Facial Fat Grafting for Asians: 5 Key Steps
Fat grafting has become popular in facial rejuvenation, either alone or in combination with other facial lifting surgeries. Aging causes skin relaxation, loss of elasticity, volume reduction, and changes in fat distribution, leading to facial hollowness and wrinkles.
Traditional lifting surgeries often failed to achieve satisfactory results. Plastic surgeons now understand the importance of restoring soft tissue volume and improving skin texture through fat grafting. Overgrafting has been attempted to counteract fat absorption, but it can lead to complications.
In this blog, we will discuss the techniques to achieve successful fat grafting for facial rejuvenation, for long-lasting and satisfactory outcomes without severe complications.
Effective communication with the patient is crucial to understand their concerns and expectations fully. The principles of fat grafting, along with its therapeutic effects and potential complications, should be clearly explained to prevent unrealistic postoperative expectations and dissatisfaction.
Asian facial features and aesthetic standards differ from Caucasians, characterized by a low forehead, flattened midface, nose collapse, and chin retraction. In Asian aesthetics, a full forehead, raised nose and chin, and smooth, soft curves on the lateral face are considered charming and glamorous. Avoiding protruding zygomatic arch and mandibular angles is essential. Therefore, facial fat grafting is strategically performed in a "T"-shaped region to create an inverted triangle on the face.
See below the figure for T-shaped area of facial fat grafting. (Taken from Yang et al, 2020)
For patients under 35 years, fat grafting focuses on correcting congenital midface depression and enhancing lateral facial contours with soft curves. In patients over 35 years, improving skin texture is achieved by regenerating microparticle fat in the superficial layer of the face. The distribution and amount of grafting are personalized based on factors such as gender, age, facial contour, skin texture, and degree of skin laxity.
5 Key Steps of Facial Fat Grafting
1) Donor Site Selection and Assessment
Fat deposits from various parts of the body can serve as donor areas for surgical procedures. Some patients undergo surgery not only for facial rejuvenation but also to enhance their overall body shape. Therefore, the patient's expectations play a role in selecting the appropriate donor areas. If the goal is solely facial rejuvenation, using fat from the abdomen or thigh as donor sites is preferred for several reasons.
Firstly, liposuction and facial lipofilling can be conveniently performed in a supine position without altering the patient's posture. Secondly, obtaining fat grafts from these areas is relatively straightforward. Moreover, research suggests that the lower abdomen and medial thigh contain higher concentrations of adipose-derived stem cells. Additionally, the technique of assessing fat thickness through skin grasping proves to be useful in such procedures.
2) Fat Harvesting
The procedure is typically performed using intravenous or local anesthesia, depending on the amount of fat required. The incisions for liposuction are carefully concealed. An incision of 2 mm is made with a No. 11 blade after administering anesthesia with 2.0 mL of 1% lidocaine and 1:100,000 epinephrine. For infiltration anesthesia, a 2.0-mm diameter 9-hole cannula is used along with a tumescent solution comprising 490 mL normal saline, 10 mL 2% lidocaine, and 1 mL 1:1000 epinephrine. This solution is injected into the subcutaneous fatty tissue as the cannula moves back and forth, ensuring uniform penetration and loosening of fibrous connective tissue, which aids in subsequent liposuction.
See below the figure which shows a 2.0-mm diameter 9-hole anesthetic infiltration cannula. (Taken from Yang et al, 2020)
The tumescent technique is employed with a ratio of 3:1 for the tumescent solution to harvested fat, allowing for sufficient anesthesia and hemostasis by waiting at least 15 minutes before starting liposuction.
Fat is harvested through the same incisions used for the tumescent solution. Two types of liposuction cannulas with a 2.5 mm diameter and 9 side holes are utilized, each having different hole sizes (3.0 mm × 1.0 mm and 1.0 mm × 0.8 mm) for obtaining fat parcels of varying sizes. The macrofat is used for deep layer filling to provide structural support and volume augmentation, while the microfat is precisely applied to the superficial layer to counteract the effects of skin aging.
See below the figure which shows the two types of liposuction cannulas. (Taken from Yang et al, 2020)
During harvesting, a liposuction cannula attached to a 20-mL syringe is gently inserted into the incision, and fat grafts are obtained using anterior and posterior movements. To minimize mechanical trauma to the fat parcels, the plunger is gently pulled back at 2 to 4 mL, maintaining minimal negative pressure by locking it. In general, the amount of fat harvested should be at least twice the anticipated quantity to ensure an adequate supply for grafting purposes.
3) Fat Processing
Using mesh/gauze for fat processing effectively removes oily components and tumescent solution. Research indicates that fat obtained through the mesh/gauze technique contains more functional adipocytes and has better volume retention compared to the Coleman centrifugation technique.
After obtaining the lipoaspirate, it is transferred into 60-mL syringes through a connector. The aqueous portion is discharged, and normal saline is added twice to rinse the fat and remove blood, cellular debris, and any remaining tumescent solution. The fat is then placed on a metal filter with a thick cotton pad below for 15 minutes to absorb any aqueous and oil components through capillary action. Coarse fibrous tissues are manually removed to prevent cannula blockage. The purified fat is collected using 20-mL syringes and carefully transferred into 1-mm syringes through a connector. It is essential to graft the fat immediately to minimize air exposure.
4) Preparation of the Recipient Site
To reduce discomfort and pain during the awake procedure, an anesthetic block is administered, typically targeting supraorbital nerves, infraorbital nerves, and mental nerves using 1% lidocaine and 1:200,000 epinephrine. The recipient areas on the face are treated with tumescent solution (0.04% lidocaine with 1:1000,000 epinephrine) using an 18-G pointed needle and a 3-hole cannula. About 50 mL of tumescent solution is required to infiltrate the entire face.
See below the figure which shows a 7 cm in length, 1.0 mm in diameter and 3 side holes anesthetic infiltration cannula. (Taken from Yang et al, 2020)
This infiltration helps in vasoconstriction, lowering the risk of vascular embolism and reducing bleeding, which is beneficial for the survival of the fat graft due to decreased inflammatory response. To ensure proper judgment during the fat grafting process, it is important to press the areas just infiltrated by the palm to mitigate the effects of swelling.
5) Fat Injection
For fat grafting, blunt-tipped cannulas of 5 to 9 cm length and 1.0 or 1.2 mm diameter are employed. The crucial technique involves using microdroplets injected in multiple layers, starting from the periosteum to the subcutaneous layer. During injection, the cannula is withdrawn to avoid injecting into blood vessels. To control the injection pressure and prevent overinjection, the end plunger of the syringe is held in the palm of the hand.
For forehead fat injection, entry points are located at the edge of the hairline, with additional points at the eyebrow tail. Careful marking of the supraorbital vessels and supratrochlear vessels on the supraorbital margin is crucial. In the superior orbital margin range, fat should be placed subcutaneously rather than on the periosteum to achieve a natural transition. Elsewhere on the forehead, fat is placed on the periosteum for structural support to address volume loss. The total amount of fat grafts needed typically ranges from 5 to 20 mL, depending on the patient's inherent contour and depression.
For temple, eyebrow arch, and upper eyelid injections, entry sites are made at the eyebrow tail and at the junction of the temporal line and hairline. The areola space between superficial and deep temporal fascia is filled with fat to enlarge the temporal fossa. Care is taken to avoid damaging blood vessels and nerves while injecting fat in the area. Excessive fat injection in the temporal region can lead to overcorrection and increase facial width. Fat volume in the temple ranges from 3 to 15 mL on each side.
To address sunken upper eyelids, a 1.0 mm diameter blunt-tipped cannula is used. Eyebrows are pulled to maintain upper eyelid skin tension, and fat is injected below the orbicularis oculi muscle through the eyebrow tail entry point. About 0.5 to 2.0 mL of fat is needed on each side, and the subcutaneous layer should be avoided to prevent complications like bloated eyelids, difficulty in eye opening, and nodules.
The site of anterior cheek serves as an entry point for middle facial fat transplants, where the fat can be easily placed in the inferior lower eyelid, medial and lateral cheeks, and nasolabial fold. An additional entry point may also be made at the suborbital lateral margin as a supplement, allowing access to the suborbital region and anterior cheek regions. For correction of the palpebral cheek sulcus and palpebral zygomatic sulcus deformity, first the larger fat parcels should be deposited in the periosteum and suborbicularis oris fat layers along the inferior orbital rim as structural support, and then the microfat parcels should be meticulously placed in the subcutaneous to avoid irregular nodules.
When the cannula is closing to the lower orbital rim, the index finger of the nondominant hand should touch the inferior orbital rim to guide the cannula to inject the fat into the proper position and prevent the cannula from penetrating the eyelid conjunctiva and injuring the eyeball. A total of no more than 3 mL of fat is placed per side. Overcorrection in these areas is not recommended. Fat grafting in the anterior cheek is critical to facial rejuvenation; it provides highlight projection. This injection can be undertaken in all layers, including deep, middle, and superficial, through the entry points of the anterior cheek and suborbital lateral margin.
To smooth out the nasolabial fold, fat should be placed in multiple layers in a fan-shaped manner, especially in the Ristrow space of nasal alar basal region (Ristow B. Personal communication, 2001). The critical technique is infiltration of the areas around the folds rather than a linear placement that will aggravate the original creases. Avoid placing fat grafts in the superficial nasolabial fat pad, because the fat pad in this area is mainly displaced downward rather than reduced with age. On each side, 2 to 4 mL of fat is required.
For correction of the lateral cheek depression, the entry point is located at the leading edge of the sideburns. Fat should be placed on the surface of the masseter fascia and parotid gland, as well as subcutaneously, with special care to avoid injuring the deep important tissues. The volume placed varies from 5 to 15 mL in each cheek area.
For fat grafting in the lower face, entry points are selected on both sides of the mental edge to approach the chin, bottom of the lips, and lateral mandible easily. Additional entry points can be made as needed, such as the lateral of the oral commissure, for fat grafting to the upper and lower lips. Fat is placed in multiple levels of the chin, and aponeurosis tissue tightly attached to the periosteum can be stripped off with a blunt cannula to create space for fat survival. Increasing horizontal chin projection is crucial for patients with insufficient mental protrusion.
For areas with significant hollowing, fat grafting is needed on both sides of the chin. To correct the drooping mouth angle, volume restoration is done by placing fat into the deep layers under the orbicularis muscle. For effacement of marionette lines, fat is infiltrated around the wrinkles in a crossed manner, similar to the nasolabial fold.
If the effect of fat grafting alone is unsatisfactory, a combination of fat grafting, facial liposuction, and facial lifting surgery can be performed to achieve better aesthetic results. The amount of fat grafted in the lower face typically ranges from 3 to 10 mL per side, depending on individual needs.
See below the figure for entry points for fat grafting on upper, middle, and lower face. (Taken from Yang et al, 2020)
Fat grafting is a safe and effective method for facial rejuvenation. Understanding the mechanism and significance of volume loss in facial aging is crucial. By skilfully applying the strategies outlined in this blog, plastic surgeons can achieve satisfactory results in facial rejuvenation procedures.
Modern Fat Grafting Techniques to the Face and Neck (2021)
Fat Grafting for Facial Rejuvenation in Asians (2020) The Future of Facial Fat Grafting (2019)
Facial Fat Grafting: Why, Where, How, and How Much (2018)
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