Facial Plastic and Reconstructive Surgery: New Patients, New Reasons, New Techniques

Another injectable filler agent is the patient’s own fat which sometimes, but not always, yields permanent effects, Dr. Papel said.

Still, the search continues for new filler agents that will last longer than those currently in use, or even be permanent.

Loss of Facial Volume

Because muscle can atrophy and even bone can change, facial plastic surgeons have recently begun to understand the aging effects of loss of volume in the face, Drs. Papel, Kridel and Sykes all emphasized. This is found most often in older people but also can occur in physically active people such as athletes with very low body fat who can have, according to Dr. Kridel, that “Abe Lincoln haggard look.”

In such a face, hollow cheeks can be corrected by submalar implants and/or by fat grafting. Dr. Kridel prefers to restore the volume to these faces, but he also may perform “suspension techniques where I elevate the skin subperiostally, taking tissue off its bony attachment, lifting it up and suspending it with sutures.”

Fat or other fillers may also be injected or grafted around the eyes of patients whose periorbital region has lost volume and the skin has thinned—a much different philosophy from the past notion in which fat was routinely removed from the eye area.

Where are the fat-harvesting sites? “We get it from the patients’ thighs or belly,” Dr. Papel said, adding: “Most of us have some to donate. And whenever you do it, everyone in the operating room says, ‘Take mine!’”

As for what eventually will be the preferred filling material, the jury is still out.

‘Cable Lifts’ or ‘Contour Threads’

Marketed over the past year and a half under various trade names, all these products are made of permanent suture material with barbs on them to hold and elevate facial skin. After they are placed via a stab incision, the patient’s skin is pulled over them. “The advantage is minimal downtime, some swelling and bruising, and less cost,” Dr. Sykes said. “Still, these lifts are unproven. We don’t know how long their effects last or whether this varies with the person. They’ve been on the market only about a year and a half.”

“When used correctly, these contour threads or cable lifts can accomplish minimal changes in people with minimal problems,” Dr. Papel said. “As with any other product, they should be used correctly with knowledge of their limitations.”

Dr. Kridel, however, feels that suspension alone without skin removed is not a worthwhile endeavor in patients with hanging skin.

Skin Resurfacing Modalities

For people with acne scars, considerable sun damage, or other problems afflicting primarily the facial epidermis, dermabrasion is still carried out and is very effective—when done correctly. “Dermabrasion is the most difficult of the skin resurfacing techniques,” Dr. Papel emphasized. “It requires the most practice, the most skill, and a good ‘feel.’ The number of surgeons who do it well is very small. Healing takes at least ten days.”