Facial Rejuvenation and beautification

As we get older certain changes make us appear aged. Previously the belief among the plastic surgeons was that by cutting off the excess skin of the face and pulling the remaining skin we can make the patient appear younger. Now we believe that the main problem with ageing is loss of volume of the face. Most of the loss occurs in the fat layer of the face. In addition to that some volume is lost in the muscle, bone and other connective tissues of the face. Now we are aware that by nature facial fat does not contain a lot of stem cells. This is specially so for women. Therefore we age faster in the face.  Human fat (with stem cells) is the best substance which can be used to fill in that lost volume. Especially because storage fat contain a large amounts of stem cells.  Now we know that storage fat contain about 100 to 1000 times more stem cells than the bone marrow. Just one gram of fat contain about one million stem cells. The other fillers (collagen, restylane, juvederm radiasse etc) has met with difficulties, including impermanence, foreign body reaction, unnatural texture, and possible disease transmission. In addition, most of the products currently available remain relatively expensive. Some materials, such as silicone, have resulted in spectacular failures. Silicone injections can lead to  complications including chronic edema, lymphadenopathy, scarring, skin ulceration, skin thinning and discoloration, and siliconomas. Fat grafting using your own fat is safe only if the proper technique is followed.  Dr Nimal Gamage has now performed over 2000 facial fat grafts without a single case of fat embolism or infection. Although many surgeons perform fat grafting in the world today his technique is unique to him. 

Attractiveness of a face depends on facial features, volumes, proportions and the degree of symetry. Aging always disrupts the facial harmony and balance and makes us unattractive.

These stem cells has the ability to repair damaged tissue. By replacing the lost fat with fat from another part of the body we can rejuvenate the face as well as replace the lost stem cells. The fat is obtained with liposuction using the tumescent technique. The removed fat is centrifuged and only the clean fat is used for injections to rejuvenate the face. Storage fat (fat in abdomen, lower back, thighs and arms) contain very large amounts of stem cells. These stem cells are the basis of facial rejuvenation. Read more about stem cells here.  Some people expect one fat graft to correct all their aging problems. Fat grafting is a technique which works better each time you repeat it. Obviously it is not a one time treatment.  Yet it is the best treatment in the world for making your face younger and prettier with no side effects. Just like with any medical or surgical procedure there is absolutely no money back guarantee with fat grafting technique.

Commonly all the troublesome lines of the face are corrected with fat injections. These include frown lines, Crows feet lines, nasolabial folds, the eye bags, marionette lines. As people age lips get thinner and start to down-slope at the corners. As the lips lose volume vertical lines appear around the lips called rytids. There are various injectable fillers which have many side effects such as reducing the normal blood supply to the face and  increasing the aging process.

What about wrinkles of the face?

These are the changes which happen to our faces with aging.

1. Brow Ptosis  which is drooping of the brows.  Most people learn to compensate for this by constantly raising their eyebrows so they can see better causing further wrinkles of the forehead.
2. Hooding of eyelids
3. Eye bags
4. Deep lines of the face (Rhytides)
5. Sliding of the tissues of the face downwards and forwards
6. Neck Bands

Aging face loses fat in all three layers. Superficial fat, Subfacial fat as well as perimuscular fat.

         For past few decades people came to their doctors and told them to lift their skin to make them look younger. They would pull their faces on the sides and see that the wrinkles get better. But they never got the beautiful young face they had 10-15 years ago. Instead they got an alien face which looked wind-swept and skeletonized. They looked weird when they tried to smile. Over-facelifted people end up looking more like lizards than like mammals. Recently the cosmetic surgeons of the world realized that the real problem is the loss of volume and you need to fill in that volume to make a persons face look younger. They also realized that persons own fat is the only way to fill their lost volume so they get the same look when they were younger.  Everybody who got a proper fat graft to the face got their faces to look thinner and lifted. (Faces look fatter when the skin is loose and drops on the sides. In addition to that fat collects in the lower face such as chin jowls and neck region as you get older). So the best way to make your face younger is to reverse that process of ageing. Fill the upper face with fat and remove fat from the lower face.  Dr Nimal Gamage has performed over 1500 fat grafting procedures to the faces both in USA and Sri Lanka. Come for a free consultation to see if you could benefit from this wonderful technique. When you are about 30-40 years one fat graft can give you results that can last up to 10 years. If you are over 50 and below 60 you may need about two fat grafts or more to get the same results. Fat grafts can be repeated for better results without any harm to your face. You have to wait at least three months before repeating the fat graft. Women get more swelling during the first week of fat graft compared to men but the swelling only lasts for one to two weeks. Most people can return to work in one week if they do not want others to see the swelling. Otherwise there is no problem with returning to the daily routine right away. Most patients can drive themselves home after the surgery.  Once the facial fat graft is done, the patient is advised to take an antibiotic for about five days and avoid sleeping with the face down on the pillow for the first five days. It is ok to take a shower in a day. Swimming should be avoided for about three days.

         Fat grafting results obviously depends on the age of the patient. For an older patient (over 50years) or with an aged face, more than one fat graft may be necessary to obtain the best results.  By repeating fat grafts you can make a person look younger and prettier to an amazing degree. No other technique in the world (fillers, face lifts, thread lifts) will give you the youth and beauty like fat grafts.

All of the above conditions can now be treated with minimally invasive techniques of fat transfer, liposhifting and subdermal laser tightening.

For example hooding of eye lids and eye bags in early stages can be treated with fat transfer techniques where the youthful appearance can be restored and further ageing can be prevented.

Some people tend to get eye lid edema. This is usually caused by other conditions such as ocular allergies, idiopathic edema, Fluid retention, hypothyroidism and renal disease.  These conditions must be treated to successfully remove the eye lid edema. For example Patanol is one of the best treatments for ocular allergies.

As you age wrinkles settle on your skin. Women worry about this to a greater extent than men. The wrinkles tend to make people look older with age. A bride waiting to capture her best look on her wedding photos does not want those wrinkles on the face. Some times wrinkles appear and get deeper even before you have aged. The main reasons are quick weight loss, sun damage, acne damage and genetic tendencies.

For a bride who wants to soften her skin wrinkles the treatment of choice would be skin fillers. There are many artificial skin fillers such as collagen, restylane, juvederm etc. These provide only a temporary relief. They displace your normal circulation therefore in the long term does not help the ageing and may in fact aggravate it. The best filler in the world to treat skin wrinkles is your own fat which contain your own stem cells.

Reasons why the fat is the best filler in the world for you are these. 1. fat is the cheapest filler 2. It can last as long as you live 3. stem cells in the fat can rejuvenate and repair your aged face 4. Excess fat can be removed with new laser techniques (fiberoptic Nd-Yag Laser) while fillers cannot be removed safely like that. 5. Fat filling gives you younger face and the most natural look since losing fat was the reason why you actually got wrinkles in the first place. 6. Fat will bring more circulation as new capillaries grow into the new fat tissues thereby slowing down your ageing process.

One of the pioneers of fat grafting Dr Sydney Coleman who is one of my teachers has said this recently. " "When I began transplanting fat twenty-four years ago, I noticed an interesting development. The quality of my patients' skin overlying the areas I had grafted improved dramatically over time. I observed decreased wrinkling, smaller pores and improved color and tone. We now know that there is a high concentration of stem cells in fat. So, with each fat transfer, stem cells that can potentially repair aging and sun damaged skin are transplanted as well. We are now looking into how to maximize that extraordinary effect."

Proper dental hygiene is paramount for prevention of infections in any facial surgery. If you have any dental problems with infections it is best to treat it first before going for the facial rejuvenation with fat grafting technique.

The above images were taken of the same person twenty years apart. Bottom image is the same patient at 18 years and then at 103 years. It shows the changes occurring in the facial skin as well as of the facial volume. Correction of the changes which occurred with ageing require skin laser treatments as well as replacement of the volume with patients own fat. In a recent study investigators noted a significant decrease in the maxilla and mandible bone mineral density for both sexes between the young and middle age groups. It is important to correct all the volume loss in the face for proper rejuvenation of the face.




Usual filling volumes for different areas of the face.

Above picture shows rejuvenation obtained with fat grafting to the face. Marionette lines have virtually disappeared in this patient. The entire face was lifted and the patient told us that she looked 20 years younger. She achieved the desired results with one operation. In certain patients with either deep wrinkles or poor circulation the fat grafting can be repeated safely after about three months to six months.

           Before                                         After

This is a great example of a patient who complained of ageing of the face as well as fattening of her face.  Her face looked fatter as she lost fat from the face and skin sagged making her face looking more like a square.  She had two fat grafts to make the correction on the right. Picture on the right was taken about one year following the before picture on the left. She is extremely happy with her results. Results are further improved with maintenance laser which is performed about once a month. 


In this patient fat is injected to improve the nasolabial folds.

In this patient the vertical lines around the lips occurred with ageing. These are called rhytides. She looks younger following augmentation of her lips with the fat grafting. Although the lips can be augmented with fillers such as collagen and restylane the results obtained with fat grafting is far superior. The artificial fillers are short lasting and can displace the natural circulation and thereby increase the ageing process. The fat grafts encourage more blood vessel formation and increases the blood supply to the face. Therefore fat grafting can slow down a persons ageing process.


This patient had fat grafting of her face for rejuvenation. She had improvement of the down-sloping of corners of her mouth, fullness of her lips and fullness of her cheeks restored as shown in the after picture.


In this patient improvement of the eyebags as well as marionette lines can be seen in the after picture. The patient was 68 years at the time of surgery and was very happy with the results.


This patient had her cheeks and lips improved with fat grafting.

Is this technique suitable for Sri Lankans? Absolutely. It works for any race and color. Can you make somebody more beautiful and younger at the same time? Absolutely.

This patient suddenly lost a lot of fat from her left cheek after a febrile illness. On the right side a remarkable improvement was seen after just one fat graft. It was further corrected with another fat graft and patient achieved complete filling of the defect.

Ideal Facial Proportions

Beauty of the face depends of having ideal facial proportions. If a person wants to look more beautiful simply augmenting features of the face with a simple fat graft to those areas can enhance your beauty without changing the identity of that person.

Above are some of the ideal angles of the face.

Parameters of the ideal female brow position is shown above.

The above photo belongs an employee of my clinic who had undergone fat grafting to improve her appearance. You can see how she has improved the proportions of her face by enhancing her cheeks, lips and chin region and removing the fat collection under the chin. 

Here is another employee of the clinic who  had sunken eyes since she was a teenager and her facial beauty has been enhanced with fat grafting  under the eye region and chin. In addition to that the skin color the tone has been improved with laser treatments.

The above photo on the left was taken two years ago when I first arrived in Sri Lanka. With the fat grafting of upper and mid face, lasers for the full face, chin and neck and special creams, the face has been made fairer, younger and prettier over the past two years. Even the acne scars of the face has been cleared to a great extent. The picture on the right was taken about two years after

In the ideal sense, cosmetic surgery involves the re-engagement of a more youthful appearance, not the metamorphosis of an individual into something else. Ideally, we are attempting to exchange poor exercise and dietary choices, the erosion of elasticity and effects of gravity for a prior moment in time. The goal is to create a refreshed and more energetic, youthful person while staying within the original canvas of the face. Realistically the outcome is an improvement and not perfection. The goal is to achieve one level of improvement.

This is how a cosmetic surgeon determines if the patient has realistic expectations.  A cosmetic surgeon reserves the right to refuse surgery for a patient who has unrealistic expectations.  

Examples of good reasons

include the following: ‘‘People tell me I look tired or angry,’’ ‘‘I simply want to do this for me,’’ ‘‘I feel young, I work out and I am healthy, but I look old’’ Each of these examples illustrates a rational reason for accommodating change. Various forms of media (eg, television) and Hollywood continue to emphasize the importance of beauty and youth in our society. The ubiquitous presence of the younger, more beautiful, and healthier image is inescapable, as is the marketing of a means to achieve that end. On the contrary, patients who respond with ‘‘My husband/boyfriend/wife wants me to do this,’’ or ‘‘I lost my significant other and am looking for a boost’’ are poor candidates emotionally and psychologically. Although cosmetic surgery can be gratifying, it is important to realize expectations and goals at the onset of the process.  Here is a news item describing improvement of burn victims joint mobility with fat grafting.