Letter to the Editor
Response to “Does a Deep-Plane Facelift
Restore Malar Volume Without Simultaneous
Fat Injection?”
Aesthetic Surgery Journal
2016, Vol 36(1) NP32–NP36
© 2015 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
[email protected]
DOI: 10.1093/asj/sjv169
www.aestheticsurgeryjournal.com
Andrew A. Jacono, MD, FACS; and Melanie H. Malone, MD
Accepted for publication August 4, 2015; online publish-ahead-of-print September 15, 2015.
We appreciate the thoughtful commentary1 to our study.2
While the concerns raised are insightful, we believe our
response will quell the author’s apprehensions.
Dr Swanson states that there is a 10-fold error in our
calculations. He explains this by a simple calculation multiplying the flat surface area of the cheek by the increase in
projection of 0.5 mm. Although multiplying these 2 numbers
seems logical, this is an inaccurate representation of volume
change of a 3-dimensional (3D) structure such as the cheek.
This method would only calculate the change in volume on
the surface of the shape, not the change that has occurred
inside the shape. It is the volume that is added internal to
that shape that has a transmitted effect on the projection
of the surface area; for example, adding 3 cc of volume
(the volume change of this study) to a balloon that is already
filled with 50 cc of water will have a much smaller transmitted effect on the surface projection of the balloon.
The correct way to calculate volume of a 3D shape is to
use a formula that calculates volume of that shape. The
cheek is more accurately characterized as a spherical structure with internal space, not a flat surface. The formula used
for calculation of the volume of a sphere is 4/3πr3. Because it
is only half of the sphere projecting exteriorly, the more accurate representation of cheek volume is (4/3πr3)/2. The
area used in this study to define the malar region spans
from the nasofacial groove to the cheek lateral to the most
prominent projection of the zygoma, which coincides with a
sphere diameter that ranges between 6 and 7 cm (depending
upon the size of the face and cheek of the individual patient)
or a radius of between 3.0 cm and 3.5 cm. The average increase in projection in this study was 0.5 mm or 0.05 cm,
which would add 0.05 cm to the radius. To calculate the
change in volume we need to make 2 volume calculations,
before and after. For example, if the radius is 3.5 cm, then
we need to make a calculation with the radius at 3.5 cm and
another one with the radius increased by 0.5 mm (the
increase projection noted in this study) or a radius of 3.55
cm. When applied to the formula for half a sphere of (4/
3πr3)/2, the volume increases from 89.6 cc to 93.5 cc, or a
change of 3.9 cc. If we assume a smaller cheek of diameter
6 cm as defined above, the radius would increase from 3.0
cm to 3.05 cm; the volume of the half sphere increases from
56.4 cc to 59.3 cc, a change of 2.9 cc. So the range of volume
change for the cheek with an increased projection of 0.5 mm
(or 0.05 cm) for a patient with a small face and cheek versus
a large face and cheek is between 2.9 cc and 3.9 cc, which
straddles our mean of 3.2 cc. We conclude that the projection data are accurate and consistent with the volumes generated by the topographic system and clearly not off by any
factor, especially not by 10 fold.
We would also like to address Dr Swanson’s concerns regarding the facial topographical comparisons. All before and
after photographs were taken in a standardized fashion by
the Canfield Vectra 3D camera (Canfield Scientific, Inc.,
Fairfield, NJ) In this system, patients are photographed in a
standardized position relative to the fixed Vectra console ensuring the same focal distance. The patient’s head position is
stabilized and matched to a reflective mirror in the Vectra
console. Six cameras take simultaneous photographs, which
are compiled to generate a 3D image. Because the images are
3D they can be rotated in all axes of space to permit viewing
Dr Jacono is the Section Head of Facial Plastic and Reconstructive
Surgery, North Shore University Hospital, Manhasset, New York;
Assistant Clinical Professor, Division of Facial Plastic and
Reconstructive Surgery, New York Eye and Ear Infirmary, New York,
New York; and Assistant Clinical Professor, Department of
Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College
of Medicine, New York, New York. Dr Malone is a fellow at a private
facial plastic surgery practice in New York, New York.
Corresponding Author:
Dr Andrew A. Jacono, 990 5th Avenue, New York, NY 10075, USA.
E-mail: [email protected]
Jacono and Malone
from different angles. Before and after pictures are registered
to one another in space using unchanging landmarks (medial
canthus, lateral canthus, tragus, subnasale, etc.) to eliminate
any potential minor differences in chin elevation or head rotation as Dr Swanson raised. Only after the pre and post
images have been superimposed and registered to one
another in the 3D grid of the image analysis software, are
they analyzed by a volume subtraction. We hope to elucidate
that this volume measurement is not based at all on manual
alignment of the photographs, or on the chin tilt and head
rotation seen in the three quarter views in Figures 4 and 5, as
these are 2-dimensional (2D) screen captures of the 3D
image that is freely rotatable in 360 degrees. This means that
if the 2D screen capture of the 3D image was taken with the
3D image rotated up or down, the head position would
appear to be changed even though the 3D image is still true.
Finally, this method of using the 3D topographic data to calculate midface volume change is not new to our study; it has
been utilized to determine midface volume change after autologous fat grafting in 3 prior publications3-5 and is considered to be a validated method.
Dr Swanson also states that volume augmentation of the
midface by our facelift repositioning method cannot be accomplished because, “There can be no net increase in facial
volume without importing tissue from another body site.”
We both agree and disagree with this statement. It is true
that the volume of the entire facial soft tissue mass does not
undergo any net change, but our study does not evaluate the
change of the entire face, just the midface region. It evaluates the relative volume gain of the malar region, which we
believe to be the result of tissue recruitment and redraping
from the excessive lower face and midface ptotic soft tissue
that is inferior to the defined perimeter of the midface analyzed in our study (from the nasofacial angle, along the perimeter of the inferior orbital rim, to the lateral cheek, and
back to and along the nasolabial fold). Magnetic resonance
imaging studies demonstrate inferior midface hypertrophy
secondary to descent of facial soft tissue.6 While the net
volume of the face does not change, the midface volume increases and the lower midface volume decreases. So we can
“borrow from Peter” (ie, the area of volume hypertrophy
inferior to the defined midface zone) “to pay Paul,” or the
defined midface zone (Figure 1).
We further disagree that the results seen in Figure 5 are
attributable to weight gain. There is an obvious decrease in
lower face ptotic soft tissue, which we believe would explain
the relative hypertrophy of the upper midface. To address
Dr Swanson’s suggestion that there is an increased width diffusely over the face in Figure 5, we performed a further analysis. The pre and post images shown from Figure 5 were
measured for width in the upper midface region and lower
face using the Vectra image analysis software. There is a
quantitative decrease in the width of the lower face in the
postoperative image compared with the preoperative image.
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There is also a quantitative increase in the width of the
upper midface along a line at the level of the zygoma in the
postoperative image. This results in a change in the ratio of
the width of the upper midface to the width of the lower face
after surgery. The preoperative ratio of the width of upper
midface to lower face increases from 1.25 to a ratio of 1.47 in
the postoperative image. We believe that this further supports the “borrowing from Peter to pay Paul” theory wherein
tissue is recruited, or “imported,” from the lower face to
restore volume in the upper midface—the paradigm of the
deep plane rhytidectomy.
Dr Swanson is concerned about cheese wiring, a known
occurrence in facelift procedures. Cheese wiring occurs
when soft tissues [superficial muscular aponeurotic system
(SMAS) and subcutaneous fat] are suspended and not released; they are therefore re-suspended under tension
against the facial retaining ligaments. The fixation sutures of
the deep plane flap in our method are under minimal
tension after dissection because the dense facial retaining ligaments are released and the flap is free to be repositioned.
Dr Swanson implies that this method does not release the
masseteric cutaneous ligaments, important facial retaining
ligaments in the lower face. Although not specifically stated
in the article, we lift the deep plane flap off the parotidomasseteric fascia from the deep plane entry point (line from
the angle of the mandible to the lateral canthus) anteriorly to
the facial artery (the limit of the dissection), and thus release
the masseteric cutaneous ligaments. This is demonstrated in
the video that is provided with this article.
Dr Swanson believes our method to be a low SMAS
fixation method and therefore, can have a limited effect
on midface repositioning. The superior most suspension
sutures of the deep plane flap are affixed at either the superior
aspect of the zygomatic arch periosteum or the deep temporal
fascia just superior to it, depending on the patient’s facial
anatomy and need for more substantial elevation. In fact, in
Figure 2 of our article the most superior suspension suture is
placed above the ear, which is about 1.5 to 2 cm superior to
the zygomatic arch. The deep temporal fascia is contiguous
with the zygomatic arch periosteum and we consider them as
a unit that we can suture to at different levels depending
upon what is required for each patient. Furthermore, one
cannot compare this technique in terms of a high or low
lateral SMAS flap. The SMAS flap is entered laterally at the zygomatic arch in a low SMAS rhytidectomy or above the zygomatic arch in a high SMAS rhytidectomy. Because the entry
point of the flap is at a more distal point (close to the ear), repositioning the flap is limited by the entry point (ie, whether
the flap is entered “low” or “high”). In the deep plane flap the
SMAS is entered approximately 4 to 5 cm more anteriorly and
inferiorly than a high lateral SMAS. This gives it a biomechanical advantage when suspended. It can be lifted vertically
several centimeters more because it is not limited by the perimeter of the lateral face as in the SMAS flap approach.
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Aesthetic Surgery Journal 36(1)
Figure 1. Preoperative (A, C) and 14-month postoperative (B, D) photographs after vertical vector deep-plane facelift in this
58-year-old woman. Recruitment of soft tissue volume from the lower face creates a relative increase in fullness of the upper
midface region with a concomitant decrease in volume of the lower midface and jowl region. Notice the redistribution of soft tissue
volume from the heavier jowl and lower face to the midface region, effectively “borrowing from Peter to pay Paul.”
We acknowledge that fat grafting is a well-established
and invaluable technique for midface volumization. As discussed in the exclusion criteria, any patient who was
undergoing fat grafting was not enrolled in the study. This
study did not compare patients who underwent fat grafting
to those who did not. The scope of this study was limited
to evaluating the volume changes in the midface in those
patients who underwent facelift. We routinely perform autologous fat grafting with rhytidectomy when additional
volume is required that is not obtainable by malar repositioning alone; this occurs in approximately 25% of cases
(Figure 2). We believe periorbital volumization is an important part of volume restoration of the face. When sufficient
orbital fat is available, we utilize fat transposition in lower
Jacono and Malone
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Figure 2. Preoperative (A, C) and 12 month postoperative (B, D) photographs after vertical vector deep-plane facelift combined
with autologous fat grafting in this 76-year-old woman. This patient was not included in the study as the performance of concomitant fat grafting was an exclusion criteria of the study. A total of 6 cc of fat was transferred to each hemi-midface. In this case, autologous fat grafting was necessary in addition to vertical vector deep-plane facelift because there is insufficient facial volume
“reservoir” to revolumize the midface by malar repositioning alone.
blepharoplasty for periorbital volumization instead of autologous fat grafting. Fat in the fat transposition technique is a
vascularized flap and has predictable take when compared
with autologous fat grafting, which is a free graft and can
have limited take. In a recent quantitative studies, an
average of 41% of grafted fat take has been documented.5
In cases where we incorporate autologous fat grafting, it
is performed prior to the facelift dissection and can be used
in conjunction with all facelift techniques, whether the dissection is performed subcutaneously or in the deep plane.
This has been well documented in the plastic surgery literature.7,8 We agree that fat transfer is an important adjunct in
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any plastic surgeon’s armamentarium, and we are in no
way saying otherwise.
We hope that this insight provides further understanding
of our findings. The data are sound, and there is a statistically
significant difference in the volume change in the midface
area by our vertical vector deep plane repositioning method.
We have seen that it can obviate the need for additional
autologous fat grafting for selected patients. This is an advantage to the patient as it minimizes surgery time, recovery,
additional cost, and the unpredictability of fat grafting.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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Aesthetic Surgery Journal 36(1)
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