Patients with significant facial atrophy and age-related loss of facial fat generally achieve suboptimal improvement from both surface treatments of facial skin and surgical lifts. Restoring lost facial volume by fat grafting is a powerful technique that is now acknowledged by most plastic surgeons and other physicians engaged in treating the aging face as one of the most important advances in aesthetic surgery. Properly performed, the addition of fat to areas of the face that have atrophied because of age or disease can produce a significant and sustained improvement in appearance that is unobtainable by other means.
Key points
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Fat grafting areas of the face that have atrophied with age can produce a significant and sustained improvement in appearance and improved outcomes in facelift procedures.
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Fat grafting provides for volumetric rejuvenation, which is a new and different means to improve facial appearance, and a new dimension for plastic surgeons to work in.
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In addition, fat grafting may induce an improvement in facial tissue quality through an as-yet undefined stem cell effect.
The aging face and the need for fat grafting
Recognizing the changes that occur as the face ages and appreciating the underlying anatomic problems responsible for them is essential to properly advising patients and planning surgical procedures. In most patients, problems will fall into in 3 general categories:
- 1.
Aging and breakdown of the skin surface
- 2.
Tissue sagging, skin redundancy, and loss of youthful facial contour
- 3.
Facial hollowing and atrophy
Skin care and skin resurfacing procedure address changes in the first category. Traditional lifts of the face, neck, forehead, and eyes address the second. Fat grafting allows clinicians to treat atrophy, something they were previously unable to do, and is now acknowledged by plastic surgeons and other physicians engaged in treating the aging face as the most important advance in aesthetic surgery in several decades or more. Properly performed, the addition of fat to areas of the face that have atrophied because of age or disease can produce a significant and sustained improvement in appearance that is unobtainable by other means. All things being otherwise equal, simultaneous facelift and fat grafting produce a better result than either technique performed alone, and when a facelift is performed in conjunction with fat grafting both loss of contour and facial atrophy can be corrected, and optimal improvement can be obtained ( Fig. 1 ).
The aging face and the need for fat grafting
Recognizing the changes that occur as the face ages and appreciating the underlying anatomic problems responsible for them is essential to properly advising patients and planning surgical procedures. In most patients, problems will fall into in 3 general categories:
- 1.
Aging and breakdown of the skin surface
- 2.
Tissue sagging, skin redundancy, and loss of youthful facial contour
- 3.
Facial hollowing and atrophy
Skin care and skin resurfacing procedure address changes in the first category. Traditional lifts of the face, neck, forehead, and eyes address the second. Fat grafting allows clinicians to treat atrophy, something they were previously unable to do, and is now acknowledged by plastic surgeons and other physicians engaged in treating the aging face as the most important advance in aesthetic surgery in several decades or more. Properly performed, the addition of fat to areas of the face that have atrophied because of age or disease can produce a significant and sustained improvement in appearance that is unobtainable by other means. All things being otherwise equal, simultaneous facelift and fat grafting produce a better result than either technique performed alone, and when a facelift is performed in conjunction with fat grafting both loss of contour and facial atrophy can be corrected, and optimal improvement can be obtained ( Fig. 1 ).
Volumetric rejuvenation, tissue integration, and stem cell effect
Fat grafting provides volumetric rejuvenation; a new and different means by which to improve facial appearance, and a new dimension for plastic surgeons to work in. Unlike nonautologous injectables, fat integrates with facial tissues, becomes part of the face, and produces an arguably more natural-appearing, sustained, and long-lasting improvement. In addition, fat grafting may induce an improvement in facial tissue quality through an as-yet not clearly defined stem cell effect, and when performed with a facelift may constitute, for the first time, rejuvenation in the true sense of the word.
Drawbacks of fat grafting
Performing fat grafting in conjunction with a facelift has certain disadvantages, including the learning curve associated with any new procedure, an increase in operating room time, increased post operative edema, a longer period of recovery, and uncertainty of graft take. Certain patient misconceptions misconceptions will also encountered and will have to including misguided beliefs that injected fat can migrate or fall, or that fat grafting makes the face look fat.
Why not just graft fat?
Age-related loss of facial fat rarely exists as an isolated event and thus patients troubled by it are rarely logically or appropriately treated by fat grafting alone. Isolated fat grafting is also of questionable benefit to patients troubled by significant facial sagging and skin redundancy. Although aggressive filling of the sagging face with fat can produce improved contour and a smoother-appearing skin surface, it generally results in an unusually large, overfilled face that appears both unnatural and unfeminine. Such an overfilled face is difficult to correct in an attractive manner at a later date, and it is both more logical and practical to perform fat grafting in conjunction with formal surgical lifts if needed, or at some time after ptotic tissue has been repositioned and redundant tissue has been removed. Our contemporary concept for facial rejuvenation can thus be summarized as one in which surgical lifts are used to reposition sagging facial tissues and reduce the size of the facial skin envelope, and fat grafting is then used synergistically, but more appropriately and effectively, to restore areas that are truly volume depleted.
Where should the fat be injected placed?
Areas in need of treatment vary from patient to patient, and planning a fat grafting procedure requires looking at the face in a different way; more as a sculptor and less as a tailor as surgeons have done in the past. Any area successfully treatable with nonautologous injectable fillers is potentially treatable with fat grafting, including, but not limited to, the temples, forehead, brow, glabella, radix, upper orbit (upper eyelid), lower orbit (lower eyelid), cheeks, tear trough, midface, lips, perioral, stomal angles, nasolabial crease, geniomandibular groove (GMG), jawline, chin crease, submental crease, and chin areas, and personal experience with fillers is a useful point of reference for planning fat additions to the face. In time, and after engaging thoughtfully in study of the aging face, surgeons will gain a deeper appreciation of facial atrophy and an increasing desire to correct it. Fig. 2 shows a patient before and after facelift and fat grafting, and the areas where fat was placed.
Sequencing fat grafting with other procedures
Although there is no consensus on when fat grafting is best performed during facelift surgery, as a practical matter it is most expedient to inject fat at the beginning of the procedure, before the facelift has been performed. The reasons for this include that it is easier to harvest the fat at the beginning of the procedure before the face has been prepped or draped and when the patient is typically in a deeper plane of anesthesia. In the beginning of the procedure the tissue planes of the face have also not been opened, the face is not swollen, and preoperatively made pen marks and facial landmarks are easier to identify. In addition, surgical principles suggest that it is best to limit the time the graft is out of the body. However, perhaps the most important reason to do the fat grafting first is that surgeons are more technically and artistically energetic in the morning, and do a better job than if the procedure is performed at the end of a long facelift procedure.
Logistics of simultaneous facelift and fat grafting
Fat grafting is often mistakenly thought to be a simple procedure that can be performed in a few minutes, but this is rarely the case, and such an attitude leads to frustration, disruption of workflow, and poor outcomes. For the procedure to be successful, fat must be harvested in a specific time-consuming manner and it must then be processed and infiltrated in a technically demanding and time-consuming process. Fat grafting is also an artistically demanding activity that requires a considerable amount of the surgeon’s creative energy. When anything other than a few small areas of the face are being treated the procedure can easily encompass an hour or more, something that can overburden a surgical team already engaged in a long and demanding facelift operation consisting of multiple procedures. Time must therefore be planned and allocated accordingly.
Fat injection technique
The basic technique for fat grafting has been described previously, and the principles set forth by Coleman are observed when fat grafting is performed.
Needed Equipment
Special instruments are required for fat harvest and injection ( Fig. 3 ), in addition to a few other pieces of equipment used to process and organize the fat ( www.tulipmedical.com , www.mentorwwllc.com ). Other than for intradermal injections, sharp hypodermic needles should not be used to inject fat because fat embolization and serious related problems, including tissue infarction and visual impairment and blindness, can occur.
Choosing a Fat Harvest Site
At present there is no scientific consensus as to what is the best site to harvest fat from for fat grafting procedures. Harvest sites are typically chosen and marked in a manner to improve the patient’s figure, although the ideal locations are arguably fat collections resistant to diet and exercise. For women this is typically the hip, outer thigh, or abdomen, and for men the love-handle and spare-tire areas. In thin patients, small harvests from multiple areas are required, and additional time must be allotted for this in the procedure. It is prudent for the sites marked for harvest to be photographed preoperatively to document what was agreed on, and to avoid any disagreement over the preoperative condition of fat harvest sites after surgery.
Preoperative Marking of the Face
Fat grafting cannot be performed casually, and deficient areas and key landmarks must be marked preoperatively with the patient in an upright position. Marking requires concentration and focus, and is best performed in an area that is private and free from distractions. Creating a proposed plan on a full-page laser print of a photograph of the patient’s face is helpful in organizing the treatment plan, and facilitates confirming with the patient the areas that will be treated. If patients wish, marks can be made while they hold a hand mirror. Once markings are complete, a new series of photographs are taken and printed up for use during the procedure. These photographs typically provide the best information to the surgeon during surgery.
Anesthesia
Well-performed facelifts are time consuming and technically demanding undertakings, and the addition of fat grafting to the procedure strains the patience and composure of most surgeons. As such, it is highly recommended that the services of an anesthesiologist or competent certified registered nurse anesthetists be enlisted when combined facelift and fat grafting procedures are performed.
Except in cases in which it is contraindicated, our facelifts are performed under deep sedation administered by an anesthesiologist using a laryngeal mask airway. This strategy allows patients to be heavily sedated while maintaining control of their airways, and the patients need not receive muscle relaxants and can be allowed to breathe spontaneously. Heavily sedated patients are also much easier to harvest fat from and comprehensively treat, especially when harvest needs to be made from multiple sites.
Harvesting Fat
Although the primary goal of fat harvest is to obtain the best tissue for the fat grafting procedure, fat harvesting should be thought of as an opportunity to improve the patient’s figure, and as such harvest must be undertaken in a thoughtful and artistic manner and generally in a bilateral and symmetric fashion.
Thin patients should be examined at the time of their consultation because patients with limited fat stores often present significant challenges, and extra time and effort are required to obtain fat from them. Anesthesia and operating room times, and the surgeon’s fee, must be calculated accordingly.
The abdomen is often cited as the best and most convenient site for fat harvest but when comprehensive treatment of the face is planned (or when the dorsum of the hands are being simultaneously treated), the amount of fat needed cannot always be readily obtained from the abdominal area alone. The abdomen also typically has thinner, less forgiving skin than the hip, waist, and outer thigh (especially in aged patients having facelifts), and is readily open to detailed inspection by the patient after the procedure. As such, it can be problematic as a sole donor site in many cases if more than a small amount of fat is needed. In contrast, the hip, waist, and outer thigh taken together typically provide more volume, are less subject to surface irregularities caused by poor skin contraction, and fat harvested from these areas generally provides more overall improvement in the patient’s silhouette, and are therefore the primary harvest sites of choice in our practice.
An estimate should be made as to the amount of fat that will be used and thus the amount that needs to be harvested before fat harvest is undertaken. Smaller fat grafting procedures generally require 15 to 30 mL, intermediate procedures 30 to 50 mL, and comprehensive procedures can encompass the placement of 50 to 100 mL (occasionally more) and harvest must be made accordingly. In estimating the amount that needs to be harvested, a helpful guideline is that after centrifugation approximately 50% of what was harvested will on average be available as usable processed fat. If the clinician wishes to perform the fat grafting procedure predominantly with stem cell–rich fat (the bottom 2 mL of fat in the centrifuged 10-mL syringe, consisting of high-density adipocytes) only 20% of what is harvested fat will be available for injection and the total amount harvested must be adjusted accordingly.
As in the case of formal liposuction, the patient’s torso must be marked preoperatively while the patient is standing if optimal contours are to be created and if irregularities are to be avoided at the harvest sites. Once markings are complete, marked areas should be photographed and the photographs printed for use during the harvesting part of the procedure.
Fat is harvested after anesthesia is initiated but before prep and drape of the face. A complete prep of the torso is not necessary and in all but unusual cases a limited prep of the marked area is made and a sterile field is established. If fat is to be harvested from the hip or lateral thigh, the patient is turned into a semilateral decubitus position; prep, drape, and harvest performed; and the patient then turned to the opposite side, where a similar procedure is performed. If the patient is positioned carefully, this position can be used to simultaneously harvest fat from multiple sites, including the hip, waist, flank, upper buttocks, outer and inner thigh, and knees ( Fig. 4 ). With practice, a well-organized operating room team can complete this process expeditiously without undue delay of the overall procedure.
Areas from which fat is to be harvested are infiltrated with a dilute 0.1% lidocaine with 1:1,000,000 epinephrine solution using a multiholed infiltration cannula ( Fig. 5 ), and an adequate time allowed for a proper anesthetic and hemostatic effect. Approximately 1 mL of this solution is injected for every 3 mL of anticipated fat removal. It is not necessary or desirable to infiltrate tumescent fashion because overwetting the tissue results in an overdilute harvest and more time spent in the harvesting process. Local anesthetic should be injected even if general anesthesia is used to limit stimulation of the patient and the overall amount of general anesthetic used.
Fat is harvested with a special harvesting cannula (see Fig. 5 ) ranging in size from 2.1 to 2.4 mm, and 15 to 25 cm long, attached to a 10-mL syringe using gently applied syringe suction to minimize vacuum barotrauma to the tissue. Sharp hypodermic needles should not be used. In general, and as mentioned previously, at least twice as much fat is harvested as is anticipated will be used to ensure that an adequate supply of processed fat will be available for use on the face.
Once fat harvest is complete, the stab incision used to obtain the fat is closed with a simple interrupted suture of 6-0 nylon. The harvest site is then washed free of prep solution and the sutured site dressed with a TegaDerm™ dressing.
Processing Harvested Fat
Harvested fat is generally not uniform in character and concentration as extracted and some type of processing is necessary to obtain uniform material for injection. Although fat can be separated from blood and local anesthetic using a tea strainer–type sieve or rolling it on Telfa™ gauze, most of the stem cells, growth factors, and chemical cellular messengers are likely to be lost when this is done. Centrifugation conversely allows separation of the oil (ruptured fat cells) and water (blood and local anesthetic) fractions from the fat cells while simultaneously concentrating these other potentially important components, and has been our favored method of fat processing for almost 2 decades.
Before centrifugation is commenced, a sterile disposable plastic cap is placed on the end of the syringe to keep its contents inside it, and the syringe plunger removed from the syringe barrel. Capped syringe barrels containing unprocessed fat are then loaded into the centrifuge in a balanced fashion and spun for 1 to 3 minutes at 1000 revolutions per minute (RPM). Many centrifuges available for this purpose have variable speed adjustments and rotors that can be sterilized so that the syringes containing the fat remain sterile and can be handled by the scrubbed surgical team. Others centrifuges have sterilizable tubes that fit into the rotor for this purpose ( Fig. 6 ).
The typical spin speeds of approximately 3500 RPM used by most single-speed desktop centrifuges sold for fat processing are said to not cause injury to fat, or compromise its take.
Once centrifuged, syringe barrels containing spun fat are removed and centrifuged fat is seen to contain an upper oil (ruptured fat cells), central fat, and lower water (blood, lidocaine) components ( Fig. 7 ).
The often blood-tinged water (local anesthetic) component is discarded by simply removing the syringe tip cap and allowing it to run out. The oil fraction is then poured off from the top of the syringe. Telfa™ sponges can also be placed inside the syringe barrel to wick up the small amount of residual oil present after most of it has been poured off (cotton sponges should not be used because fat would be contaminated with microscopic inflammatory fibers). A laboratory test tube–type rack to hold and organize the syringes containing fat greatly facilitates fat processing activities ( Fig. 8 ).
Injecting Fat
After centrifugation and the separation and discarding of the resulting oil and water components has been accomplished, the resultant fat is transferred into 1-mL Luer lock syringes using a transfer coupling ( Fig. 9 ), because proper infiltration of fat requires injection in very small amounts that cannot reliably be made with 10-mL, 5-mL, or even 3-mL syringes. The bottom 2 mL of fat in the syringe containing the highest concentrations of high-density adipocytes (or adipose-derived regenerative cells) are segregated and are used preferentially in the procedure and for critical areas (orbits, lips, and tear trough). If an adequate overharvest is made, enough high-density fat will be obtained for the entire facial fat grafting procedure.
Nerve blocks are then performed with 0.25% bupivacaine with epinephrine 1:200,000 local anesthetic solution. It is typically not necessary to directly infiltrate areas to be treated with local anesthetic in patients having facelifts if nerve blocks are properly performed and adequate sedation has been administered.
Once nerve blocks have been administered, 0.7-mm, 0.9-mm, and 1.2-mm (22-gauge to 18-gauge) cannulas are used to infiltrate fat into the face through small stab incisions made in the facial skin with an 11-blade scalpel or a 20-gauge needle. These incisions are so small that they do not require suturing on completion of the procedure.
Infiltration is made in multiple passes, injecting on both the in and out strokes in planes appropriate for the area being treated, usually from 2 separate injection sites, and feathering into adjacent areas. Injecting from 2 separate injection sites allows crisscrossing of cannula passes during graft placement, provides smoother fat infiltration, and helps avert a row-of-corn effect that may result if injection is made from only 1 site.
How much should be injected?
Deciding how much fat needs to be injected at a given site requires empirical information and the surgeon cannot simply rely on what is seen in the operating room. In most cases the amount needed exceeds what intuition and direct observation suggest and it is best decided preoperatively based on the degree of deficiency seen in the preoperative photographs. As a practical matter, there is an empirical range and a small, medium, and large treatment within that range applicable to each site. For small problems, a volume at the low end of the empirical range is used. For medium-sized problems, a volume in the midrange is chosen. For large problems, an injection volume at the high end of the range is used.
How Is the fat injected?
As the cannula is advanced, tissue resistance is felt for, and if resistance is felt a small injection is made. Approximately 0.5 mL or less should be injected per pass, which corresponds with 20 to 40 back-and-forth passes or more for each 1-mL syringe of processed fat. If tissue resistance is not felt as the injection cannula is advanced, this indicates that a pass and injection has likely already been made in that area, so injection is not made and the cannula is directed to another area. The goal is to inject the fat in a way that optimizes its chances of developing a blood supply and surviving, and the mental model should be one of scattering tiny particles of fat into the recipient site in multiple crisscrossing fine trails in such a way that each particle sits in its own compartment and has maximal surface contact with perfused tissue. If fat is injected in a bolus, fat cells will be clumped together and only those on the periphery of the injected area will have tissue contact and be likely survive. Most of the more centrally situated fat particles will only have contact with each other, will be less likely to survive, and can lead to the formation of oil cysts. Put in more practical terms, the procedure should be thought of as analogous to spray painting and not caulking.
Advancement and withdrawal of the injection cannula is typically made slowly by the beginning injector, but, as familiarity with the technique is acquired, the movements can and should be made faster. Ultimately, all other things being equal, faster movements are desirable in that, if the injection cannula is constantly in motion, intravascular injection is less likely, and the likelihood that an accidental bolus injection into one area will be made is reduced. Rapid back-and-forth movements also ensure the smoothest and most uniform infiltration of fat.
How the syringe is held is also important in avoiding overinjection and controlling the volume injected with each pass. If the syringe is held in the manner that would traditionally be used to give an injection, with the thumb on the end of the syringe plunger, it is easy to inject too much fat if tissue resistance changes or injection cannula resistance suddenly decreases. More control can generally be maintained, and overinjection more easily avoided, if the syringe is held with the end of the plunger in the palm of the hand ( Fig. 10 ). Held in this manner, a slight closing of the hand results in a small amount of fat only being expressed from the cannula, and overinjection of any area can more readily be avoided.
Related posts:
History of Fat Grafting
Adipose Tissue and Stem/Progenitor Cells
How Does Fat Survive and Remodel After Grafting?
Update on Cryopreservation of Adipose Tissue and Adipose-derived Stem Cells
Gluteal Augmentation with Fat Grafting
Fat Grafting for Treatment of Burns, Burn Scars, and Other Difficult Wounds
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