Permanent Composite Midface Volume Replacement: Artefill, Silastic Implants, and Stem Cell Enriched Fat Grafting

Background: Midface rejuvenation centers upon the treatment of facial wrinkles, resuspension of ptotic soft tissues, and facial volume replacement with permanency often requested. Objectives: Evaluate aesthetic permanent composite midface volume enhancement using bovine collagen gel suspended polymethylmethacrylate microspheres or Artefill with a name change to Bellafill, standard or patient-specific silastic implants, and autologous stem cell enriched fat grafting. Methods: Retrospective review of consecutive patients electing permanent midface volume following a composite midface volume analysis and protocol. Most midface silastic implants had preoperative photoimaging. Artefill was injected using microcannulas in the subdermal and/or supraperiosteal planes. Fat grafts were prepared using low suction extraction, administration within 1-2 hours of harvesting, centrifugation-filtered at 3000 rpms for 3 minutes without washing, and stem cell/stromal vascular fraction enrichment with platelet rich plasma to optimize graft survival. When simultaneously body contouring, ultrasound energy (60% pulsed mode) prior to fat harvesting was minimized. Results: Patients chose Artefill (154), silastic implants (52), and fat grafting (44). Combination Artefill and fat grafting were performed in 25%. Simultaneous facelifts with silastic implants performed in 23.1%. Combination silastic implants and artefill in 15.4%. The overall patient satisfaction rate for all permanent volume options was 95.6% (239 of 250 patients) using the Global Aesthetic Improvement Scale with very much improved or improved responses. The reason for lack of satisfaction was that volume replacement did not achieve their aesthetic goals. Artefill had two with excess fullness successfully treated. Fat grafting observed one seroma and two with isolated fullness successfully treated. Silastic implants had four with asymmetries successfully treated with replacement (n = 2) and Artefill filler addition (n = 2). Conclusions: Isolated or combination use of Artefill, silastic implants, and fat grafting are valuable components of a composite midface volume replacement strategy with high patient satisfaction and a low complication rate. A permanent volume replacement option flowsheet was presented to ease the volume decision process.