The discovery of facial fat compartments and loss of volume in these compartments with aging has been well described. Both deep and superficial fat compartments lose volume, which contributes significantly to facial aging. The purpose of this chapter is to describe the authors’ approach to full facial revolumization and restoration of fat compartment volume using autologous fat.
13 Fat Grafting to the Face as an Isolated Procedure
Key Points
Detailed preoperative facial analysis is critical to accurately identify and correct facial asymmetry.
Key deep compartments include nasolabial and deep malar compartments. More superficial compartments include middle malar, superior cheek, temporal, perioral, and submental (Fig. 13.1 and Fig. 13.2).
Deep facial compartments are always restored first because they are the foundation of facial volumization (Fig. 13.3). Preoperative bony contour and distribution of fullness dictate the contour and volume of grafting.
Fig. 13.1(a) The superficial facial fat compartments are situated in the subcutaneous plane, partitioned by the terminal extensions of the retaining ligaments. The five superficial compartments of the cheek from lateral to medial are (1) lateral, (2) middle, (3) malar, (4) jowl, and (5) nasolabial. Each compartment has its own septal boundaries, a separate perforator blood supply, and its own tendency to deflation on aging. (b) Cadaver dissection of the facial fat compartments of the cheek. The inked compartment shown is the middle compartment. The red arrow marks the transition between the middle and malar compartments, which are separated by a high density of zygomatic ligaments along the lateral zygoma. (Reproduced with permission from Rohrich R, Stuzin J, Dayan E, Ross E. Facial Danger Zones. New York: Thieme; 2019.)Fig. 13.2 The deep facial fat compartments are situated deep to the mimetic muscles and superficial to the periosteum of the midface. The deep fat of the lower eyelid is located just deep to the orbicularis oculi and is divided into medial and lateral components. The deep malar fat similarly is situated deep to the elevators of the upper lip and is separated into medial and lateral components. In youth, the deep periorbital fat blends with the deep malar fat to volumetrically support the lower eyelid and cheek. Aging causes deflation of deep fat resulting in the loss of anterior cheek volume and an abrupt demarcation along the eyelid–cheek junction, and it contributes to the formation of the infraorbital V-deformity. (Reproduced with permission from Rohrich R, Stuzin J, Dayan E, Ross E. Facial Danger Zones. New York: Thieme; 2019.)Fig. 13.3 Four key midfacial fat compartments to address with fat grafting in facial rejuvenation procedures. (Reproduced with permission from Schultz K, Raghuram A, Davis M, et al. Fat grafting for facial rejuvenation. Semin Plast Surg 2020;34(1):30–37.)
13.1 Preoperative Steps
The facial rejuvenation procedure begins with a thorough preoperative analysis to identify areas of volume deflation and rhytides.
Areas of volume deflation as well as deep rhytides are marked preoperatively in the dependent position to facilitate intraoperative accuracy.
Careful donor site assessment and estimation of volume needed for volume restoration are key to a well-planned operation.
Discussion with the patient is important to manage expectations of donor site incision placement.
Fat is generally harvested from the medial thigh as this area contains the highest concentration of stromal vascular cells and is associated with the least amount of pain.
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