Facial rejuvenation with structural fat grafting

Key points

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Fat grafting provides a less invasive, more anatomic rejuvenation of the aging face by replacing missing volume. As such, the risks associated with open facial procedures are significantly reduced.
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The concepts of aging are changing, with increasing emphasis on volume loss and volumetric enhancement. Fat represents a generally ubiquitous tissue source that when grafted is very long lasting.
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There is a steep learning curve for structural fat grafting, especially in the less forgiving areas of the face, such as the eyelids. Proper handling and placement of the fat is essential for consistent results.
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The technique for fat placement is slightly different based on the anatomical part of the face being treated. This technique can be applied to a broad spectrum of patients with both early and advanced signs of aging.
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Fat grafting can be easily performed in conjunction with other facial procedures. Patient selection is very important and procedures must be individualized based on deviations from youth.

Introduction

For decades aesthetic surgeons have been performing facial rejuvenation procedures involving the excision and resuspension of the skin and underlying structures. While at times this may be the best option, often, similar or better results can be obtained by restoring the facial volume lost with aging. Autologous fat grafting can restore volume to the aging face in a manner that can be natural, long-lasting, minimally invasive, and safe. With the introduction of more and more temporary, semi-permanent, and permanent fillers, surgeons are becoming more comfortable with the idea of adding volume to the face. However, unlike these temporary fillers, there is a steep learning curve to structural fat grafting, especially in the less forgiving areas of the face such as the eyelids. To obtain reliable, consistent and predictable results, steps must be followed to ensure graft viability and graft take. Fat must be harvested as atraumatically as possible to ensure viability of cells, processed in a manner that preserves viability and cell integrity, and integrated into the tissues for stability and longevity. In addition, patients must be selected properly to ensure success of the procedure and to obtain the most optimal results for each individual.

Patient selection

Young patients who have not aged significantly can benefit from fat grafting to improve overall contours and change facial proportions, but ideal candidates for facial rejuvenation using structural fat grafting are those with mild to moderate skin laxity and mild to moderate skin wrinkling. Where there is a tremendous amount of skin laxity, the amount of fat required to refill and/or resuspend the tissues would be excessive, creating a face that is unusually large and unnatural. Similarly, when wrinkling is very severe, there may be some improvement or softening of the rhytids, but they cannot be completely filled or ablated. Mild to moderate skin laxity, however, can be improved by the radial expansion that occurs when volume is added back to the face. This can often give not only the illusion but also the reality of lifting and tightening the skin. Mild to moderate rhytids are improved by the actual filling of deep lines and folds. The tightening that occurs with the addition of volume, and the likely stem cell effect over time seems to improve the texture, pigmentation, and overall quality of the skin.

Indications

Structural fat grafting has multiple applications, including the following:

Facial rejuvenation

Fat grafting corrects loss of fullness in the temples, upper and lower eyelids, glabella, cheeks, nasolabial folds, lips, chin, and jaw line. The soft, full contours associated with the youthful face can be successfully restored with the selective addition of fat to areas of the face that are deficient. The most common areas of the face that lose volume are:

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The temples – loss of volume in this region results in concavities that are not present in youth. This results in a more skeletal appearance of the upper face and usually makes veins in this region more visible.
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The upper eyelid, with posterior hollowing into the orbit and deflation of the sub brow volume. This can present as either hollowing of the orbit or as an apparent excess of skin. On occasion, it may present as both problems and require not only filling, but also excision of excess skin.
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The lower eyelids, with accentuation of the tear troughs and elongation of the lid–cheek junction. This results in either a tired or sad appearance as the cheek appears to descend and expose the infraorbital rim.
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The glabella, with increased wrinkling of the skin and accentuation of the depression in the radix, making the nose look longer and larger. Loss of volume in this region can also make patients look angry or unhappy as the wrinkles become deeper and more obvious.
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The cheeks, with loss of fullness in the lateral cheek, hollowing of the buccal cheek, and flattening/indenting of the anterior cheek, accentuating the nasolabial fold. Fullness in the lateral and anterior cheek is often seen as more attractive, while loss of volume in the buccal cheek can be a sign of age and also poor health.
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The nasolabial fold, which is partly due to loss of volume in the area and partly due to loss of volume in the cheek, which allows the cheek to descend. Deepening of the nasolabial folds often gives the face an angry or sad appearance.
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The lips, which never contained fat, but which begin to invert with loss of volume in both the upper and lower lip. Thin lips can often convey a very stern, unhappy, older appearance, while lips with more fullness are associated with youth.
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The chin, which flattens and becomes less prominent and less shapely with age. Adding a small amount of volume to the anterior chin can improve the profile and often improve the appearance of the submental region at the same time.
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The jaw line, which loses volume both anteriorly, accentuating the jowls, and posteriorly, creating a poorly defined mandibular border and a wavy jaw line that is not present in youth. Adding volume back to the anterior jaw line (pre-jowl area) can disguise the jowls without removing or resuspending them. The posterior jaw line should be straight and distinct from the neck, which can be achieved with the addition of volume in this area.

Change in facial proportion

Fat grafting can augments the structure of the cheek, chin, and jaw line, creating a more balanced, aesthetic facial proportion. Younger patients who do not have signs of aging, but instead feel that their facial proportions are deficient or unaesthetic, can benefit from the addition of volume in the form of fat grafting. For example, patients with flat, hypoplastic midfaces can achieve the appearance of full, high cheekbones with the addition of fat instead of an alloplastic implant. In addition, a short face or indistinct jaw line can be lengthened, broadened or defined with fat. The chin can also be augmented with results similar to those achieved using alloplastic implants.

Reconstruction

Fat grafting may be used for patients with hemifacial microsomia/atrophy, craniofacial anomalies such as Treacher Collins’ syndrome, traumatic defects, post-radiation changes, and post-surgical defects from both cancer resection as well as aesthetic procedure complications such as excessive fat removal from the neck, face, or eyelids. An example is the flattening of the posterior jaw line that often occurs after facelifts, which can be augmented with fat to restore normal contours. In addition, the upper and lower eyelid hollowing that is often seen post-blepharoplasty can be restored with the judicious use of fat grafts in these areas.

Lipoatrophy

Drug-related lipoatrophy secondary to anti-retroviral medications can be corrected with structural fat grafting, restoring a more normal facial architecture and eliminating the obvious stigmata of the disease. This is usually a result of loss of volume in the temples and in the buccal cheeks.

Operative technique

Pre-operative preparation

An extensive facial analysis using the patient in front of a mirror, photos of the patient at a younger age, and photos taken during a two-part consultation is performed for every structural fat grafting patient. The photos of the patient at a younger age are extremely helpful in determining the patient’s anatomy during youth and can be used as a springboard for discussing the desired goals of the patient. The ultimate goal is to reverse or change the undesirable aspects and make the patient look more as they did when they were younger, rather than different. Occasionally, the patient’s objective is to look different, which needs to be discussed and a clear objective developed. A tracing of the patient’s face is made during the consultation and this is used to plan the exact placement of the fat grafts as well as the incisions and the harvesting sites. Age appropriate blood work and medical clearance is performed prior to procedures done under general anesthesia. On the day of surgery, the tracing is used as a guide to place precise markings on the face for fat placement.

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