Facial Plastic Surgery


Fat transfer to nasolabial folds or “laugh lines” can provide the same effect as traditional fillers like Juvederm and Restylane, or sometimes even give better results because it uses the most natural material—your own fat.

 

Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted videos on Snapchat to demonstrate a female patient who received fat injection to smooth out her laugh lines.

 

fat transfer to nasolabial folds

The appearance of laugh lines stems from two things: The sagging of your skin and other soft tissues, and facial volume loss.

 

In “younger” patients—i.e., 50 years and below—the nasolabial folds are mainly caused by facial volume or fat loss. Hence, they can avoid or at least postpone facelift, which relies on tightening the skin and soft tissue, and instead resort to volume restoration treatments such as conventional fillers and fat injection.

 

Fillers made of hyaluronic acid products like Restylane and Juvederm have impressive safety record because HA is naturally found in the body; in fact, it gives the skin its youthful glow and texture. However, the improvement only lasts 4-6 months on average, says Dr. Smiley.

 

If you are looking for a more permanent solution for your nasolabial folds, or any depression that primarily stems from volume loss, using your fat is a much better approach. Just a few teaspoons of unwanted fat from your tummy or thigh is enough to conceal your laugh lines.

 

And since your body does not treat your fat as a foreign material, your immune system will not attack it. This is not always the case with facial implants and synthetic, non-degradable fillers like ArteFill.

 

Aside from the long-term results of fat transfer to nasolabial folds, Dr. Smiley says the approach tends to provide more natural results than facial implants and conventional fillers. Moreover, fat shrinks and expands as you lose or gain weight, further leading to its natural effects.

 

The fat is also rich in stem cells and so the skin in the areas where the fat has been grafted will experience “visible” improvements, says Dr. Smiley.

 

It may come as a surprise that not every facial plastic surgeon offers fat transfer despite its more natural and longer-lasting effects compared to conventional fillers. Take note that it entails a steep learning curve to ensure high survival rate of fat grafts.

 

Conventional fillers, meanwhile, are much easier to perform than fat injection.

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When eyelid surgery and fillers are performed together they can provide a more natural result and a more potent rejuvenating effect, said renowned Beverly Hills plastic surgeon Dr. Tarick Smiley in his recent post on Snapchat.

 

Dr. Smiley has posted a series of videos demonstrating a female patient who received upper and lower eyelid surgery complemented by the most natural filler material—her very own fat collected from her tummy.

eyelid surgery and fillers

 

The fat was injected to create a smoother transition between her lower lid and cheek and to soften the nasolabial folds or “laugh lines.”

 

“The fat moves more naturally and so it provides more natural results than standard fillers. Also, fat cells expand and shrink as the patient gains and loses weight, further contributing to its natural outcome,” explained Dr. Smiley.

 

Furthermore, Dr. Smiley said that about 70 percent of the fat volume is expected to persist long term and therefore fat grafting is more cost-effective than traditional fillers such as Juvederm and Restylane, which on average require 6-12 months “retouch.”

 

The patient also had bulging orbital fat in the upper eyelid, which Dr. Smiley reduced before removing the loose skin that was causing the “hooded” appearance of the lid.

 

The excess orbital fat must be removed to eliminate the bulging or puffy appearance. Nonetheless, fat injection remains advisable to create additional carpeting right beneath the skin. Unlike the deeper fat that protrudes with aging, the superficial fat tends to shrink.

He also reduced the deeper orbital fat in the lower lid, which was causing the patient’s under eye-bags.

 

While reducing the orbital fat may sound counter-intuitive given that the patient also received a simultaneous fat transfer in her lower lid, Dr. Smiley said these two surgical maneuvers accomplish two different things.

 

“Reducing the deeper orbital fat in the lower lid eliminates the bulging, while injecting fat right beneath the skin creates this carpeting that results in smoother and more youthful transition, Dr. Smiley explained.

 

In terms of scar appearance, Dr. Smiley ensured that the upper eyelid incision was placed precisely at the skin fold for optimal scar concealment, while the lower lid incision was positioned immediately below the “root” of the eyelashes so it remains undetectable at conversational distances.

 

Aside from “precise” placement of incision, the celebrity surgeon said meticulous wound closure further ensures invisible scar.

 

For the vast majority of patients, Dr. Smiley said the eyelid surgery and fillers result in undetectable scar because the skin in the area is markedly thin and thus resistant to scar tissue.

 

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In 2016, about 215,000 cosmetic plastic surgeries were performed in men, accounting for 13 percent of all aesthetic procedures; their popular requests included facelift, eyelid lift, and rhinoplasty (nose job), according to a survey released by the American Society of Plastic Surgeons.

 

Aside from gender-based beauty standards, men’s facial plastic surgery is different from women’s due to their underlying anatomy. For instance, their skin is more vascularized and thus more susceptible to bleeding and bruising compared to females.

 

men's facial plastic surgery

Men’s facial plastic surgery requires a different approach than women’s.

Furthermore, any scar that may result from facial plastic surgery is more difficult for men to hide since they do not wear makeup, as most women do.

 

Another notable difference is the men’s tendency to ask for subtler results because unlike women, they are less likely to disclose their plastic surgery to other people probably due to “double standard” stigma.

 

Fortunately, achieving subtle and natural results from men’s facial plastic surgery is possible with correct surgical maneuvers and deep understanding of universal guidelines of facial proportion and masculine beauty.

 

Leading Beverly Hills plastic surgeon Dr. Tarick Smiley explains the three most commonly sought facial plastic surgeries of men and the core principles that help him deliver natural and gender-appropriate results.

 

  • Facelift

 

Men are more prone to hair loss than women, making it more challenging to hide the scar. It is important to note that facelift typically uses incisions within or behind the hairline to hide the scar, which can be difficult in patients with receding hairline, unless a short-scar or mini lift is used.

 

Another issue with male facelift is the surgical stigmata—e.g., flat cheeks, overly pulled appearance, and hollowing of the lower lid. However, these can be avoided with the correct vector of pull.

 

Aging causes the vertical descent of the skin and other soft tissue; hence, the correct vector of pull should be oblique and not a “blunt” horizontal.

By lifting the skin at a 45-degree angle, several wonderful things happen: the jowling is reduced, the softness of the cheek fat pad is restored, and the face appears tighter but not too taut.

 

Another nuance of male facelift is the propensity of patients to ask their surgeons to maintain a few small wrinkles for a more realistic, natural result.

 

  • Rhinoplasty

 

Men generally seek nose-reshaping surgery to reduce their hump and refine their tip without causing them to lose the masculinity of their face. Hence, great surgeons avoid over-resection of the tissue, which is also linked to increased risk of nasal collapse and other deformity.

 

The ideal nose is defined by universal beauty tenets instead of a highly rigid set of rules. The goal is to reshape the nose that will fit the face of the patients, respect their gender and ethnicity, and meet their aesthetic goals.

 

Several studies have attempted to describe what constitute an ideal male nose and these are some of their findings: It is “biologically” bigger than female’s possibly due to men’s increased muscle mass that requires more oxygen; it has a prominent dorsum or bridge; its tip has an angle of rotation around 90 degrees giving it a straighter profile (a slight upturned appearance is enough to feminize the face); and the overall profile appears strong instead of delicate.

 

  • Eyelid surgery

 

Eyelid surgery eliminates the hooding of the upper lid and the under eye-bags. However, even the slightest error—i.e., removing just a few millimeters of fat or skin than intended—can lead to stigmata such as lid retraction, deep tear trough, and abrupt lower lid-cheek transition.

 

To deliver natural and gender-appropriate results, doctors ensure that after surgery the upper lid appears “heavier” and lower compared to women’s, and there is a smooth lower lid and cheek junction.

 

And to preserve smooth transition between the lower lid and cheek, eyelid surgery is now commonly performed together with fat injection.

 

Another issue with male eyelid surgery is the risk of scar. This can be avoided by placing the incision precisely at the skin fold of the upper lid, and very close to the lower lash line margin.

 

All efforts are made to ensure that the scar remains concealed because men do not wear makeup to hide surgical stigmata.

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A holistic facial rejuvenation surgery is typically a combination of facelift and structural fat grafting. Ocasionally, eyelid surgery, forehead lift, neck lift, and/or liposuction are combined to achieve a more natural and more “consistent” result. Combination procedures are particuarly common in patients 55 years and older due to their advanced facial aging.

 

Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has presented photos of two patients to demonstrate natural-looking results from facial rejuvenation surgery.

 

Patient no. 1 before and after photos

 

Patient no. 1 has received deep plane SMAS facelift and neck lift, a technique that pulls the skin, connective tissue, fat, and muscle as a single unit. The deeper structures need to be tightened and elevated before any excess skin is removed.

 

The SMAS layer beneath the skin is relatively thick and heavy, and so any facelift technique which does not address this deeper structure leads to short-lived results, overly tight appearance, and poor scarring due to the tension on skin. Hence, Dr. Smiley says he does not perform skin-only lift.

 

Dr. Smiley incorporated neck lift to ensure that it would not detract from the more youthful and tighter face. He positioned a small incision beneath the chin, specifically within the natural skin fold for optimal scar concealment, to tighten the separated platysma muscle that was causing the visible neck bands.

 

Despite the tightening effects of facelift, it has one major caveat: There is a reduction in the anterior dimension of the face as the soft tissue rests closer to the bone.

 

To counteract this untoward side effect of facelift, Dr. Smiley says structural fat grafting is typically combined with the surgery. The idea is to restore the youthful fullness.

 

For this particular patient, fat grafting was used to restore the fullness of the mid face, leading to the appearance of more prominent cheeks, which is one of the critical emblems of youth.

 

Patient no. 2 before and after photos

 

Patient no. 2 has also received deep plane SMAS facelift and neck lift due to the extent of her facial sagging. But to truly create “consistent results,” Dr. Smiley also performed a simultaneous upper eyelid surgery, or blepharoplasty.

 

Her blepharoplasty was performed with the use of small incision placed precisely at the skin fold so the scar could blend into the background. Afterwards, the excess “hooding” skin was removed, leading to more alert, more youthful eyes.

 

To prevent an abrupt transition between the lower eyelid and cheek, which is one of the most common facelift stigmata, Dr. Smiley injected fat into the “junction” to create smoother results.

 

And to eliminate the patient’s severe jowling, he pulled the skin at a 45 degrees angle, which is the correct vector of pull. Any direction otherwise can lead to skin pleating along the lateral neck, flat cheeks, and “lifted” appearance.

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Should I have dermal fillers vs fat transfer? This is arguably the most common question of patients wanting to rejuvenate their face with the use of “volumizers,” which can be combined with facelift surgery for a more holistic, more natural result.

 

Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says that dermal fillers are readily available materials injected into the soft tissue, while fat transfer uses the most natural material possible—i.e., the patient’s own fat that is usually derived from the tummy and flanks, areas that typically carry “unwanted” fat cells.

 

dermal fillers vs fat transfer

Photo Credit: Restylane.com

In essence, dermal fillers and fat transfer fill in the cracks and depressions that are typically caused by age-induced facial volume loss, while facelift removes the loose skin and tighten the deeper structures.

 

Dr. Smiley says that patients older than 55 typically require both procedures because their aging appearance are caused by facial volume loss and soft tissue laxity (sagging).

 

The celebrity plastic surgeon says he prefers fat transfer to dermal fillers because of the former’s longer lasting results, averaging 12-15 years.

 

Fillers, meanwhile, are usually repeated at 3-4 month intervals to maintain the plump up appearance. Hence, it is safe to surmise that in the long run they are more expensive than fat transfer, says Dr. Smiley.

 

Aside from the “long term” cost of dermal fillers, many surgeons have suggested that fat transfer remains superior because it adheres to the core principle of “replacing likes with likes” and so the results are perceived to be softer and more natural looking.

 

Should there is a need to address deep depression and cracks at the time of facelift surgery, Dr. Smiley performs a simultaneous fat transfer; this is more convenient than having two separate procedures, which of course can lead to additional cost and multiple recovery.

 

Dr. Smiley often uses a simultaneous fat transfer to further soften the nasolabial folds, or laugh lines; and to create a smooth transition between the lower lid and upper cheek.

 

Failure to address the “abrupt” lid-cheek junction, Dr. Smiley warns, can lead to unnatural facelift results manifested by skeletonized eye socket and crescent-shaped bulge right below the lower lid. Simply put, fat transfer “fine tunes” the effects of facial rejuvenation surgery.

 

Meanwhile, Dr. Smiley typically reserves dermal fillers for first-time patients who need volumizers as a stand-alone procedure. Should they are happy with the results, they may ask for a more permanent treatment in the form of fat transfer later on.

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A pre-jowl chin implant extends more laterally to fill in the skin creases or conceal the “bulge” on each side of the chin caused by sagging tissues such as the skin and deeper structures. This is different from the standard chin implant whose primary purpose is to improve the convexity and profile (or forward projection) of the chin.

 

A face that is deemed youthful and attractive has a taut jawline, but with aging (or massive weight loss) it develops dips and bulges on each side of the chin; these are referred to as pre-jowl sulcus.

 

Unlike the jowl that extends far more laterally and so facelift might become warranted, the pre-jowl sulcus can be concealed with a special type of chin implant, as suggested by leading Los Angeles plastic surgery expert Dr. Tarick Smiley.

 

pre-jowl-chin-implant

Placement of pre-jowl implant to conceal the bulge or dip on each side of the chin.  Notice that it extends more laterally compared to “ordinary” chin implants. (Photo Credit: Implantech website)

Pre-jowl chin implants are typically designed having a relatively thin anterior portion while the lateral sides are thicker so only the pre-jowl sulcus is augmented. However, some newer designers provide additional volume to the chin and the pre-jowl area as well.

 

To determine the most ideal pre-jowl chin implant design, Dr. Smiley highlights the importance of a candid discussion between a surgeon and his patient to outline the latter’s specific goals. Of course, a physical exam will further help the surgeon identify the most cost-effective approach.

 

Instead of using pre-jowl chin implant, patients with smaller “bulges” on each side of their chin may opt for dermal fillers such as Radiesse. By adding volume along the depressions, the dip is concealed and there is now a smoother transition between the chin and the adjacent area.

 

But for a full-blown jowl—i.e., the entire jawline is affected by the loose skin and deeper structures—facelift is generally the best approach. This surgery can create a tauter jawline by pulling its skin at a 45 degree angle, which is the correct vector of pull as it can also tighten the neck skin and reposition the sagging mid face.

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