Advances in Facial Rejuvenation – How They Occur by Paul S. Howard, MD, FACS

Facelift Alabama

Plastic Surgeon Birmingham Alabama

“Doc, how can you make me look better, fresher, and maybe even a little younger looking?”

The answer to this question depends on many variables, but actually is easy for each individual surgeon to answer.  In fact, all surgical advances begin with a patient asking a doctor his opinion on a problem that is bothersome to the patient.  In the early 1900’s, the question may have been, “Doc, can you get rid of this unsightly hump on my nose?”  Maybe it was a teenager who wondered if her protruding “Dumbo ears” could be set back.  In the 60’s it might have been, “Doc, what can you do for these fat deposits on my thighs?”  Each of these questions was first met with skepticism by the surgeon followed by a moment of reflection and ending with the promise to get back to the patient after having a chance to think about it.  These accumulated “moments of reflection” are the substance of hundreds of manuscripts and then textbooks describing all of the innovations that have become the essence of Plastic Surgery as we know it today.

Recently, the question that continues to arise refers to looking more youthful, but is tainted by the attempt of many surgeons and non-surgeons to answer this question with a multitude of poorly conceived procedures, potions, lotions, and quick fixes that frequently fail to provide the answer to the question.  Photos that are presented fail to show youthfulness and frequently are not honest and believable.

The part of this anti-aging scenario that surgeons have come closer to accomplishing is the anti-gravity part where the desire for a procedure that lifts drooping facial tissue, especially the cheeks, forehead and neck, is accomplished with minimal incisions, safe anesthetic techniques and a rapid recovery time to the resumption of normal activities.  These accomplishments in facelifting are actually recent because advancements only happen when our patients ask for them.  There came a time when massive swelling and bruising, general anesthetic and a month recovery was not good enough and patients asked for more (or less).  It became clear that simply tightening skin to elevate facial fat and remove wrinkles was a simplistic approach to facial rejuvenation.  Although lifting and tightening worked to a certain degree, it did little or nothing to address that facial deflation by the loss of fat is an integral component of the aging process.  The use of fat transplantation, as is has now been perfected, has provided a therapeutic answer to deflation while fulfilling basic Plastic Surgical principles as described by Ralph Millard, MD.  In a nutshell, fat transfer is the result of identifying a problem, replacing what is lost with tissue in-kind, all the while improving the donor site via liposuction – Dr. Millard would love it!

This is the magical point in the scenario where luck comes into play as it applies to the “law of unintended consequences.”  The smartest of our brethren saw it almost immediately, but the rest of us took a while to see that which was right in front of us.  Our fat grafts carried with them a myriad of growth factors, cytokines, and unknown chemicals that helped the grafts “take,” but also exerted their influence on the overlying skin; the last aspect of the aging face addressed surgically.  By the simplest of methods – observation – it was noticed that the skin was visibly improved by the fat grafts; it had more collagen, more elasticity, improved texture, and an improvement in the fine lines and wrinkles.  As our knowledge evolved it became clear that these secondary consequences were the result of the stem cells that we now know to exist within the fat grafts.  The next small step was to isolate the adipose-derived stem cells from the fat and reintroduce the stem cells to improve the “take” of the fat and add improvement to the skin.  The addition of other known growth factors found in platelets as a PRP boosted the rejuvenation ability of fat grafts even more.  I think it has also become quite clear that depositing these rejuvenating aspects with an appropriate scaffold (fat) beneath the skin improves the results drastically from the awkward attempts to simply rub these against on the skin’s surface.  It follows that the best we can do from the surface is to accelerate the turnover of the skin cells and remove as many of the dead cells as possible; hoping to unveil the dermal and sub-dermal improvements obtained from our stem cell assisted lipo-transfer protocol.

What I have described is the way Plastic Surgical advances happen.  Doctors and patients have been dancing this question and answer Waltz for over a hundred years so it should be of no surprise that many of the questions were asked a hundred years ago, but the answers have only recently shown themselves to those who continue to look for them.

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Count Dracula and the “Vampire Facelift™”

Vampire Stem Cell Face Lift

Count Vlad’s Castle in Romania. Dr. Paul S. Howard visited Romania several years ago to operate on orphaned children born with facial deformities.

Author Anne Rice benefited from the allure of the Vampire in pop culture where there has always been a certain interest in all things Romania.  From Count Vlad “the Impaler,” to the gypsy culture and even gymnast Nadia Comaneci have all fueled interest in the darkest of the former Eastern Bloc Soviet satellite countries.  Our fascination with Romanian people may stem from their unique Eastern European history.  The Romanian is proud of his Dacian ancestry making their culture and language more like that in Rome than their geographic neighbors which are Slavic countries such as Hungary, Serbia, Moldavia, and Bulgaria.

The myth that is Dracula has a basis in fact steeped in the history of Romania and the Dark Ages of Europe.  Vlad III, Prince of Wallachia, member of the House of Draculesti, known by the patronymic name Dracula was born in Transylvania in 1431.  The translation of the name Dracula comes from his father Vlad Dracula, meaning “dragon” or “devil.”  Vlad III was known in his adult life as the son of the devil.  It was only after his death in 1476 that he became known as tepes or “the spike,” alluding to his famous battles with the Islamic Turks and his father’s battles with the Boyer Family for the thrown of Wallachia.  Both the Boyers and the Turks were “spiked” or impaled as punishment and as a deterrent.  Thus, Vlad “The Impaler” was born.  It was left to the Irish author, Bram Stoker, to rekindle the Dracula legend as well as embellish it to include the Vampire myth in his 1899 gothic horror novel, Dracula.

The recent fascination with the Vampire myth was stoked by any number of books including those by Ann Rice and the TV series Vampire Chronicles.  It comes as no surprise that medical marketing would jump into the Vampire craze even though the institution of Vampire tales is beginning to wear thin even in pop culture.  We now have a non-surgeon entering the pop-culture marketplace with the so called “Vampire Facelift.”  The connection with vampires is interesting in that vampires are a Gothic myth with no factual basis much like the vampire Facelift™ is more of a New Age myth with no basis in fact.  The connection to Vampire culture is through the use of Platelet Rich Plasma (PRP) as an adjunct to the use of temporary foreign fillers (Juvederm™, Restylane™) to effect some sort of facial rejuvenation akin to the well-worn “Liquid Lift™.  Fillers plus PRP equals the Vampire Facelift™.

Platelet Rich Plasma is obtained by drawing blood from the patient’s arm (not the neck as in vampire-lore), and by processing the blood one obtains platelet poor plasma (PPP) and platelet rich plasma.  The most well-known use of PPP is “fibrin glue,” a soft tissue sealant used in many kinds of surgery.  PRP has a bewildering array of uses, but all of the known benefits come from the activation and stimulation of growth factors and cytokines.  These are necessary for cellular activity which benefits blood supply, healing and specifically the “take” of fat grafts mediated through the activation of stem cells.

Recently it has come to light that activated stem cells and PRP have a beneficial effect on aging skin causing increased collagen synthesis, may be helpful to increase elasticity and is believed to improve skin texture as well.

Platelet Rich Plasma, coming from blood, has many important functions, but none of these functions create volume nor “lift” tissues in any way.  Additionally, PRP is very easy to obtain from blood.  The actual skill involved is drawing the blood which is easily processed to PRP, is easy to activate with calcium and thrombin, and actually is a source of protein when swallowed (vampire’s diet).

Utilization of PRP is a useful adjunct for facial rejuvenation, but in and of itself has not shown to have much of a rejuvenating effect.  The addition of temporary fillers does not improve what is already known about the temporary volumizing effect of hyaluronic acid based fillers.  The two together serve to prove the uselessness of trademark laws as applied to medical science.

Dr. Paul Howard is Board Certified by the American Board of Plastic Surgery.

The Stem Cell Revolution

The law of unintended consequences applies to President George W. Bush when he banned embryonic stem cell research.  The unintended consequence was the search for adult stem cells and the knowledge that there is an almost limitless amount of adult stem cells located in fat or adipose tissue.  This fact places Plastic Surgeons at the epicenter of the stem cell revolution.  Who better than a Board Certified Plastic Surgeon is in a position to obtain the necessary fat (liposuction) which is then processed to obtain adipose tissue derived stem cells?

These adipose derived stem cells can be utilized for a myriad of cosmetic and reconstructive procedures.  For our purposes, these all-purpose stem cells are the basis of all of our facial and skin rejuvenation procedures.  It is a well-documented fact that stem cells, when reintroduced into the face, causes any fat which is re-injected, to “take” better and as a secondary benefit the stem cells release a number of “growth factors” that improve  skin by reducing the visible signs of aging.

It is important to realize that you cannot share your stem cells with anyone else nor can you use stem cells from another person.  The fat must be processed immediately and re-injected with the stem cells during the same operation as it is difficult to store adipose tissue for further use.  We have developed a “stem cell lab” within the confines of our sterile operating room.  The lab equipment costs little and only requires basic laboratory experience (such as the experience obtained with a B.S. in Chemistry).

Every medical breakthrough goes through stages.  First, there is disbelief followed by hyperbole.  The hyperbole stage is manifest by over hyping the benefits and the beginning of named procedures such as the “Stem Cell Lift” which basically does not exist.  Realistically, stem cells do not tighten skin or “lift” anything.  They are a great addition to volume enhancement by increasing the take of fat grafts and clearly stem cells cause your skin to rejuvenate by erasing age spots, increase skin thickness, and improve fine lines and wrinkles.  Most patients who have had our stem cell rejuvenation describe their skin as smoother and typically glowing.  Stem cell augmented fat transfer has become a staple in our rejuvenation procedures and at a minimal charge to the patient.

Read more about top facelift surgeon Dr. Paul Howard and view facelift before/after photos.

Stem Cells, Fat Grafting, & Facelifts

The facelift operation as practiced by Board Certified Plastic Surgeons continues to relentlessly evolve as surgical science and cell biology uncover new applications which can be utilized to improve our already outstanding results.  Responding to the wishes of our patients, operations have tended to become less invasive and shorter in duration with less swelling, bruising, and a much shorter down-time.  The short scar facelift has seen a resurgence with new and original methods of dealing with the SMAS, such as our progressive, multiple vector SMAS plication.  The blending of the improved mid-facelift with the lower eyelids and less invasive neck surgery when possible had been our idea of a modern facelift.  Due to the teachings of Sydney Coleman in New York City, we added structured fat grafting to our lips much improving the perioral area and enhancing the cheeks and what has been architecturally described as the facial “ogee.”  I believe fat grafting as now practiced was a huge step forward in facial rejuvenation completely replacing foreign body fillers such a Juvederm® and Restylane®.  In some circles, the efficacy of fat grafting is still questioned even as the evidence of graft takes in the 80-95% range are routinely described.  Over the last couple of years, the basic science of cell biology has given us new information on adipose biology and the nature of adult adipose derived stem cells.  The term “stem cell” occupies front page position in almost every modern women magazines.  Until recently, it has been unclear how this new information could be applied to Plastic Surgical science.

The evolution of stem cell biology including the fact that we could isolate stem cells from our own body fat seemed almost too good to be true.  Rather than throwing away the fat we obtain with liposuction, we can now take this fat, process it in the office, obtain stem cells, and then utilize the stem cells for improving fat graft take even further as well as adding growth factors to the fat grafts that have a beneficial effect on aging skin.  Body contouring with liposuction complimenting facial rejuvenation is truly a “scots” efficiency as Dr. Ralph Millard would say.  The beneficial effect of growth factors on healing and facial skin aging has been known for several years, but exactly how to utilize this knowledge never progressed after the discovery of its use as “fibrin glue.”  More recently, we have added platelet rich plasma (PRP) obtained by drawing blood at the onset of the surgical procedure, processing the blood to get PRP which adds large quantities of growth factors when added to fat and fat stem cells used for facial contouring and rejuvenation.  All of these biologic enhancements to fat grafting are obtained from the patient and therefore are autologous with no problem with rejection such as that which occurs with foreign body fillers.

To summarize our current facelift techniques, incisions are of the “short scar” variety, the SMAS is handled with progressive tension suturing in multiple vectors, micro-drains are used for 24 hours to reduce bruising, the glabella, cheeks, lips, chin, and perioral areas are enhanced by fat grafting augmented with stem cells and PRP.  Cost controls include doing the procedure in the office with local anesthetics and mild sedation.  The sum of these procedures we like to call the “Howard Lift” for lack of a more descriptive term.

Read more about top facelift surgeon Dr. Paul Howard in Birmingham, Alabama.

The Stem Cell Facelift – Fact or Fabrication

The Stem Cell Facelift - Fact or Fabrication

Gargoyle of St. Severin in Paris, France - Photo taken by Dr. Paul Howard

If one were to internet search “stem cell facelift” or “non-surgical facelift” you get hundreds of search results describing outrageous claims of facial rejuvenation that exceed the results of “surgical facelifting.”  There will always be people following the holy grail of “non-surgical” procedures of all types.  These same people probably believe in gremlins, gargoyles, and the tooth fairy, all myths that get some play over the internet.  All good myths (and lies) seem credible because they were based initially on facts.  For instance, let’s look at the so-called “liquid lift” touted as some version of the “non-surgical facelift.”  Plastic Surgeons have known and is replete in our literature that one aspect of facial aging is due to a loss of soft tissue (mainly fat) volume, no one who studies the aging process believes that simply addressing facial volume issues will in effect result in “lifting” of facial structures, i.e. the “liquid facelift.”  The proposition will always find an audience with those individuals who, for varied reasons, are frightened of surgery.  The proposition of volume lifting gets momentum as its practitioners recommend using one of today’s off the shelf fillers at $200-300 per milliliter.  It could take 30cc of filler to achieve the fullness necessary to claim the face is lifted.  This is a perfect example of utilizing a true discovery to develop a non-surgical marketing slogan such as the “liquid lift.”  If such a procedure actually worked, we could all take our marbles and go home as the answer to facial rejuvenation would be upon us.  As much as this would benefit the non-surgeon, it happens to be untrue, but still worth a try if you cannot do a proper facelift or obtain autologous fat as a filler rather than having a basically painless and simple surgical facelift.

The Stem Cell Face Lift is another of these stylized marketing slogans based on actual scientific discovery (stem cell biology) adulterated as some sort of magic bullet that “lifts” faces.  I think that the gargoyles protecting Notre Dame in Paris makes more sense than a stem cell “lifting” anything.  This is not to say stem cells don’t exist or that their discovery isn’t useful when applied to the biology fat grafting and actual facial skin rejuvenation.  An understanding of stem cell biology and how to isolate them from adipose tissue will probably become routine for all Plastic Surgeon’s in the near future.  Hopefully, as more and more is published on the subject of stem cells there will be fewer practitioners with a financial incentive to propagate the fantasy which is the “stem cell facelift.”  The final straw may be the fact that many of the non-surgeons are parlaying some knowledge of stem cell biology into a $20,000 procedure!

In the final analysis common sense dictates that stem cells are real and are a really important adjunct to my facial rejuvenation procedures, but by themselves cannot “lift” anything, particularly an aged face.

What’s up with Stem Cells?

First of all, what is a stem cell and why are they now so popular?  One of the essential wonders of mankind is that all human beings are derived from two cells – one egg and one sperm cell.  These two cells and their DNA become a single cell which divides and subsequently differentiates into all of the individual cells which comprise the human organism.  As the early cells divide to reproduce themselves some of them begin to differentiate into the cell lines that form different parts of the body as well as the blood flowing in our veins.  These cells which are only partially differentiated and still have the potential to become more than one type of cell are called stem cells.  If these cells are liberated during the embryonic phase of development they are called embryonic stem cells.   If the embryo is allowed to grow and the cells differentiate further the cell lines become more specific to each body part.  As these cell lines develop into their structures (skin, muscle, fat, blood) they lose their ability to reverse course and again become “pluripotential” stem cells.  Once they differentiate down their pluripotent lines they become more and specific as to their ultimate destination (i.e. skin, blood, brain, muscle, fat).  These slightly more differentiated cells are called multipotential stem cells and include our now famous adipose (fat) derived stem cells.   Think of this process as a gently flowing river – if one puts in and is slowly taken downstream there will come a point where it is not possible to paddle back upstream to the starting point.  As we travel further downstream, our momentum increases so that it becomes less possible to reverse course.  At this point where reversal, or in the cellular world – re-programming, becomes impossible, you have multipotent stem cells.  A little further downstream you have more specific adipose derived stem cells which after transversing a white water rapid becomes the fat cells and fatty tissue.  The fat tissue itself is the end of the river as it flows into the sea.  Luckily each part of our body retains a few less differentiated multipotent stem cells so that the end tissue (fat in this case) can keep renewing itself as cells live and are programmed to die (apoptosis) and be regenerated by fat cell division and adipose stem cell differentiation.  As much as we wish our excessive fatty tissue would die off, it would be catastrophic to our health as fat cells have been shown to be highly active and responsive to many chemical, protein or hormonal stimuli.  So, some fat is good and too much is not so good!

The coolest discovery occurred when adipose derived stem cells (ADSC) where discovered as a precursor to fat and were available and relatively easy to isolate from our fat and have all the necessary growth factor proteins to stimulate these cells to grow into the fatty tissue we all love so.  These growth factors, primarily platelet derived growth factor (PDGF) and
transforming growth factor – Beta (TGF-B) among other proteins and cytokines stimulate the growth and vascularization of adipose tissue especially if used as a “fat graft.”  An unintended consequence of augmenting fat grafts with ADSC is that many of the stimulated cellular products have a trophic and rejuvenating effect on the adjacent skin.  This effect is particularly noticeable on facial skin which is aged, sun damaged, and environmentally damaged.  It has been shown that the ADSC augmented fat graft induces neoangiogenesis (blood vessel growth) causing an improved blood supply and “take” of the fat grafts (protein and growth factor modulated), increased collagen and extracellular matrix synthesis (macrocryptin and pre-adipocyte modulated) as well as the simulation of the ADSCs to transform (multipotent) into fibroblasts which further augment the damaged
skin.  The rejuvenation and thickening of the skin is primarily due to the increased collagen synthesis.  The possible addition of activated platelet rich plasma (a-PRP) may help to enhance even further the tissue response to fat grafting.

If I lost you at the river metaphor, I can summarize that the addition of science to the art of facial rejuvenation will yield some miraculous rejuvenating effects simply by understanding the biology (science) behind the plastic surgical art.