Introduction

History

The first report of fat grafting was in 1893 by German surgeon Gustav Neuber¹ when he transplanted adipose tissue harvested from the arm to correct a depressed facial scar that had resulted from osteomyelitis. This was followed 2 years later by Vincenz Czerny, who transferred a fist-sized lipoma from the buttock to the breast.² Even then, fat grafting was considered difficult, time consuming to perform, and somewhat unpredictable; therefore new solutions were sought.

The use of paraffin to correct deformities had been described in 1830 by Baron Karl von Reichenbach. By the late 1800s, Robert Gersuny and Leonard Corning were using paraffin either injected alone, with petroleum jelly, or with a combination of petroleum jelly and olive oil, into facial defects. Initially, the paraffin and petroleum jelly filled in soft tissue defects nicely, providing a soft, natural appearing contour. It appeared to be an easy remedy for numerous deformities; but unfortunately, after a time, complications such as paraffinomas, or hard local swellings, began to emerge. Thus paraffin lost favor within the medical community.

Looking for a solution to the problems caused by paraffin, Eugene Holländer proposed the use of fat injected through a cannula to correct deformities.^3,4 He noted considerable reabsorption of the fat and therefore began mixing human fat with fat from a ram in an attempt to stabilize it. This resulted in a painful rash which lasted several days, however a good cosmetic result was obtained. Later, in 1919, Erich Lexer published a two-volume book dedicated to the technique of fat grafting.⁵ In this book, he presented a wide variety of conditions such as depressed scars, breast asymmetry, knee ankylosis, tendon adhesions, and micrognathia and the successful results after treatment with fat grafting. Charles Miller also described the injection of transplanted fat for the correction of facial folds and wrinkles in his 1926 publication, Cannula Implants and Review of Implantation Technics in Esthetic Surgery.⁶ Despite some favorable results from these pioneers, fat grafting was still unpredictable and it thus fell out of favor.

It wasn’t until the 1950s when Lyndon Peer studied the gross and microscopic appearance of transplanted fat that we began to understand and improve the predictability of fat grafting.⁷ He discovered that adipose grafts lose approximately 45% of their weight and volume at 1 year due to cell rupture and subsequent death. The fat cells that do not rupture, however, will survive and volume will be maintained. Improper handling of the fat prior to and during transplantation was also found to decrease the survival of the fat. Graft size also appeared to play a role in survival. A graft the size of a walnut was found to lose volume more rapidly than multiple smaller grafts of similar weight, likely due to the increased surface area of the smaller grafts. Revascularization, as seen microscopically, was noted by Peer to be essential for fat graft survival.

With the advent of liposuction in the 1980s by Fournier⁸ and Illouz,⁹ there was a renewed interest in fat grafting. Results, however, were only partially successful and the thought at the time was that perhaps better preparation of the fat was essential for its survival. Chajchir¹⁰ and Benzaquen took this advice and made some recommendations based on their own favorable results; yet there was still great confusion as to what really worked until the 1990s, when Coleman standardized the technique. This technique, called Lipostructure®, emphasizes gentle extraction of fat, centrifugation, and micro particle injections in multiple tissue planes. Dr Coleman has used this technique for more than 20 years and has documented the longevity and stability of fat grafting performed in this manner.^11–14

Aging and atrophy

What is the process by which we age?²³ Our concepts of how the face and body change with time are evolving, and the traditional ways of thinking about the problems and their solutions are being modified. We have been taught that over time, there is loss of elasticity of the tissues which results in descent and sagging of the skin. In the face, our traditional response to the descent has been to resuspend the tissues and to remove the excess skin. What we have ignored is the reason for the descent in the first place. While there are obvious environmental and genetic components to aging, one of the main reasons that the tissue starts to sag is lack of support, or lack of volume beneath it. One component of this volume is fat, but there are also components including collagen, elastin, hyaluronic acid, etc. that are involved. The goal then should be to replace the missing fullness, which will support and reposition the skin. In most cases, the body supplies us with a significant source of filling material to restore the volume lost with aging in the form of fat. There are, of course, limitations as to the ability of volume to support the overlying tissues. If there is a tremendous amount of sagging or excess skin, then manual resuspension and trimming may be necessary.

The easiest way to analyze a face to determine how it has changed is to study photographs of patients when they were younger compared to their current state. Depending on the degree of aging, one can often easily see that as the face ages, typical patterns emerge. The model shown in Figure 14.1 exemplifies the changes that occur, from left to right, going from age 20 to 50 to 70 years.

Fig. 14.1 Model of aging. From left to right in each row: (A,D) 20-year-old, (B,E) 50-year-old, and (C,F) 70-year-old.

The 20-year-old model (Fig. 20.1A,D) has a full, smooth face. Her temples are flat and her brow and glabella are unfurrowed. Her upper eyelids are full beneath the brow and there is a short distance between the ciliary margin and the lid crease. The lower eyelids are smooth and there is minimal hollowing medially. Her cheeks are round with the zygomatic arches well covered with soft tissue. There is a slight hollowing in the buccal cheek, but she does not look gaunt. She has mild nasolabial folds compared with her full cheeks, but she does not have deep folds or creases within the folds. The lips are full, pouty and everted and the lower lip is slightly larger than the upper lip. Her jaw line and chin are well-defined and smooth.

As we move from left to right in this model of aging, we have a 20-year-old followed by a 50-year-old and finally a 70-year-old. As we go across, we see hollowing of the temples with skeletonization of the area. Wrinkles become more and more obvious in the forehead and glabella secondary to loss of youthful fullness over areas of muscular activity, especially in the glabella. The fullness that was previously present beneath the brow is now diminished and the upper eyelids appear to either collapse and fold anteriorly or collapse posteriorly to reveal the hollow orbit. There may be a real excess of skin, but there may also be merely the illusion of excess skin that disappears when the volume is restored. The lower eyelids begin to deflate, making the orbital rim more apparent and elongating the lid-cheek junction. The tear trough extends diagonally into the anterior cheek, breaking up the continuous line of cheek fullness and accentuating the nasolabial folds.

The zygomatic arches lose their soft tissue covering to reveal the bony outlines beneath and hollow buccal cheeks. The vermillion of the lips becomes thinner and thinner with time and the lips begin to invert, which accentuates the length of the cutaneous upper lip. The anterior chin becomes less well-defined and more rounded like one button instead of two defined mounds with a central cleft. As volume and support is lost along the posterior aspect of the jaw line, the mandibular border becomes less well-defined and wavy, and the lower face slides forward to accentuate the jowls and perimental hollows/pre-jowl sulci.

Diagnosis, patient presentation, indications

Patients who desire fat grafting to the face will present for numerous different reasons. One of the most common reasons is aging. These patients are generally over 40 years of age and present with loss of facial fullness, resulting in skin laxity, wrinkles, or a gaunt, skeletal appearance. As volume is restored to their face, their appearance will begin to resemble their younger photographs.

The younger patient who presents for facial fat grafting is generally one who is unhappy with a facial feature such as the cheeks, chin, or jaw line. These patients can benefit from fat grafting to augment these deficient structures in a manner similar to bone grafts or solid implants. The facial proportions can be significantly altered to create a more aesthetically pleasing balance.

Patients may also present for facial fat grafting for corrective purposes. This includes patients with congenital deformities such as hemifacial microsomia and Treacher Collins syndrome. In addition, patients who have sustained previous trauma resulting in significant scarring or tissue loss can often benefit from fat grafting.²⁴ Patients who have undergone previous facial cosmetic surgery often present with iatrogenic deformities such as hollow upper and/or lower eyelids and flattening of the posterior jaw line. These areas can be restored to a more youthful and natural appearance with fat grafting.

Facial atrophy from etiologies other than aging^25,26 have been increasing over the last few decades, especially drug-related lipodystrophy seen in patients taking antiretroviral and protease inhibitor therapies. These patients often present with a maldistribution of not only facial fat but also body fat. While an excess of fat may appear as a dorsal hump on the upper back/lower neck, the face usually appears hollow in the temples and buccal cheeks, creating an appearance pathognomonic for the drug-related lipoatrophy. Fat can be removed from the dorsal hump by suctioning, but should probably not be used for grafting purposes, as it could have an unusual growth pattern.

What happens to the hands over time that will give away the age of the patient if the face does not? Again, there is a loss of volume, or soft tissue coverage over the veins and tendons of the dorsal hand. The hands of a 20-year-old are generally smooth and full, with the extensor tendons and dorsal veins barely visible. There is naturally little fat over the dorsum of the hands, but with thinning of the skin and loss of interosseous muscle fullness, the hands can take on a wasted appearance that can be reversed with fat grafting. Fat grafting not only restores a subtle fullness to the dorsal hand, but appears to thicken the skin as well, which partially obscures the tendons and veins so obvious in aging skin.²⁷

Related posts:

Technology innovation in plastic surgery Cleft and craniofacial orthognathic surgery Managing the cosmetic patient Free TRAM breast reconstruction Facelift Facial transplant

Stay updated, free articles. Join our Telegram channel

Join