positions, excessive alcohol consumption, poor diet, smoking, and sun damage. 99% of your wrinkles are caused by sun exposure, which leads to a process called elastosis in which your skin loses it suppleness and the collagen begins to degrade. Without protection from the sun’s rays, just a few minutes of exposure each day over the years will cause noticeable changes to your skin. Photoaging is the term dermatologists use to describe this type of aging and with repeated exposure to the sun; your skin loses the ability to repair itself. Scientific studies have shown that ultraviolet (UV) exposure can cause you to develop actinic keratoses (AKs) and skin cancer and while it may seem that the signs of photoaging appear overnight, they actually lie dormant beneath the surface of your skin for years. Sun exposure leads to distinct damage to the skin such as Elastosis, which is the deposition of thickened, irregular, partially degraded elastic fibers in the dermis.
Aging skin is characterized by decreased thickness, elasticity and adherence to underlying tissue. In the epidermis, the number of melanocytes and Langerhans cells decreases. The rete pegs interconnecting the epidermis and dermis flatten, causing increased susceptibility to shear forces. The dermis atrophies as loss of ground substance, elastic fibers, and collagen occurs. Thanks to technology and advancements in modern medicine, age maintenance is a manageable goal and there are several alternatives available that restore your natural looks and reduce your visible signs of aging. Although you might try solving the problem yourself by purchasing expensive skincare products or by getting mild facial treatments, you will soon discover that these solutions are temporary if they work at all. When you make the decision to seek professional help, you will discover that the market is flooded with virtually hundreds of choices. Most patients would like to diminish wrinkles or add volume to their facial features without having to undergo invasive surgery and a long recovery process. Injectable treatments such as BOTOX Cosmetic and dermal fillers make this possible but some patients are not candidates for these procedures due to allergic reactions or they may simply want results that last longer without the never-ending expense of the maintenance treatments necessary to retain their effect.
Fat transfer is the injection of fat to various areas of your body to increase volume. Fat transfer of viable fat cells can augment areas that have lost fullness, such as your face, cheeks, lips, neck, and chin. The procedure is a complex process: fat must be harvested in such a way as to preserve the integrity of the fat cells. Ordinary liposuction, laser liposuction, and ultrasonic liposuction that disrupt the cell membrane of the fat cell will not produce living fat cells. Concentration of the fat and washing the fat will also affect the results.
Although the popularity of fat transplantation is a relatively recent development in plastic surgery, the concept of fat transfer is not new. As early as 1893, free fat autografts were used to fill a soft tissue defect. The use of autogenous abdominal fat to correct deficits in the malar area and chin was reported in 1909. Throughout the early part of the 20th century, attempts were made to correct other conditions, including hemifacial atrophy and breast defects, but modern fat grafting did not develop until the early 1980s with the popularity of liposuction. Illouz reported the transfer of liposuction aspirate fat in 1984 while Ellenbogen reported the use of free pearl fat autografts in a variety of atrophic and posttraumatic facial deficits in 1986. With refinements in technique, fat grafting has become the procedure of choice for an array of problems.
There has been a long-standing need for filler materials in the field of cosmetic surgery. The most popular fillers in use today are Juvederm or Restylane, which are hyaluronic acid fillers temporary in nature. Patients are usually happy with their results immediately after injection but the benefits fade over time as the fillers dissolve. Semi-permanent injectable fillers such as silicone, Radiesse, Radiance, Artecoll, and Artefill have been associated with lump formation and chronic problems. Permanent fillers such as Gortex, SAM, or lip implants tend to feel unnatural and it has been reported that patients who receive fat injections are often disappointed by the long period of swelling followed by re-absorption or the loss of the graft over time. Many materials have been tried for the correction of soft tissue defects and deficits. However, the use of most of these substances has met with difficulties, including impermanence, foreign body reaction, unnatural texture, and possible disease transmission. In addition, most of the products currently available remain relatively expensive.
Some of the materials used in in restoring facial volume include:
Silicone: Some materials, such as small volumes of liquid silicone, have resulted in enormous failures. Defects are intentionally under-filled since the ongoing soft tissue reaction creates additional volume. The reaction of the host tissue can lead to late complications including chronic edema, lymphadenopathy, scarring, skin ulceration, skin thinning, skin discoloration, and siliconomas.
Collagen: Collagen is currently widely used. Available collagen consists of purified bovine collagen. Zyderm is 95% type I collagen, and 5% type III collagen. The addition of glutaraldehyde cross-linking (Zyplast) slows resorption; however, the host nonetheless eventually degrades the substance. While collagen works for the correction of fine lines, results for deeper furrows are less impressive. The major drawback to the use of collagen is the short duration of the response. Within 3-6 months, the collagen is resorbed completely and the improvement is lost. Also, because the collagen is bovine-derived, allergic response is possible.
Gore-Tex: The Food and Drug Administration (FDA) approved Gore-Tex (solid polytetrafluoroethylene) for facial plastic surgery in 1993. The result is generally predictable because the substance is nonreactive but the resulting feel of the tissue is somewhat unnatural. The substance is rigid and is not available in an injectable form. In addition, infection remains a potential problem because the substance is a foreign body.
Poly-L-Lactic Acid: Use of injectable poly-L-lactic acid (PLLA) has gained popularity in Europe since its approval for cosmetic correction in 1999. PLLA is a synthetic polymer of lactic acid that is biodegradable, re-absorbable, and biocompatible. The large particle size of PLLA (40-63 µm) prevents it from being phagocytosed by macrophages, but it can still be used in needles as fine as 26–gauge (ga). The outcome in patients with a loss of facial volume and contours appears good however many cases of granulomas and inflammatory reactions have been reported which are difficult to treat.
Hyaluronic Acid (HA): Hyaluronic Acid is a carbohydrate polymer and one of the major components of the extracellular matrix. It is found extensively in neural, connective and epithelial tissues. Although pure HA is not biocompatible with dermal tissues, the cross-linked form is biocompatible. HA was initially extracted from cock combs but possible allergic reactions limited its use. This problem was overcome by the compound Restylane, which is produced from non-animal cells through a process of fermentation and filtration. Complications are usually related to local inflammatory responses.
Autologous Tissue: An ideal substance that is soft, readily available, inexpensive, long lasting, not immunogenic, feels natural, and does not cause adverse immunologic reactions is autologous tissue. Several types of tissue can be transferred. Fascia and dermis require longer scars for harvesting but ideally, dermis can be harvested from the area of a previous incision, such as a cesarean delivery or abdominal scar, to avoid a new donor site defect. Strips of these tissues can be useful for larger areas and deeper defects. Fat can be harvested through inconspicuous incisions and the harvesting does not leave a defect and the removal of fat is often desirable.
Autologous fat transfer has been used for correction of facial scarring, including acne scars. Enhancement of facial volume also can be achieved for disease processes such as hemifacial atrophy and for patients with aesthetic concerns, such as those who request lip augmentation. Signs of facial aging also can be improved and the old concept of one type of facelift for all is obsolete. Restorative facial surgery (facelift) dates back to the early 20th century when American and European surgeons explored the possibility of correcting wrinkles in the skin. Early operations involved the use of incisions around the ears and hairline to allow undermining of the facial skin and upward-backward traction on the sagging countenance. Although this procedure created some improvement, it also produced an overly taut appearance with visible alterations in the hairline. In recent years, facelift techniques have undergone major changes as plastic surgeons strive for a more natural look with a goal to target the specific areas of your face that need addressing rather than performing one large procedure for your entire face. Along with new technology, a better understanding of the aging sequence and facial anatomy has been critical to surgical progress. Today’s techniques are unlimited and involve the correction of the deep, inelastic facial structures and fat, along with the skin.
Dr. Moelleken defines a facelift as a technique to tighten the skin of the face. He says beyond that, every facelift is different and the skill and training of the surgeon performing the facelift is crucial to a successful outcome. Modern facelifts incorporate numerous ancillary procedures not just to tighten but to replace volume as the paradigm of just tightening a face and not restoring lost volume is outdated. Dr. Moelleken feels the deep layers should be restructured and elevated, not just tightened, because this gives the face a fresher, more youthful look. Another signature procedure invented by Dr. Moelleken is the 360 Facelift®. The 360 Facelift® combines the many extra procedures that go along with the facelift such as brow elevation, eyelid surgery, cheeklifts, laser resurfacing, chin implants, lip lifts, neck tightening, earlobe reduction, and LiveFill® graft insertion into your lips, nasolabial folds, marionette lines, and other customized areas that need volume. Dr. Moelleken feels all of these procedures are as important as the facelift itself because they enable him to rejuvenate your entire face harmoniously rather than just in one area. Dr. Moelleken now frequently incorporates LiveFill® while performing facelifts (including his trademarked 360 Facelift®) blepharoplasties, brow lifts, or his signature superficial cheek lift operation.
Dr. Moelleken says, “At some point, we as plastic surgeons must be realistic. Patients are not, in large part, happy with fat injection results.” Fat injection grafts are aspirated through a syringe, centrifuged, and then injected into the patient. Most of the cells from fat injection are dead when they are first injected, as confirmed in many different method (metabolic and cellular) studies. Graft survival depends on how alive the graft is when it goes in. If the fat starts out with viability rates as low as 5% by metabolic studies, it cannot be expected to survive.
Another factor is that there needs to be enough surface area to allow the graft to get a new blood supply. Dr. Moelleken explains that a doctor cannot simply pack in a huge amount of fat injection and expect it to survive. He says grafting a large piece of tissue with no blood supply onto an area without enough blood supply to sustain it is horrifying. He feels this is another reason fat injection specimens do not survive.
Plastic Surgeons are taught to remove dead tissue meticulously. Your body fights against dead tissue with the defenses of the immune system so it would never willingly accept 80% dead tissue. The reason survival of fat is so unpredictable is that a doctor cannot tell which of the fat cells are alive and which are dead and this accounts for the unevenness often seen with fat injections. When different groups of cells are analyzed under a microscope with various staining techniques, some areas demonstrate high viability (up to 50%) while other areas show almost zero and they are right next to each other. The combination of live cells, dead cells, and free fat that is injected is also variable. Sometimes the fat (liquid dead fat) stays in bubbles and is walled off as fatty cysts. These fatty cysts can become broken by trauma and press on the area while at other times, inflammatory reaction can set in that gradually eats away at the dead cells. This is called lobular panniculitis and is commonly seen in fat injection specimens.
The recurrent theme is that fat injection is technique dependent. Some doctors apparently say they have a vacuum system that sucks cells out of their living milieu without traumatizing them. Others say they are so gentle at injecting tissue that the basement membranes of the very delicate cells are not disrupted. They claim the very delicate walls of the fat cells are completely undamaged when they are injected through a needle in some cases and not in others. Based on experience and training, Dr. Moelleken does not feel these claims are valid. He says, “Not a day goes by when I do not see a patient who has had fat injection who is not happy with their result.” The three main complaints are: It did not last. It is lumpy. It is uneven. Grafts cannot be better than when they are placed. Therein lies the conflict with fat injection and all of its common problems, which include inconstancy, variability, lack of permanence, and firmness. Because of this, Dr. Moelleken prefers completely untraumatized fat-fascial grafts for facial volume augmentation or LiveFill ®.
Once LiveFill ® has been placed in your body, it becomes an integral part of your body’s tissue. When a biopsy is taken of LiveFill®, it appears to be normal tissue with its own blood supply. This is not true of any temporary filler or fat injection. The genetic markers of LiveFill® are identical to the patient’s, since the tissue comes from the patient’s own body, so there is no chance of rejection of one’s own tissue. It is possible that minor irregularities can result from the LiveFill® technique and if this happens, they are easily corrected under local anesthesia. The chance of this happening however is less than 5%. Any surgery should be carefully considered and during your first consultation, Dr. Moelleken will discuss the potential risks, benefits, and any concerns or questions you might have. Healing time is very rapid, since no over-correction is necessary, and patients typically require only a long weekend to recover. They may begin mild exercise approximately two weeks after their procedure and full exercise workouts by six weeks.