In recent years, social and mainstream media has made the aging face a battleground, pigeonholing people into taking sides. Are you Team Filler (often younger and surgery-averse) or Team Facelift (likely older and not scared of the scalpel)?
In reality, the science (and art) of facial rejuvenation is not so black and white. Many women are discovering the downfalls of decades of dermal filler use (those chipmunk cheeks don’t come cheap), while others are disappointed when a facelift alone can’t solve their cosmetic concerns. The truth is, facial aging is a complex conundrum for which there is no single fix — quick or otherwise. To tackle the multidimensional problem, modern plastic surgeons have been increasingly combining tightening and volumizing techniques (both surgical and non-invasive) to improve facial contour.
Today, there are three main ways surgeons restore lost volume:
- Repositioning underlying tissues (as in a high SMAS or deep plane facelift)
- Fat transfer (a.k.a. autologous fat grafting)
- Injecting dermal fillers (most commonly, hyaluronic acid-based)
To learn more about how injectable fillers and facelifts work together, we tapped three top plastic surgeons.
What Is Facial Aging Exactly?
Now’s the perfect time to talk about facial aging. For starters, it’s more complicated than you might think. We tend to characterize aging as simply a losing battle against gravity (and, unfortunately, that’s partly true) but other factors, like losing facial bone mass, are involved.
“Sagging is definitely related to volume loss, but it is not entirely due to it,” says Andrew Frankel, MD, a double board certified facial plastic and reconstructive surgeon in Beverly Hills. “The elasticity of the skin and underlying soft tissues plays a role. The underlying supporting ligaments and the bony skeleton also are important factors. As the bone remodels and shrinks the overlying skin and soft tissue begin to sag because they are draping over a smaller shape.”
Simply put: your face isn’t just falling, it’s also going flat, and changing shape, and stretching (oh my). Generally speaking, a rhytidectomy (a.k.a. facelift) is a surgical procedure that tightens up the tissues of the lower face. Because this sagging along the jawline (read: jowling) is associated with age, a facelift is pretty much guaranteed to turn back the clock at least a few years.
Plastic surgery techniques have come a long way since the super-taut ‘70s, with aesthetic surgeons today focused more on tightening up the underlying tissues rather than just pulling on the skin. While there are many different types of facelifts — including deep plane, high SMAS, and the so-called ‘mini’ — they all share the common goal of counteracting the aging effects of gravity, genetics, and lifestyle choices that lead to sagging.
Does a Facelift Restore Volume?
Those of you paying close attention already know that, historically, facelifts were primarily about skin tightening. But, too often, just pulling the skin taut resulted in a stiff, angular, unnatural result. This is because stretching skin that’s lost elasticity over an aging bone structure can’t make you look 25 again.
“Imagine a balloon that loses air and deflates,” explains David Isaacs, MD, a board certified oculofacial plastic and reconstructive surgeon in Beverly Hills. “You start to see the creases, wrinkles, hollows, and the balloon starts to change shape.” When you take all those factors into account, you realize the true complexity of the aging process. “Facial rejuvenation has traditionally been approached as a vertical vector, ‘y-plane’ problem, but it's really a three-dimensional problem,” he adds.
With that in mind, you might be wondering what the modern facelift can accomplish. “A facelift elevates tissues and repositions things into a more desirable anatomic position,” Dr. Frankel explains. “It also helps to stretch wrinkles and fine lines and, therefore, makes the skin appear smoother.”
So, what can’t it do? “A facelift does not add volume, and, oftentimes, fillers are required to soften the patients’ appearance,” he says. “If tissues are tightly stretched across two bony high points, for example, there can be some evidence of the direction of the tension or some folds develop over time in the hollow area between those high points.”
Adding Volume with a Facelift
Whether using synthetic dermal fillers or fat transfer (more on both below!), here are some of the most common areas of the face where plastic surgeons add volume in conjunction with a facelift:
- Jawline: “Some people have indentations on either side of their chin where the jaw narrows a bit before it becomes wider again,” Dr. Frankel explains. “These indentations can exaggerate the degree of jowls and break up an otherwise nice jawline. Placing some filler along the bone in these areas can be helpful.”
- Lateral Cheeks: According to Dr. Isaacs, “the high lateral cheeks” are often addressed post-facelift. “This can give more of a sweet-heart shaped face many patients desire,” he says, adding that certain facelift techniques (like a deep plane approach) may achieve those results without filler.
- Nasolabial Folds & Anterior Cheeks: These are common areas of concern, but they aren't dramatically affected by a facelift, according to Jason Roostaeian, MD, a board certified plastic and reconstructive surgeon at UCLA. “A deep plane technique does help lift up the cheek a little bit, but, if their cheek is already under volumized, I’d much rather do it with their own natural tissue than with a filler,” he explains. “If somebody has really deep nasolabial folds, I do fat grafting first.”
Facial Filler vs. Facial Fat Grafting
Plastic surgeons are unique in their preferences for using dermal fillers or fat transfer in conjunction with facelifts. Sometimes, it’s not an ‘either or’ situation. It can be determined on a case-specific basis and will be dependent on the patient’s anatomy and preferences. Here’s a closer look at each:
Some plastic surgeons like using synthetic dermal filler (like Juvederm® or Restylane®) after a facelift. Dr. Frankel, for instance, says he favors injectable filler over fat grafting procedures because it’s more predictable, is reversible, and doesn’t carry the risks associated with harvesting from a donor site.
The 411 on Filler:
- Lab-created hyaluronic acid (based on substance found naturally in the body)
- Temporary and generally reversible
- Less risk of bruising; shorter recovery period
- May clog lymphatics and cause swelling
- Injected 8 to 12 weeks after facelift surgery (once post-op swelling resolves)
- Regular maintenance required
Filler smooths out the junctions and hollows “and also can make the edges of the bony landmarks appear less harsh,” Dr. Frankel notes. Another benefit? “Fillers can also add some height at various key points around the face to improve overall balance,” he says. But it does require a separate appointment. “Approximately eight weeks after the surgery, we reevaluate the need for filler and where it should be placed,” Dr. Frankel explains. “When the filler is injected at this stage, it provides greater projection and does not fall under its own weight. I find this to be much more effective than trying to inject lax skin.”
Other surgeons feel strongly that facial fat grafting is the best way to restore volume, especially when performed in conjunction with other facial plastic surgery (think: facelifts). “If you just do a facelift and never rely on fat grafting, you’re holding back on your results significantly," Dr. Jason says. “We all recognize that loss of volume is a huge part of aging — there’s no question about that. So, why would you rely completely on filler when you have that perfect opportunity to be in the operating room and use fat at the same time?”
The 411 on Fat Grafting:
- Natural harvested fat cells collected via liposuction from donor site
- Longer-lasting results than synthetic filler
- Injected at the same time as facelift surgery
- May add downtime to facelift recovery due to bruising
- Little to no maintenance required
- Less costly over time
Dr. Jason believes that using your body's own fat (which contains stem cells) leads to more natural results. “I don’t worry about overdoing somebody with fat grafting," he explains. “Filler is an unnatural substance that takes on a lot of water. At some point, if the percentage of filler starts to become equal to or more than the amount of natural tissue that you have in the area, it’s going to look swollen because it draws in water.” That’s what can lead to an unnatural appearance. “We all know when we see those faces that just look a little swollen and weird,” Dr. Jason says. “That’s from filler, not from fat grafting.”
If you are curious about cost effectiveness, a facial fat transfer procedure will likely be a larger initial investment than filler but prove to be less costly in the long run. “The beauty of fat grafting is that I am doing a broad, very comprehensive grafting to your whole face,” Dr. Jason says. And the procedure rarely needs to be touched up. “Usually, we’re injecting something like at least 10 cc of fat in a widespread area,” he shares. “That’s like $10,000 worth of filler, but you don't have to keep injecting it.”
Do I Need Filler, a Facelift, or Both?
At the end of the day, our experts agree that the only way to determine whether a patient needs filler (be it fat or synthetic), a facelift, or both to meet their aesthetic goals is to consult with a board certified plastic surgeon. “The degree of facial volume needed for optimal rejuvenation is highly variable,” Dr. Frankel says.
Even so, there are some genetic and lifestyle factors that may shed some light on the decision-making process. “In general, people who were born with a full face tend to age better, as the volume diminishes and their features become more defined,” Dr. Frankel shares. In such cases, the patient may “not need much or any additional volume” and would instead “benefit from redistributing their existing volume to achieve a more youthful appearance,” he says.
On the contrary, if someone has chiseled features in their twenties, “they are more likely to require additional volume as they age,” Dr. Frankel notes. In these cases, it’s important to seek a skilled injector that understands the subtleties of the face. “Caution should be used when injecting these patients so as not to add too much volume or place it into areas that would change their original look,” he says.
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