Facial Contouring after Permanent Filler Removal with Combined Facelift and Fat Grafting: A Case Series

Abstract

Background:

Aesthetic procedures for addressing aging range from simple injection of dermal fillers to facelift surgery. The last few decades have witnessed the development of diverse techniques to minimize facial wrinkles, volumize the face, and restore a youthful appearance. For example, fillers are a group of compounds used for cosmetic and reconstructive purposes, especially related to the face. Therefore, this study aimed to demonstrate specific cases where problematic dermal fillers were evacuated in combination with facelift procedures and fat grafting. It therefore demonstrates means to manage and treat permanent filler complications with a multidisciplinary evidence-based approach to achieve functional and cosmetic outcomes.

Methods:

Between January 2020 and August 2022, 50 patients were subjected to drainage of permanent dermal filler followed by facelift and fat grafting with a minimum 6-month follow-up recorded.

Results:

A total of 50 female patients between 30 and 56 years of age underwent permanent dermal filler removal in conjunction with facelift and fat grafting. The surgery was successful in all cases, but four cases of seroma and four cases of facial mandibular nerve neuropraxia, five cases of scar hypertrophy, two cases of wound infection and one case of pixie ear deformity were encountered during the follow-up.

Conclusion:

In this study, we present the characteristics of combining facelift and fat grafting procedures after surgical drainage of permanent dermal fillers to achieve aesthetically favorable results.

Takeaways

Question: How to achieve functional and cosmetic outcomes that are satisfactory for both patient and surgeon after removal of facial permanent fillers.

Findings: The design of this systematic three-step operative technique demonstrates an invigorating potential to treat the commonly encountered filler complications with aesthetically transformative outcomes.

Meaning: Combining facelift and fat grafting procedures after surgical drainage of permanent dermal fillers achieves aesthetically favorable results.

INTRODUCTION

Aging is a multifactorial process demonstrated by loosening and ptosis of the soft tissue of the face and neck due to gravity and loss of the distinct contour of the neck and jawline. This, hence, results in the stigmata related to facial aging. Since the introduction of filler injection procedures for cosmetic and reconstructive purposes, it has become widely popular with patients seeking treatment for signs of aging with a quick return to daily life.^1–3

According to some authors, the negative reactions of permanent fillers are produced by a low-grade bacterial infection surrounding foreign substances. The development of related fibrosis is determined by the implant’s physical attributes and inherent traits.⁴ Hence, management of such complications has mostly focused on general anti-inflammatory medications and sometimes surgical removal followed by a facelifting procedure to minimize any resulting deformity. In the present era of facelift surgery, advances in technology and our understanding of facial anatomy have given the rhytidectomy surgeon the opportunity to offer greater results than we could have imagined years ago. This includes a deeper understanding of the anatomic basis of the soft tissue planes of the face and neck, the superficial and deep fat compartments, and the facial musculature. Specific therapies for each facial segment impacted by the aging process have long been part of facial rejuvenation techniques.⁵ The anterior neck and platysma complex and acquired jowls have been treated using traditional face rejuvenation procedures. These procedures frequently ignored the nasolabial complex and the infraorbital depression.⁶

Permanent (not degradable), semipermanent, and temporary (degradable) materials can all be categorized as filler materials. Hyaluronic acid and collagen, which are used as temporary fillers, are entirely broken down by the surrounding tissue after a few months. Permanent fillers, such those made of silicon oil and minerals, are not biodegradable and can have negative side effects that are severe and irreversible. Because they are biodegradable, they stay in place, making them a viable choice for deep wrinkles and acne scars.⁷ Because they have a high degree of permanence, patients mostly need several injections to achieve the desired volume. Temporary fillers invariably cause temporary side effects, whereas those of permanent fillers may last forever.⁸

Patients with an interquartile age between 30 and 56 years were subjected to drainage of permanent dermal filler combined with facelift and fat grafting. The minimum follow-up period was 6 months. Most patients were checked preoperatively using ultrasound and MRI to determine the nature, quantity, and location of filler. Preoperative photographs of the patients were taken before the procedure, intraoperatively, postoperatively, at the first outpatient visit, and at the final follow-up visit to confirm cosmetic and functional results. Patients were closely monitored for any subsequent complications.

METHODOLOGY

This study was approved by the local ethical committee of the faculty of medicine, Ain Shams University, Cairo, Egypt. Between January 2020 and August 2022, 50 patients were subjected to drainage of permanent dermal filler followed by facelift and fat grafting with a minimum 6-month follow-up.

Our inclusion criteria were women aged between 30 and 56 years who were willing to participate in the study, were cooperative and fit for surgery, and had previously applied permanent filler causing complications. Exclusion criteria were associated medical conditions, such as diabetes mellitus or hypertension; patients with liver or renal failure; pregnant women; and acute infection of filler and facial deformities that may affect the result, such as hemi facial macrosomia (see Table 1).

Table 1.

Demographic Characteristics of Patients

Age	No.	%
30–40	7	14
41–45	5	10
46–50	17	34
Above 50	21	42
Sex
Male	0	0
Female	50	100
BMI
Less than 25	7	14
25–30	25	50
30–35	13	26
35–40	5	10
Educational level
Intermediate	5	10
High	45	90
Smoking
Yes	20	40
No	30	60

Preoperative Assessment

A thorough preoperative examination and evaluation of the face was undertaken in each patient to assess the quality and elasticity of the skin and permanent filler complications. The identification of filler-related issues is crucial to preventing time-consuming and unnecessary workups. Diligent history-taking is done with evaluation of signs of filler presence such as malar edema, visible/palpable filler, or blue-gray discoloration. In addition, signs of overlying infection and asymmetry between both sides of the face were checked. This was followed by preoperative MRI and immediate preoperative ultrasound in all cases to determine the site, depth, and size of the filler. Postoperative MRI was done in suspected cases with incomplete filler evacuation due to the filler’s granulated nature. Preoperative planning and markings were done on the day of the procedure. The photographs were taken pre- and postoperatively to document the preoperative condition and evaluate the outcomes compared with the findings of the preoperative condition with special care given to patient privacy (Fig. 1). Complaints of patients were complications of fillers, such as contour irregularities (42 patients, 84%), facial edema (12 patients, 24%), recurrent infection (eight patients, 16%), and pain (seven patients, 14%) (Table 2).

Fig. 1.

A 40-year-old woman with permanent fillers injected 14 years ago, complaining of facial asymmetry. A, Preoperative markings, frontal view. B, Preoperative markings, lateral view.

Table 2.

Preoperative Filler-related Complications

Total Cases (N = 50)		Variable
%	No.
84	42	Contour irregularities
24	12	Facial edema
16	8	Recurrent infection
14	7	Pain

Surgical Technique

Our surgery was done through a three-step approach: removal of permanent fillers; facelifting; and finally, fat grafting. Time lapse differed from one patient to another, but most patients presented after many years from filler injection to improve dropping of the face. We operate only on the patients with no signs of overlying infection. If a patient presents with an acute infection, we prescribe systemic antibiotics and NSAIDs till the infection is completely resolved. If there is an abscess formation, we go to the operation room, not for fat grafting but to evacuate the abscess. Then antibiotics and NSAIDs are prescribed for 3 weeks to make sure that the infection is resolved, and then we plan for our triple-stage surgery.

The infection, if present, was limited to sites where fillers were mostly injected (prezygomatic, premasseteric, and buccal spaces). No signs of skin necrosis had been observed. And as we mentioned previously, we waited for at least 3 weeks until the infection resolved to prevent any signs of delayed wound healing.

Skin Incision

Tumescent solution (50 mL NaCl each side plus 5 mL tranexamic acid 1000 mg/10mL plus adrenaline 1/500) into the subcutaneous plane had been infiltrated as hemostasis. The incision crosses the posttragal and enters the postauricular sulcus after starting in the temporal region before the ear [See Video 1 (online), which displays the skin incision. The incision crosses the posttragal and enters the postauricular sulcus after starting in the temporal region before the ear].

Video 1. displays the skin incision. The incision crosses the post-tragal and enters the post-auricular sulcus after starting in the temporal region prior to the ear.

Download video file ^{(72.1MB, mp4)}

Each patient underwent determined subcutaneous incision, which is satisfactory to visualize the whole SMAS traction field, and a posterior extension is used, as necessary. We waited about 25 minutes⁹ after infiltration to decrease the bleeding as much as we can. We infiltrated both the incision markings and all the areas that we would dissect.

Undermining

The dissection starts bluntly in the temporal region, subcutaneously superficially to the superficial temporalis fascia till it reaches the orbicularis oculi muscle. Then it goes through the preauricular incision subcutaneously till reaching the line of deep entry point (from lateral canthus to the gonial angle). The SMAS is incised at the deep entry point to the deeper plane superficial to the deep three parotidomassetric fascia, exploring the prezygomatic, buccal, and premassetric fascial spaces, where the permanent filler usually exists. The neck skin flap is undermined forward from the sternocleidomastoid muscle’s posterior border and then downward below the earlobe till the midline (Fig. 2).

Fig. 2.

Intraoperative photograph.

Drainage of Permanent Filler

Usually, permanent filler exists in the prezygomatic, buccal, and premasseteric fascial spaces. The subcutaneous layers are gradually dissected to identify the filler pocket. Once the pocket is determined, evacuation of the filler and suction is done if needed. It can be evacuated as one mass or may be fragmented. Here, preoperative MRI is important to assess the location and consistency of filler to be removed completely without any remnant. Postoperative MRI was done in patients whom we suspected to have incomplete evacuation because of the nature of filler, which was granulated material with deep tissue penetration. Most of these fillers were AQUA filler, which is mostly liquid in nature. However, another type was detected, which is semiliquid in nature with granulating appearance; this type was difficult to be evacuated due to its nature. We could determine that all these fillers were permanent because they were injected many years ago, and most of our patients had documentation by nature. We used a portable immediate wireless preoperative ultrasound to determine the size and exact location of filler pockets, and we used ultrasound postevacuation to ensure complete evacuation of filler materials (Fig. 3). [See Video 2 (online), which displays filler removal. The subcutaneous layers are gradually dissected to identify the filler pocket. Once the pocket is determined, evacuation of the filler and suction is done.]

Fig. 3.

Intraoperative ultrasound. A, Pre filler evacuation. B, Post filler evacuation.

Video 2. displays filler removal. The subcutaneous layers are gradually dissected to identify the filler pocket. Once the pocket is determined, evacuation of the filler and suction is done.

Download video file ^{(21.1MB, mp4)}

We used a portable immediate wireless preoperative ultrasound device called Clarius L7 HD₃ with a frequency of 4-13 MHz and a max depth of 11 cm. [See Video 3 (online), which displays the portable immediate wireless preoperative ultrasound device called Clarius L7 HD3 with a frequency of 4–13 MHz and a max depth of 11 cm.]

The amount of filler removed varied from one patient to another, but the average was about 5 gr. We tried to remove the capsule surrounding the filler whenever possible.

Video 3. displays the portable immediate wireless pre-operative ultrasound device called Clarius L7 HD3.With: Frequency: 4-13 MHz and Max Depth: 11 cm.

Download video file ^{(7.1MB, mp4)}

Facelift

The main technique used in our study is deep plane facelift. Sub SMAS (superficial musculoaponeurotic system) dissection is done over the zygomatic musculature with release of the retaining ligaments (zygomatic and parotidomasseteric ligaments), followed by robust suspension using PDS 2/0 hanging suturing to effectively treat the jowl. The anterior SMAS is pulled in a posterosuperior direction. This SMAS is subsequently joined to the mostly immobile preauricular parotid-masseteric fascia. The platysma is suspended over the mastoid fascia by PDS 2/0 after subplatysmal dissection till reaching 3–4 cm below the border of the mandible. The auricle is then pulled forward by the surgeon assistant to commence skin closure, which begins in the postauricular area. The postauricular flap is first pulled superiorly and posteriorly. Excess skin is then removed and repositioned after meticulous hemostasis. Regarding the temporal incision, the posterior leading edge of the preauricular flap is divided at the root of the zygoma, and excess skin is removed as well. In most of our cases, deep plane facelift was associated with lateral deep plane neck lift to achieve better contouring. Neck lifting was done through an incision in the submental crease, plication of the platysma in the midline, and release of the cervical retaining ligaments, especially in patients older than 50 years. If the patient presented with signs of infection, we went for drainage and then prescribed antibiotics and NSAIDs¹⁰ and waited till the infection was completely resolved; then performed for surgery. Superficial meticulous undermining of skin in the subcutaneous plane decreases the incidence of necrotic skin flaps, hematoma collection, and ecchymosis through preserving the vascularity. Healing of skin was rapid because there was no tension over the suture, which is important, especially in the preauricular region (Figs. 4 and 5).

Fig. 4.

A 47-year-old woman with facial asymmetry underwent deep plane facelift. A, The patient presented with cheek swelling and facial asymmetry. B, Preoperative left oblique view. C, Preoperative right oblique view. D, Preoperative left lateral view, E, Preoperative right lateral view.

Fig. 5.

Postoperative results of deep plane facelift surgery. A, postoperative anterior view. B, postoperative left oblique view. C, postoperative right oblique view. D, postoperative left lateral view. E, postoperative right lateral view.

Incision Closure

Skin closure is done in a tension-free manner, starting at the temporal region and refashioning at the preauricular incision and tragus, followed by postauricular closure. Excess skin is then removed and repositioned after meticulous hemostasis. A suction drain had been applied to prevent any underlying hematoma or seroma collection. Incision closure does not result in the creation of lumps or dog ears. The drain is then covered with a facelift dressing. We use two types of suturing for SMAS plication. First, we make deep plication by using PDS 2/0 sutures; then, we tighten our plication by more superficial sutures using PDS 3/0. Regarding skin closure, we make subcutaneous sutures using Monocryl 5/0, and then we make simple or continuous skin sutures using Prolene 6/0.

After that we put in a suction drain. The suction drain was 16 FR; the exit point was postauricular just above the suture line, and we left it for about 2 days to make sure that no hematoma was collected.

Fat Grafting

Fat grafting is a common aesthetic technique that aims to inject the harvested adipose into diverse compartments underneath the skin. After thorough preparation of the donor sites (which include the abdomen; periumbilical area; buttocks; and medial, lateral, and anterior thigh), a wetting solution is infiltrated with the ratio of 250 mL normal saline, 25 mL of 2% lidocaine, and 0.5 mL epinephrine. After 15–20 minutes, liposuction is done using a fat-harvesting cannula with low negative pressure, and fat is extracted by a consistent back and forth movement through the donor site (Table 3). Fat processing is then done by placing the syringes with the harvested graft vertically for 45 minutes to separate the variable constituents by gravitational energy, causing the least damage to collected adipocytes. Fat harvesting was done by low pressure syringe, and the amount of fat was about 15–30 mL (Table 3). The volume of injected micro fat is determined to the level that achieves better contouring. The plane of fat injection was mostly subcutaneous and supra periosteal in upper cheek. Immediate fat grafting is done in the same operation in the subperiosteal and superficial plane, especially in upper cheek over the zygoma, to address any residual volumetric deformities and/or correct contour irregularities complicated by fibrosis, and to volumize the undissected areas in the upper cheek. [See Video 4 (online), which displays fat grafting. Immediate fat grafting is done to address any residual volumetric deformities]. The fat injection was not done in the same plane of previous filler application. Previous anatomical filler injection planes were the prezygomatic, premasseteric and buccal spaces. However, we injected fat mostly over the periosteum of the infra orbital rim to give a contour to the upper cheek, and the fat injection was limited to the patient with marked contour irregularity.¹¹ The average operative time was about 4–6 hours.

Table 3.

Amount of Lipoaspirate and Fat Injection and Hospital Stay

Variable	Range (cc)	Mean
Lipoaspirate	15–30	22.67
Fat injection	5–20	13.55
Hospital stay	24–48	32.45

Video 4. which displays fat grafting. Immediate fat grafting is done to address any residual volumetric deformities.

Download video file ^{(19.9MB, mp4)}

Postoperative Care

All patients were advised to apply Vitamin A ointment over the hairline incisions after dabbing with regular saline every other day for 2 weeks. Regarding the postoperative prescription, it was antibiotics, anti-edematous measures (semisetting position, cold foments, anti-edematous drugs), analgesics, corticosteroids, and fluids. We first used micropore surgical tape over the skin to tighten the skin and make it redrape correctly. Then we used compressive dressing to decrease edema; the dressing was over the forehead and chin. Sutural removal is done in two stages, where a portion of the simple interrupted sutures is removed after 5 days, followed by the removal of the continuous sutures after an average of 7–10 days. Patients are strictly followed up after 1 or 2 weeks, and then after 1, 3, and 6 months, with an average hospital stay of 24–48 hours postoperative (Table 3).

RESULTS

Cosmetic Outcomes

Patient and surgeon satisfaction with postoperative cosmetic outcomes was assessed using a proforma scale whereby poor and excellent results scored 1–5, respectively. Mean scores of 4.3 (range 2–5) and 4.5 (3–5) were obtained for surgeons and patients initially, and 4.43 (2–5) and 4.55 (3–5) finally.

Complications Assessment

Fifty women underwent facelifting combined with fat grafting and removal of permanent fillers, of ages ranging between 30 and 56 years with average length of postoperative hospitalization of about 1 day. In all cases, the procedure combined removal of permanent filler, facelift, and autologous fat graft, which enabled treatment of each of the components of midface aging with effective and lasting results. Regarding postoperative complications, four cases of seroma and four cases of facial nerve neuroapraxia injury (with the most affected branches being the buccal and marginal mandibular branches and most cases being unilateral) were encountered during follow-up. Five cases of hypertrophied scar and a solitary case of pixie ear deformity due to inferior malposition of ear lobule have also been reported. No case of iatrogenic hypesthesia due to great auricular nerve injury were detected (Table 4).

Table 4.

Incidence of Complications in This Study

Total Cases (N = 50)		Variable
%	No
8	4	Seroma
8	4	Facial nerve neuroapraxia
10	5	Scar hypertrophy
4	2	Infection
0.5	1	Pixie ear deformity

DISCUSSION

Nowadays, the growing use of permanent dermal fillers for soft tissue augmentation of the aging face presents the urgent need to educate patients about their increasing complications. They are classically classified into early, late, and delayed, and they include bruising, swelling, edema, infections, foreign body reaction, skin discoloration, and biofilm formation, in addition to vascular compromise.¹² Despite the low overall incidence of adverse filler outcomes, the considerable number of patients who have permanent nonresorbable filler injections has a significant clinical impact. In addition, regulatory bodies do not easily approve the use of such permanent substances. However, these limitations are often bypassed by patients who seek cosmetic treatment and are eventually injected with unapproved fillers. Consequently, complications are on the rise, as expected and evidenced by numerous accounts in the literature.¹³ Optimal management of such complications remains a challenge to many plastic surgeons, and hence, represents an unmet need in the field of aesthetic medicine. Due to lack of objective assessment parameters for facelift,¹⁴ we used a subjective scale to assess both patient and surgeon satisfaction. A high score of both satisfaction grades was detected in the initial and final review. This study’s prospective designs and lack of exclusions are its strong points. In this study, we present a novel incorporative technique that integrates the ramifications of permanent filler removal with the aesthetic advantages of facelift and fat grafting procedures, curating a multidimensional methodology for plastic surgeons to overcome this growing challenge. Its efficiency is proven by patient satisfaction and the minor incidence of postoperative complications. The cases of seroma underwent conservative management until resolution was achieved. As for the cases of facial nerve neuroapraxia, they were treated by massage of affected muscles, physiotherapies in the form of galvanic stimulation, corticosteroids, and vitamin B12 injection for 8 weeks until complete recovery, which was usually achieved between 3 weeks and 3 months. The postoperative bacterial infection mainly affected the subcutaneous tissue.

The infection passed smoothly without any sequelae or lipograft affection. The management was massage, foments, and systemic antibiotics.

Regarding the main characteristics of fillers that we found intraoperatively, as mentioned previously, most of these fillers were AQUA filler, which is mostly liquid in nature. Another type of filler was found, which was semiliquid in nature with granulating appearance. This type was difficult to evacuate.

CONCLUSIONS

As the aging population continues to increase, the need for facial aesthetic surgery also increases. Proper understanding of facelift procedures is essential to achieve aesthetically pleasing outcomes and to treat postfiller sequelae with proper drainage and soft tissue volumizing. This study is designed to report the outcomes of a multifaceted approach that combines permanent filler removal with facelifting and fat grafting. The design of this systematic three-step operative technique demonstrates an invigorating potential to treat the commonly encountered filler complications with aesthetically transformative outcomes.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

The patients provided written consent for the use of their images.