Facial Fat Grafting: Why, Where, How, and How Much?
According to Facial Fat Grafting: Why, Where, How, and How Much by Timothy Marten, Dino Elyassnia (2018), the importance of volume loss in the aging face is now well recognized and fat grafting has increasingly become an integral part of contemporary facelift procedures.
For optimal results, facial rejuvenation procedures should address both the tissue laxity and volume deflation associated with facial aging. The lift-and-fill face lift, in which fat grafting provides volumetric rejuvenation to the face while surgical lift effectively repositions and removes ptotic and redundant tissue, has revolutionized the plastic surgeon's approach to the aged face.
An understanding of the intricate anatomy of distinct facial fat compartments and a systematic method to assess areas of fat atrophy and volume depletion are keys to provide patients with a natural and youthful result. Fat grafting may be used to improve contour in any area treatable by nonautologous injectable fillers, including the temples, forehead, upper and lower orbit, cheeks, perioral region, nasolabial fold, jawline, and chin—with the benefit of a more natural contour and integration with native tissue.
Fat Grafting
Also referred to as fat transfer or fat injections, is the surgical process by which fat is transferred from one area of the body to another area.
Fat provides crucial structural support to the face. Therefore, age-associated soft tissue changes require both volume augmentation as well as resuspension of ptotic tissue and removal of redundant tissue.
The surgical goal is to improve or augment the area where the fat is injected. The technique involves extracting adipose fat by liposuction, processing the fat, and then re-injecting purified fat into the area needing improvement.
Why?
The skin of the periorbital area and specifically the tear trough region is thin and closely attached to the underlying orbicularis oculi muscle.
Fat grafting allows us to treat atrophy, something we have previously been unable to do, and stands as a powerful technique now acknowledged by most plastic surgeons and other physicians engaged in treating the aging face as the ‘‘missing link’’ and 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 due to age or disease can produce a significant and sustained improvement in appearance unobtainable by other means. When a facelift is performed in conjunction with fat injections, both loss of contour and facial atrophy can be corrected, and optimal improvement can be obtained.
Where?
Areas in need of treatment will vary from patient, and planning fat injections requires looking at the face in a different way and more as a ‘‘sculptor’’ and less as a ‘‘tailor’’ as we have done in the past.
Any area successfully treatable with non-autologous injectable fillers is potentially treatable with fat injections including, but not limited to, the temples, forehead, brow, glabella, radix, upper orbit (‘‘upper eyelid’’), lower orbit (‘‘lower eyelid’’), cheeks, mid-face, buccal recess, lips, perioral, nasolabial crease, geniomandibular groove, and jawline.
Perhaps the best way to decide where fat is needed is for the surgeon to study her or his facelift outcomes carefully and identify areas where the procedure has fallen short. In most cases, the biggest shortcoming for the experienced surgeon will be evident as the failure to replenish lost volume. In time, and after engaging thoughtfully in such study, one will gain a deeper appreciation of facial atrophy and an increasing desire to correct it.
How?
Fat grafting is often mistakenly regarded as a simple procedure that can be performed in a few minutes time, and this misguided perception is one of the major impediments to success that the surgeon trying to learn the procedure will encounter.
This is rarely the case, however, and such an approach will lead to frustration, disruption of work-flow, and poor outcomes. For the procedure to be successful, fat must be harvested in a specific gentle, atraumatic, time-consuming manner, and it must then be processed and infiltrated in a technically and artistically demanding and time-consuming process. Procedure involves preparation of fat grafting equipments, donor site selection, preoperative face marking, anaesthesia, harvesting fat, processing fat, injecting fat, determining amount to inject & injection technique.
Fat grafting is performed to deep and superficial fat compartments followed by superficial musculoaponeurotic system (SMAS) and platysma manipulation. Subsequent superficial fat grafting may be performed on the forehead, temples, tear trough, oral commissure, chin, and any other regions requiring volume augmentation.
When anything other than a few small areas of the face are being treated the entire 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 appropriately.
How Much?
Unless one is willing to submit to a long process of trial and error, deciding upon how much fat needs to be injected at a given site requires empirical information provided by others who have experience with the procedure and one cannot simply rely on what one sees in the operating room.
In general, there is a tendency to treat most areas too conservatively if amounts to be administered are decided by intuition and observation alone, and some ‘‘over-correction’’ is needed as not all the graft will survive. A prudent strategy for determining the amount of fat needed for a given site is to rate the severity of the degree of atrophy for each region of the face based on what is seen in the preoperative photographs and then to use empirical published data to choose the amount to be administered to each area.
As a practical matter, this amounts to simply rating or categorizing the severity of atrophy at each proposed site of treatment as ‘‘small,’’ ‘‘medium,’’ and ‘‘large,’’ and then using data published regarding range of amounts typically needed as a guide for treatment of each area. If the defect is ‘‘small,’’ one would choose an amount from the low end of the recommended range. If the defect is ‘‘large,’’ one would choose an amount from the high end, and if ‘‘medium’’ somewhere in between.
Conclusion
Facial aging is a complex and dynamic process that is the result of changes to the facial skin, skeleton, and subcutaneous soft tissue. An understanding of these changes is key to properly restoring natural, attractive, and youthful facial characteristics in facial rejuvenation procedures.
Despite what we thought in the past, ‘‘lifting’’ cannot correct all aspects of the aging change in the face and fat grafting allows treatment of age-associated loss of facial volume not addressed by face lift surgery. It comprises the ‘‘missing link’’ in facial rejuvenation, and it stands as the most important new addition to facelift surgery since the introduction of the SMAS technique.
Incorporating fat grafting into facial rejuvenation procedures is arguably more important that what facelift technique is used. Fat grafting may result in an improvement in skin quality mediated through a stem cell effect, and effect not only evident on the face but on the dorsum of the hands, the de ́colletage, and the neck.
In conclusion, these benefits may offset the drawbacks of increased operating time, uncertainty of graft take, and a longer period of recovery associated with the fat grafting procedure.
Reference
Facial Fat Grafting: Why, Where, How, and How Much by Timothy Marten, Dino Elyassnia (2018)
Fat grafting history and applications BY Ricardo Rodriguez, Baltimore (2015)
Fat Grafting for Facial Rejuvenation by Kelly P. Schultz, Anjali Raghuram, Matthew J. Davis, Amjed Abu-Ghname, Edward Chamata, Rod J. Rohrich (2020)
Learn skilled Liposuction, Harvest and Fat Transfer Techniques under Local Anaesthesia in our upcoming Liposuction & Fat Transfer for Face & Body Mini Fellowship (Hands-On) happening:
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Liposuction & Fat Transfer for Face & body under Local Anaesthesia
December 15-16, 2022 - Seoul, South Korea - [Register Now]
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Korean Non-surgical Aesthetic Injections: Lip Augmentation, Eye Rejuvenation & Facial Contouring
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