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Articles - Year2001 - Volume16 - Issue 2

The following case report was submitted by Dr. Murilo César Abreu and assessed by Dr. Luiz Haroldo Pereira and Dr. José Horácio Costa Aboudib Jr.

1. Case Description

Sixty year-old patient presenting a depression in the medium third of the face (cheek subsidence). The patient had had a face-lift 15 years before. Presently wants to correct the changes.

How would you solve the case? (Figs. 1 and 2)

Fig. 1

Fig. 2

2. Assessment

Luiz Haroldo Pereira

The patient has cheek depression, evident platysma bands and rounding. In order to correct the cheeks, I would indicate lipografung, using the abdomen or knees as donating areas. I would remove fat with a 10 cc syringe connected to a 1mm cannula. I would prepare the fat by washing it with a saline solution and would perform a 10 to 15 cc fat graft on each cheek.

The present case is a good case for facial liposculpture, because the depression corresponds to the absorption of absence of the Bichat bursa.

The patient clearly needs secondary lifting in order to correct the neck and eyelids.

José Horácio Aboudib

I found the solution given to the case quite appropriate, particularly with regard to the neck. I also consider the solution given to the patient's main complaint, quite ingenious. I only fear that, with flaccidity of SMAS, the problem may recur, mainly on the left side (where the problem was greater). I believe that sub-SMAS lipografting, even given the solution suggested, would be helpful in terms of the result.

3. Solution

The patient came into the office complaining only about the depression in the medium third of her face as shown by the pictures. After having examined the patient, we found flaccidity of the skin and facial mimic muscles with the descent of malar fat, and no accumulation of fat on the lateral part of the face, however. After having talked to the patient, we proposed a cervicofacial lifting, with ample detachment of the skin and of the SMAS-platysma complex, along with vertical traction of SMAS to reposition malar fat into its anatomical site, thus filling the whole depression. A one-year follow-up can be observed (Fig. 3).

Fig. 3


In cosmetic surgery, as in the case of any other medical specialty, correct diagnosis is necessary for proposing perfect case management. It is necessary to perform an accurate examination of the deformity presented and to discuss the best management plan with the patient him/herself in order to show the patient the advantages and disadvantages of each procedure, if more than one, so he/she can take part in the best treatment option.

4. Discussion

Luiz Haroldo Pereira

I would like to congratulate the surgeon on the result of the cervicofacial lifting to solve the problem. After analyzing the post-operative result however, I believe a lipograft of the genion needs to be performed, because the Bichat Bursa was absorbed.

José Horácio Aboudib

The surgery was performed 15 years ago and there is no description as to the resection of the Bichat fat. There are, anyway, other signs of aging, such as platysma bands and facial flaccidity.

I would perform a rhytidoplasty with detachment limited to the proximal portion of the depression. I would put a fat graft in the subcutaneous plan and sub-SMAS plan, with minor hypercorrection. I would probably perform a "W" cut at the base of the hair (one cannot assess from a frontal picture). I would resect some of the skin of the upper left eyelid.


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