LAS VEGAS Augmenting volume in the midface area can range from rewarding to frustrating, but it's a necessary part of facial rejuvenation, Dr. Suzan Obagi said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.
"If we want to accomplish full-face rejuvenation, we have to augment the midface region," said Dr. Obagi, who is director of the Cosmetic Surgery and Skin Health Center at the University of Pittsburgh.
The literature lacks human studies of the best techniques and patient selection, so Dr. Obagi shared tips from her own experience.
She prefers using autologous fat transplantation for the midface area because of its many advantages.
"It's the closest we have to an ideal filler," she said.
Autologous fat is nonallergenic, and there's no risk of transmitting HIV, hepatitis, or other diseases.
Fat usually is available in relative abundance for harvesting, and it takes on the properties of the tissue into which it is injected. Although some clinicians have reported dissatisfaction with the duration of fat injections, the procedure has the potential to last many years, depending on patient selection and on the quality of the fat that is harvested.
In Dr. Obagi's practice, autologous fat augmentation in the midface area lasts about 3 years, she said.
Fat transplantation also is cost effective for patients. "I typically use 20 cc of fat. That much Restylane would be equivalent to the cost of a facelift," she commented.
The best patients are youngerunder age 55 yearsbecause they have healthier, better fat. The ideal patient is a nonsmoker with a normal or above-normal body mass index, no prior facial surgery, and good skin tone and skin thickness.
"I'm convinced that patient age is the key factor to decide between one, two, three, or four" sessions of fat transplantation, Dr. Obagi said. In younger patients, one fat transplantation might be sufficient, but older patients could need two or more sessions. Prepare older patients for the possibility of multiple sessions.
Thicker skin is more forgiving and less likely to show lumps after fat transplantation.
Heavier patients tend to have better outcomes after midface fat augmentation than do thinner patients, but the thin ones might be in greater need of the procedure. The best combination might be a patient with a thinner face but more body fat than normal, Dr. Obagi suggested.
Fat will not fill in wrinkles from sun damage, she noted; those are better treated with laser resurfacing.
Assess the facial volume loss to decide where to transfer the fat. Likely sites include the forehead, brow, temples, intraorbital areas, regions of malar atrophy, lateral cheeks, jawline, chin, and perioral areas.
Results may be less satisfactory in patients with prior facelifts, eye lifts, brow lifts, cheek implants, or permanent fillers. Avoid fat augmentation in patients with prior transcutaneous lower blepharoplasty, because the fat injection can cause prolonged edema, she warned.
It's probably also wise to avoid midface fat augmentation in patients with unrealistic expectations, those with malar festoons, and tobacco users, she said, adding that some medications are contraindicated with this procedure.
Prednisone impairs healing. Depression may be triggered in patients on antipsychotic agents, Dr. Obagi said. Aspirin, NSAIDs, or warfarin can cause bleeding that harms the transplanted fat's life span.