Restore Facial Volume - what options do I have?

​I.        Temporary volume and contour restoration. Temporary Fillers
​
  1.           Radiesse - Calcium Hydroxylapatite based filler 
  2.          Sculptra - Poly-L-Lactic acid based filler 
  3.          Hyaluronic Acid based fillers (dissolvable) - Juvederm Voluma and Restylane Lyft
                HA Fillers for the Overall Volume/Face Contour
                HA Fillers for the Under the Eye Hollows

​II.        Permanent and Semipermanent Options for Volume and Contour Restoration and Augmentation

       Permanent and Semipermanent Fillers 
  1.           Allofill - Human Adipose Tissue based filler 
  2.          Bellafill - Semi-Permanent Polymethyl-Methacrylate (PMMA) Filler
  3.          Silikon-1000 - Permanent Silicone Filler

  4.          Autologous fat injections, also known as an autologous fat transfer, facial fat grafting, and microlipoinjection
    4.A.          Autologous Lipocyte Micronized Injection (ALMI)

  5.           Facial Implants
    5.1.            Silastic (silicone) implants
    5.2.           Gore-tex (expanded polytetrafluorethylene – E-PTFE) implants

See the list of references and literature and links to the above cosmetic products manufacturer websites. 

The challenge with restoring a youthful look for women in their late 30-s and 40-s is that addressing the skin quality alone (dermis and epidermis, layer 1 in the facial anatomy layers picture), - for example by laser resurfacing, micro-needling, IPL/photofacial, chemical peels, device assisted skin tightening, topical use of retinoids, vitamin C, AHA/BHA – is going to produce young(er) looking skin/surface on the middle-aged deflated and flattened facial structure, thus failing to fully achieve the goal of an overall young looking face (read more about age-related loss of volume in the deep fat layer of the face that leads to facial deflation and sagging).

For a woman in this age group seeking to restore a youthful look, an experienced plastic surgeon or a cosmetic dermatologist would be recommending a combination approach: address the skin quality AND replace the lost facial volume where it was lost.
 
This publication provides a complete list and comparison of all currently available options to replace lost facial volume, which vary in cost, invasiveness, down-time, side effects, and duration of the results.

You can jump to a summary table with a side-by-side comparison of all options to restore facial volume. 
Or keep on reading to find out details.

​I. Temporary Volume and Contour Restoration. Temporary Fillers 

Fillers are cosmetic products that are injected either in the skin or in one of the facial layers under the skin to restore volume, correct lines and wrinkles, or to enhance facial features.

Modern temporary fillers are resorbed or dissolved by the body within 4 to 36 months, and repeat treatments are required to maintain the results.
This is a summary of temporary fillers suitable for volume restoration. A complete list of all fillers available in the USA is compiled on this page (FDA, 2017).

Volume Filler/ Comparison Point	Brief Description	Duration of the results	Cost per unit	Total Procedure Cost***	Results immediate?	Downtime	Risk, Possible Compli- cations	Removal if needed
Restylane Lyft	Highly lifting and volumizing Hyaluronic Acid Filler	18 months and more	$500 - $900 per 1 ml syringe	$500 - $2,700	Yes	None/ Minor	None/rare**	Easy - dissolved with an injection of Hyaluronidase
Juvederm Voluma	Highly lifting and volumizing Hyaluronic Acid Filler	24 months and more	$800 - $1,200 per 1 ml syringe	$ 800 - $ 3,600	Yes	None/ Minor	None/rare**	Easy - dissolved with an injection of Hyaluronidase
Sculptra	An injectable filler; Poly-L-lactic acid based collagen stimulator	24 months and more	$600 - $900 per vial	$ 1,800 - $ 3,600 for a woman in her 40-s	Yes. Then go down, then improve	None/ Minor	None/rare**	N/A; wait until dissipates
Radiesse	An injectable filler; Calcium Hydroxilapatite based collagen stimulator	12 months and more	$500 - $1,000 per 1.5 ml syringe	$500 - $2,000	Yes. Then go down, then improve	None/ Minor	None/rare**	N/A; wait until dissipates

 

A volumetric filler injection on the cheekbone - under the skin layer - to compensate for the volume loss in the deep fat pockets and to restore facial youthfulness

In 2016, over 2.7 million injections of temporary fillers (Hyaluronic Acid, Calcium Hydroxilapatite, and Poly-L-Lactic-Acid) were performed in the USA, making them the second most popular, after Botox injections, non-invasive procedure, 10% up from 2015. This treatment is more popular and frequent than laser hair removal, photo rejuvenation (IPL) and chemical peels combined. Of those 2.7 million injections, almost 2.5 were injections of the Hyaluronic Acid based fillers, and that was a 16% increase from 2015 (The American Society for Aesthetic Plastic Surgery, 2017).
 
What you may also want to know about fillers:

• Fillers are narrowly approved by FDA for use in one or several particular areas on the face. Most fillers are approved for the nasolabial fold. That is called an on-label use; the manufacturers and the manufacturer representatives and their web-sites are limited - in what they can say or claim - with those FDA approved on-label uses. In reality, with some limitations, many fillers may be used on many different areas of the face or in hands, they may be injected with many different techniques, into different layers of skin and face.
• The other interesting point concerns the duration of fillers. After an initial treatment, the effect of the filler will last close to what is stated on label or is generally described as its duration.However, from numerous observations by patients and medical professionals, repeat treatments result in longer duration compared to the initial injections. After your second or third treatment, that same filler in the same area may now last up to 8-36 months (versus the original 4 to 24).
• The results of treatment with fillers are what is called operator-dependent. It is important what filler is used. It is, however, even more important where precisely and how the filler is placed, through how many entry points, the depth of the injection, the particular injection technique, and the amount of filler placed. An injector who does not 1) possess a thorough understanding of the facial anatomy, fat compartments and their precise locations, then 2) understand of the anatomy of the facial aging, and 3) have an artistic eye to envision the final result, - may have a difficulty placing fillers in a way that creates natural and aesthetically pleasing results.

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I.1 Radiesse - Calcium Hydroxylapatite Based Filler 

​Radiesse (by Merz) – is the only calcium hydroxylapatite filler approved by the FDA in the USA. Radiesse is a biodegradable collagen stimulator and is made of Calcium Hydroxylapatite (CaHA) microspheres suspended in an aqueous gel carrier. The CaHA microspheres in Radiesse has particle size 25 – 45 microns.
Calcium Hydroxilapatite is a bio material and similar to the bones in our bodies. Therefore, there is no risk of body rejecting the material.
The CaHA for Radiesse is lab produced, not an animal sourced, and does not require allergy testing before an injection. 
 
An injection of Radiesse deposits calcium in the skin creating sort of a matrix. Within days and weeks after the injection, the gel is absorbed by the body; at the same time collagen growth is gradually stimulated in this calcium matrix. Later on, calcium is at least partially absorbed by the body too leaving behind the collagen.
It is a thick filler that may create lumps and bumps if injected superficially and should not be used under eyes or around the lips.
 
Some minor redness, itching bruising and swelling may occur after the injection.
Results from Radiesse last somewhere between 9 and 16 months.
Radiesse comes in two syringe sizes: 0.8cc and 1.5 cc.
 
The cost per 1.5 cc syringe ranges from $ 500 to $ 1,000. Just like with any filler, the number of syringes and, hence, the total cost, depend on how much volume needs to be added to the face.
 
The pros of Radiesse 
- Somewhat longer lasting results compared to HA fillers especially if injected on the periosteum;
-
The cons of Radiesse – 
- Minor risk of lumps (undispersed Calcium Hydroxylapatite) and granuloma (Tissue reaction around the Radiesse) formation;
- Unlike HA fillers, it cannot be dissolved or removed. There is no antidote for Radiesse. If the results are unsatisfactory or a nodule is formed, they will last for 9 to 16 months until the filler dissipates.
 
Read more about Radiesse here http://www.radiesse.com/how-it-works/

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I.2 Sculptra - Poly-L-Lactic Acid Based Filler

Sculptra (by Galderma) is the only Poly-L-lactic acid filler approved in the USA by the FDA.
Just like Radiesse, Sculptra is a collagen stimulator. The drawback of this filler is that the immediate volumizing result only lasts several days; the volume then dissipates, and gradually rebuilds over the course of several weeks. Poly-L-Lactic acid triggers collagen synthesis, which leads to a dual outcome: 1) collagen formed around the PLLA creates volume and 2) fibrosis results in the reinforcement of the fibrous tissue, and that leads to some lifting. 
 
Some injectors use Sculptra under the eyes. However, since Sculptra is not dissolvable, if you develop a lump, it will not be possible to remove it.
Sculptra injections may be placed in the sub dermal or supra-periosteum areas to stimulate the fibroblasts; to avoid the risk of nodules this filler should not be injected superficially.
 
A typical treatment consists of three treatments spaced at 4 to 6 weeks apart, with one to three vials injected per visit. According to many medical practitioners, a rule of thumb is a vial per decade of life, which means that a woman in her 30-s and 40-s will need about 3-4 vials in total, or a vial per visit.
Sculptra may last up to two years and longer.
The cost per vial ranges between $ 600 and $ 900.
 
Pros of Sculptra - 
- From the category of the temporary fillers, the longest lasting results – 2 years and more, at par with Voluma by Allergan.
 
Cons of Sculptra – 

• A little more time consuming than HA fillers to see the final results, because typically three treatment sessions are required.

 
Read more about Sculptra here https://www.sculptraaesthetic.com/

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I.3 Hyaluronic Acid Based Fillers (Dissolvable)

As the name implies, the main ingredient of these fillers is Hyaluronic Acid (HA), a substance naturally occurring in our bodies and more abundant in our skin and joints when we are young. The hyaluronic acid in the upper layers of the skin gives it plumpness and glow. 
Hyaluronic acid fillers are sometimes referred to as dermal fillers. That is not a correct description because specially formulated thicker HA fillers are also used for injections below the skin (below dermis) into lower facial layers, to restore volume and contour.  

Different manufacturers of HA fillers use slightly different manufacturing process and technology, and their fillers differ by: the particle size of HA molecules, concentration of the HA in the carrier filler gel, the type of cross-linking between HA molecules, HA gel hardness/thickness (aka G prime), and cohesivity of the HA gels. Those differences are responsible for the difference in duration and lifting properties of different fillers. Cross-linking of the hyaluronic acid molecules is necessary to make HAS fillers last. 
 
All HA based fillers share the following properties: the procedure is fast and non-invasive with immediate results; the results are temporary; the filler can be dissolved.
All in all, from all the facial volume restoration options, HA based fillers are the easiest, most conservative, minimal risk, minimal side effects, and short term - least expensive procedure, leading to its great and continuously rising popularity.
Out of 2.7 million of filler injections in the USA in 2016, almost 2.5 million were the injections of HA fillers, that is a 16% increase compared to 2015 (American Society for Aesthetic Plastic Surgery. 2017).
 
Pros of all the HA fillers –

• Hyaluronic Acid is a substance naturally occurring in our bodies. It is not perceived by our bodies as a foreign material so there is no risk of rejecting it or developing an inflammation or nodule/granuloma around the injected substance;
• Immediate results;
• Because the results are immediately visible during the treatment procedure, it is very difficult to unintentionally overdo the HA fillers;
• Even if a patient does not like the result, HA based fillers can be dissolved by an injection of a Hyaluronidase enzyme;
• Very low risk of developing adverse reactions;
• Little to no downtime;
• Very non-invasive;
• The duration of the results gets longer with repeat treatments (Smith SR; 2010);
• Lower price per syringe compared to other more permanent options.

 
Cons of all the HA fillers –

• The results are not permanent as over time the body absorbs the injected HA. To maintain the result, repeat procedures are required every 4 to 36 months;
• Long term, due to the repeat expense, this may be a more expensive option than a more permanent solution, especially if a lot of volume needs to be restored.

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Hyaluronic Acid Fillers for the Overall Volume

Hyaluronic acid fillers for the facial volume and contour are thicker and longer lasting than other fillers.
​They should be injected in the deeper layers of the face, where the deep fat pockets are deflated.

On-label, the only fillers approved by the FDA in the USA to restore facial volume in mid face is Voluma (Allergan) and Restylane Lyft (Galderma).
 
Voluma and Restylane Lyft are the two most lifting and longest lasting fillers approved by the FDA in the USA. For this reason, they are the best HA fillers for the compensation of the fat deflation in the deep fat compartments on the upper cheeks, cheek bone, on the mid face, and in the temporal area.
 
There have been no head-to-head trials comparing the two fillers, but they seem to provide very similar results. The major differences are summarized in the table. 

* After repeat treatments, fillers are likely to last longer than after the very first injection and longer than is stated on-label.

Comparison Point/Filler	Juviderm Voluma	Restylane Lyft
Manufacturer	Allergan	Galderma
On-label Duration	20 - 24 months	15 - 18 months
Syringe Size	1 ml	1 ml
Typical Price per Syringe	$800 - $1,200	$500 - $900
How it achieves its lifting and volumizing effect and longevity	The Vycross cross-linking technology creating cohesivity of the gel	The particle size of the hyaluronic acid inside the filler gel

If you happen to travel to Europe or Canada and decide on having a filler treatment there, there are many other reputable and well established manufacturers and volumetric filler options that are approved there, but not available in the USA: 
* In its Belotero line of the HA fillers, Merz also offers a volumetric filler Belotero Volume. Belotero Volume is stated to last up to 18 months (on label, after the initial injection).
* A Swiss company Teoxane founded by the developer of Juviderm, before it was purchased by Allergan, offers Teosyal range of fillers. Teosyal Deep and Teosyal Ultimate are their fillers for the facial volume. 
* Neauvia Organic fillers by MatexLab, Italy. The unique feature of these fillers is that they are organic. Neauvia Organic Intense fillers can be used for deep volume. The drawback of this line is that their products do not contain lidocaine, therefore, a numbing should be performed separately before the injection of the filler. 
* Princess fillers by Chroma-Pharma GmbH, Austria. Princess Volume is their volumetric filler. 
 
Off label, technically, any HA filler can be used for the volume restoration to compensate for the deep fat pockets deflation.
FDA has also approved Juviderm Ultra, Volbella, Vollure (Allergan); Restylane, Restylane Refyne, Restylane Defyne (Galderma); Belotero Balance (Merz) for the treatment of lines and folds. However, all the fillers listed in this paragraph last less and may hold the shape and lift the tissue worse than Voluma and Restylate Lyft, which were specifically formulated for the volume restoration.
 
For restoration and augmentation of facial volume, the injection is performed in the deeper layers of the face - deep dermis, deep fat compartments, or above the bone on the periosteum. Some research shows that injecting volumetric fillers on the periosteum near the bone may produce even longer lasting results by the stimulation of the new bone tissue, which is even more relevant for the older age group that already experiences bone loss (Mashiko T, 2013).
​
Read more about Voluma here http://hcp.juvedermvoluma.com/ (information from a more medical angle) or here, for consumers, https://www.juvederm.com/cheek-fillers 
Read more about Restylane Lyft here https://www.restylaneusa.com/restylane-lyft

​Read about fillers for the under-the-eye hollow here. 

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II. Permanent and Semi-Permanent Options for Facial Volume and Contour Restoration and Augmentation 

Permanent and Semi-Permanent Fillers 

Fillers are cosmetic products that are injected either in the skin or in one of the facial layers under the skin to restore volume, correct lines and wrinkles, or enhance facial features.

All fillers - 

• share the treatment method: they are injected from a syringe with either a needle or a canula. The treatment does not include any surgical cutting and is considered minimally invasive;
• do not require general or local anesthesia (possibly, topical numbing only);
• the downtime after an injection is minimal to none;
• have often immediate results.

 
As the title for this category implies, these fillers provide permanent and semi-permanent effect. 
However, the materials used in the three permanent/semi-permanent fillers are so different, that the results, implications, durations, cons and pros are very different; and we showed each permanent/semi-permanent filler as a separate category.
 
A complete list of all fillers available in the USA is compiled here.

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II.1.  Allofill - Human Adipose Tissue Based Filler 

Allofill by Biologica Technologies is a relatively new filler that stands out as a category of its own.
Allofill is made of allografts, donated human fat tissue. The allografts have been safely used for years, but Allofill by Biologica Technologies has been launched in 2016.
 
This filler is made of human fat tissue that was cleansed and processed, and is ready to inject, not requiring a prior fat harvesting and fat processing. It has not been on the market long enough to say how permanent the results will be. Given the material, the results should be approximately as permanent as from a regular fat transfer procedure. This filler comes in a 3cc syringe, and injectors charge anywhere between $ 1,500 and $ 2,000 per syringe.
 
Pros of Allofill -

• Does not require any additional procedures like fat harvesting;
• Minimally-invasive just like any filler;
• Little to no downtime with some immediate results;
• Natural material – human fat tissue;
• Possibly, permanent just like with the fat transfer.

 
Cons of Allofill -

• Given that not all the transferred volume will take off, and a patient will likely require multiple syringes and multiple treatments, the cost of treatments with Allofill may possibly be more expensive than injecting your own adipose tissue,
• The final result is apparent in 2 – 4 months;
• Although allografts go through strict screening, testing, and sterilization methods, and terminal sterilization, the potential for transmission of infectious agents may exist IF the donor tissue contained an unknown virus that was undetected and not tested. This is highly unlikely, yet possible.

 
Read more about Allofill: http://www.allofill.com

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II.2.  Bellafill (Artefill) - PMMA Based Semipermanent Filler

Bellafill, formerly Artefill, formerly Artecoll, by Suneva Medical, is a permanent/semi-permanent filler and a collagen stimulator that has been approved by FDA since 2006. Bellafill is made of:
- Purified Bovine Collagen (80%), and
- PMMA – polymethyl-methacrylate (20%) – the non-resorbable, non-metabolized (permanent) component of this filler. The PMMA in the filler comes in the size of about 40 microns, about the size of a cell, the smallest particles of all the fillers on the market.
 
At the time of the injection, the volume is created mostly by the collagen component. Within weeks of the injection, the collagen portion of Bellafill is absorbed by the body. At the same time, the microspheres of PMMA stimulate the body to produce its own collagen, and each microspere gets encapsulated in that collagen, thus creating new lasting volume. 
A study by Suneva that enrolled 1,008 patients showed that five years after an injection, 83% of the patients retained 87% of the original volume augmentation and wrinkle correction results. http://www.sunevamedical.com/suneva-medical-announces-landmark-clinical-study-confirming-long-term-safety-of-bellafill-through-five-years/
 
The filler is placed subcutaneously. To avoid formation of the nodules, a surgeon should use small amounts (microdroplets of 1/10th cc) over large areas, with a canula. Another approach to minimize the risk of the nodules formation that can be used in addition to the proper injection technique is to use steroids with the injection. Some very experienced surgeons may be able to place it under the eyes, in which case it should be injected under the muscle (under the SMAS).
Bellafill syringe size is 0.8 cc, and the cost per syringe for patients ranges from $800 to $1,200.
 
Pros of Bellafill -

• Permanance/semi-permanence;
• Results improve over the course of several months;
• Long-term cost saving compared to the recurring injections of temporary fillers.

 
Cons of Bellafill -

• If the result is unsatisfactory, it is permanent;
• A 1.7% risk of granulomas (nodules);
• An allergy testing is required before the treatment due to the bovine collagen component.

​Read more about Bellafill here: https://www.bellafill.com/smile-lines/

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II.3. Silikon-1000 - an Off-Label Permanent Filler 

Sillikon-1000 (by Alcon Labs, Fort Worth, Texas) is a medical grade pure form of silicone, a silicone fluid and a truly permanent filler. The full proper name of the material is purified polydimethylsiloxane.
Sillikon-1000 has been approved by FDA in 1997 for treatment of retinal detachment of the eye. It has not been approved by FDA for use as a facial filler. However, ever since its 1997 approval for the retina treatment, for 20 years by now, Sillikon-1000 has also been used off-label to enhance lips, correct nasolabial folds, add cheek volume, and also to treat tear trough deformity. 
Silicone is one of the most controversial substances in aesthetic medicine, and medical practitioner opinions on using Sillikon-1000 as a filler vary widely –

• from advocating its use as an ideal filler, or a better option for cheek augmentation than an implant, and even for an under-eye injection that gives natural looking results; to
• recommending to stay away from it due to the unpredictable risk of complications, a look of “hardened grapes” and difficulties in treating the complications.

 
Silicone granules in the Sillikon-1000 fluid are perceived by our bodies as foreign objects, which may lead to a chronic inflammation response or a granuloma formation (Ellis LZ, 2012). There is a risk of delayed reaction from the body, even years after the injection; the risk of scarring, hard tissue and a migration of the material. If a doctor is experienced with the use of this particular filler, the complications seem to be rare. The injection technique that is most suitable for this filler is the serial puncture, micro-droplet technique.
Sillikon-1000 comes in 0.4 cc and .8 cc bottles; and injectors charge anywhere between $500 to $ 1,500 for the injection of that bottle.
 
Pros of Sillikon-1000 as a filler –

• If results are satisfactory, they are permanent;
• Long-term cost saving compared to the recurring injections of temporary fillers.

 
Cons of Sillikon-1000 –

• A 2% risk, statistically, of developing nodules, bumps or granulomas, even months and years after the injection, and it is unclear whether this complication is operator-dependent;
• There appears to be no reliable way to deal with the complications from this filler if they occur; a surgery is required to remove bumps if they are formed. While lumps and ridges can be surgically removed, that may leave scars. 

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II.4. Autologous fat injections/fat transfer

 Autologous fat injections are also known as an autologous fat transfer, facial fat grafting, and microlipoinjection 
​
In 2016, over 56,000 fat transfer procedures, 17% up from 2015, were performed in the USA (American Society for Aesthetic Plastic Surgery. 2017).
 
From the category of the permanent and semi-permanent options, fat transfer, along with Allofill, is the least risky procedure for treatment of under the eye area due to the material used.
The procedure involves three steps:

1. Harvesting: a gentle mini liposuction with a syringe of the patient fat from a donor site (jowls, abdomen, thighs, or buttocks);
2. Processing of the collected fat: isolation and cleansing of the fat cells and or micronization. Typically, the fat is centrifuged to remove excess oil and fluid;
3. Injection of the fat cells into the target facial areas (i.e., the fat cell transplantation).

There is a great variation in how steps 2 and 3 are performed, depending on the doctor, including the type of anesthesia used – general or local or none.
 
How permanent the results will be, depends on many factors. Studies (Eto H, 2012) show that the majority of the transferred/injected adult adipocites (adult fat cells) die after the fat transfer. The majority of what does take off and becomes a part of the host area is the preadipocites, in other words - fat stem cells or embryo fat cells. The better the fat is harvested and processed, the more of the injected substance is going to survive.
 
This is one of the procedures where it is impossible to overemphasize the importance of the surgeon you choose to perform the procedure:

• His/her knowledge of the facial anatomy with its deep and superficial fat compartments and anatomy of the aging face,
• his/her artistic eye with an ability to envision, recommend and work towards a 3-D, aesthetically pleasing and young looking result,
• methods and techniques he/she uses.

 
The cost of the fat transfer to the face varies from $ 3,000 to $7,000.
The downtime so greatly depends on the precise procedure and techniques used by the doctor, that it varies from practically no down-time in ALMI (covered below) to a recovery from general anesthesia followed by several weeks of swelling and bruising from traditional invasive fat transfer or when combined with a facelift.
 
 
Pros of the autologous fat transfer -

• The procedure utilizes your very own tissue, bio-compatible with your body, so there is no risk of allergic reaction or rejection;
• Whatever portion of the fat takes off, gets integrated into the existing facial tissue, it becomes a part of the area where it is transferred just like the fat or muscle that have been there since your birth. The results are natural and lasting;
• May be not very invasive IF the surgeon utilizes a gentle fat harvesting and fat injection techniques and does not use the general anesthesia;
• Cost. This is a two edged sword. In the short term, this is NOT a cheap procedure. It may cost somewhere between $2,000 and $ 7,000 depending on the areas and surgeon rates. However, due to its relative permanency, in the long term, a one-time investment in the fat transfer is going to cost less than multiple filler injections over the years.

 
Cons of the autologous fat transfer -

• The major drawback is the downtime as the injection area is likely to be swollen and/or bruised for a week to three weeks depending on the injection techniques and injection sites. However, there are surgeons that are able to perform a procedure so gently that the bruising and swelling are minimal, and can be covered with the make up in just 3 – 5 days;
• Not all the transferred fat survives; and the final results are only visible in a couple of months after the procedure;
• If a person continues losing weight after the fat transfer to the face, that newly transferred fat will deflate just like the fat that was originally in the face;
• Short term cost. The initial one time cost is typically higher than for the facial fillers. 

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II.4.A. ALMI - Autologous Lipocyte Micronized Injection 

In ALMI, the harvested fat is micronized to become liquid and injectable like a filler with a fine needle

​ A new and exciting variation of the fat transfer procedure is ALMI – Autologous Lipocyte Micronized Injection. Sometimes it is referred to as nano fat grafting or micro fat grafting. The procedure combines transfer of the micronized fat with PRP – platelet rich plasma (patient’s own blood cleansed of red blood cells). Unlike the traditional fat transfer, ALMI has none to minimal downtime, it is minimally invasive, and not only restores facial volume, but also stimulates rejuvenation of the skin. It thus not only addresses the volume and contour, but also helps with wrinkles, skin texture, tone, and elasticity. 
 
In that procedure, the harvested fat is micronized to the particle size of about 400 microns. The created tissue is liquid enough to become injectable like a filler. It is also placed through a filter that removes adult fat cells (majority of which die within 72 hours of transfer/injection), which results in up to 98.5% survival rate (Eto H, 2012).
The resultant “material” contains some adult fat cells, and most of the cells in what is called Stromal Vascular Fraction of SVF or, another term, Autologous Cellular Matrix.
​
Numerous studies demonstrated the effectiveness of SVF in regenerative medicine. Injections of SVF have been shown to increase collagen production and lead to thickening of the dermis (with age, dermis is thinning) (Amirkhani MA, 2016). To highlight the meaning of this, the use of SVF in ALMI combines volume restoration effect of a traditional fat transfer with regenerative medicine of gentle and natural skin rejuvenation.
​
In ALMI, SVF is used together with PRP - Platelet Rich Plasma. Fat tissue contains regenerative cells, and so when injected, combined with the rejuvenation properties of the PRP, it not only restores the volume, but also rejuvenates the skin. PRP also helps with vascularization, formation of the new blood vessels, of the newly formed fat tissue.
 
This procedure does not require anesthesia, only local numbing, and has minimal to no downtime. ALMI is a relatively new and branded procedure and is priced similarly to the traditional fat transfer without the anesthesia.
 
Supposedly, the ALMI procedure for the fat transfer also addresses one of the major issues with the fat transfer - predictability of fat survival. The rate of the fat survival with ALMI is supposed to be higher than with the traditional fat transfer due to -

• the composition of the transferred tissue – a minimal amount of adult fat cells and mostly stem fat cells;
• harvested tissue processing - micronizing adipose tissue creates tissue-SVF, exposing the pre-adipocytes (stem fat cells); a
• enrichment of the fat grafts with PRP. There is some evidence that fat grafts enriched with 20% PRP have demonstrated increased fat retention and survival when used for soft tissue augmentation (Modarressi A, 2013). Opinions among plastic surgeons on this matter vary.

 
The results of ALMI are supposed to last somewhere between 3-5 up to 10 years.
 
Pros of ALMI –

• Rejuvenates the skin along with the volume restoration;
• Minimally invasive;
• Minimal to no downtime;
• Overall results continue improving over the following weeks;
• The body only has very minimal amount of dying adult fat cells to remove, which results in less swelling compared to the traditional fat transfer;
• Utilizes the body’s own tissue – no risk of an allergic reaction or rejection.

 
Cons of ALMI –

• The final result is visible after several weeks;
• Compared to temporary fillers - cost.

 
Read more about ALMI here - https://www.almiprocedure.com/about  

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II.5. Facial Implants

This is the most invasive of all the options listed as it requires a surgical placement of an implant.

This option may be a good solution 1) either for an older age group when the loss of the facial fat is already accompanied by the loss of the bone (not yet the case in our 30-s and 40-s), or 2) when a person is interested in an enhancement of the facial features along with the volume restoration.
Implants are permanent, so the precise placement of an implant is very important, along with its shape and size. Make sure to choose a surgeon not only experienced with this type of a procedure, but also with an artistic sense for balance, proportion and vision of an aesthetically pleasing final result.
 
The recovery from a facial implants surgery is mild compared to other plastic surgery procedures. The incision site may have some swelling and redness for several weeks. The incisions are typically made inside the mouth or through a corner of the eye so that no visible scars are left.
 
Pros of all facial implants -
- The most obvious advantage of this option is the same as its biggest drawback – the permanence.
 
Cons of all facial implants -
- Permanence (if the result is not satisfactory, the only option is surgical removal);
- Invasiveness of the procedure, and the need for either the general anesthesia or a combination of local anesthesia and conscious sedation as inserting an implant is a surgery;
- Bulging or shifting of the implant. This can be minimized by attaching of the implant with a screw to prevent the implant movement;
- An allergic reaction to the implanted material or an irritating (non-allergic) reaction;
- Risk of complications present with any surgery: bleeding, infections, loss of sensation.
 
The two types of implants used for the enhancement and correction of the facial shape and volume are silicone an Goretex (E-PTFE) implants. The other two types of facial implants available in the USA are Medpor and Mersilene mesh. They are not discussed here, because they are used for the structural face augmentation, e.g. chin, ear, that is not related to the volume restoration or rejuvenation.
 
To summarize the implant option, it is the most invasive procedure for the restoration of the facial volume. It is also the most permanent. The facial implants may be better suited when an augmentation of the facial features is desired along with the volume restoration, or for an older patient group where the implant is replacing the bone loss along with the deep fat loss.

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II. 5.1. Silastic (Silicone) Implants 

​Silicone implants have been used for breast augmentation since 1963. However, now also for decades, silicone implants have been used in the facial aesthetics in the cheek, chin, and under the eye areas. They are most popular in the cheeks and chin and come in various shapes and sizes.
Unlike breast implants, facial silicone implants are solid, and there is no chance of a rupture.
Facial silicone implants are manufactured from medical-grade polymer of dimethylpolysiloxane, a noncarcinogenic, biocompatible material that induces very little inflammatory response when implanted subcutaneously (Aschheim K, 2015).
Silastic implants are non-porous; that prevents tissue ingrowth, which would fix the implant to the surrounding area. Instead, the tissue around an implant encapsulates the implants and holds it in place. To prevent migration of an implant, it can also be secured in place with a small screw or sutures.
 
If a silicone implant is used for the restoration or augmentation of volume on the cheek bone, the implant is placed on the cheek bone itself, on the periosteum, through the inside the mouth and should leave no noticeable scars.  Just like with any treatment that restores cheek volume, the enhancement of the cheeks with silicone implants will lift the sagging facial tissue, decrease the nasolabial fold and under the eye hollowness.
 
The total fees for a procedure with silicone facial implants range between $1,500 to $6,000.
 
Pros of the silicone implants (in addition to those outlined for all implants) -

• Natural looking result where the implant is used in lieu of soft tissues;
• Easier to remove compared to the Goretex implants (reviewed below).

Cons of the silicone implants -

• Mobility and migration (can be prevented by attachment with a screw);
• A risk of erosion and resorption of an underlying bone​

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II.5.2.  Gore-tex (expanded polytetrafluorethylene - E-PTFE) Implants 

Gore-tex or Gore S.A.M. (subcutaneous augmentation material) implants have been used since 1971 and have been approved by FDA for use as Subcutaneous Augmentation Material since 1994. The expanded polytetrafluorethylene is made of non-organic biocompatible materials designed to produce the least reaction from the body. Since the time the Gore-tex implants have been used, over half-a-million procedures have been performed, and no cases of an implant rejection were reported. (Berman N. What You Really Need to Know About Cosmetic Surgery)
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Gore-tex facial implants come in various shapes and sizes, and a surgeon can also remodel them to suit a particular patient.
The microporous structure of the Gore-tex implants allows tissue ingrowth that fixates the implants in place without forming typical scar tissue encapsulation.
The ingrowth starts around two months after the procedure and continues over time. New blood vessels have been found in tissues that are 1 year or older (Berman N. What You Really Need to Know About Cosmetic Surgery)
The total fees for a procedure with Gore-tex facial implants range between $2,000 to $7,000.
 
Pros of the Gor-tex implants (in addition to those outlined for all implants) –

• Compared to the silicone implants, Gore-tex porous structure allows natural tissue growth within the pores. Because of this ingrowth, there is less mobility, as integration will immobilize the implant to a higher degree;
• Comparted to the silicone implants, higher resistance against infections can come from the increased, more integrated vascularity (Nguyen H, 2015)

 
Cons of the Gore-tex implants - 

• May shrink and lose volume over time;  
• Very difficult to remove due to the tissue ingrowth, especially after one year. The material becomes akin person’s own bone, and if a correction or a removal is required/desired, the only way to do so would be cutting or shaving it, just like the bone itself.  

 
Gore-tex implants are also used in the nasal dorsum (nose), which is an enhancement rather than a rejuvenation procedure.

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