Enhancing Facial Contours: Fat Grafting for Temporal Region and Midface
Facial volume loss, affecting both bony and soft tissues, can lead to a concave facial contour, hollowness, and sagging skin, resulting in an aged appearance. While autologous fat grafting is a widely accepted method for augmenting soft tissues, there is no consensus on the specific technique for fat grafting, including the entry site for the cannula and the plane for fat placement.
Different fat grafting techniques have been developed, such as the Coleman technique, 3M3L technique, cell-assisted lipotransfer, and nanofat grafting, focusing on harvesting, refining, and grafting skills. However, long-term outcomes of fat grafting vary across recipient sites, particularly in the temporal region, which has shown lower satisfaction rates. The diversity in outcomes is likely due to the recipient sites' unique anatomical characteristics, which directly affect fat survival, risk of neurovascular injury, and fat tissue retention.
Considering these factors and anatomical studies of the temporal region, midface, and hand, this blog explores a targeted fat grafting technique, which emphasizes the restoration of the physiological distribution and volume of fat compartments using appropriate cannula entry sites and injection planes. Previous clinical studies conducted have demonstrated the effectiveness and safety of this technique in facial contouring, augmentation of temporal hollowing, and hand rejuvenation, suggesting its potential for other regions as well.
Preoperative Evaluation
Before undergoing surgery, each patient should undergo evaluations for general medical conditions as well as specific preoperative assessments, as listed below:
1. Preoperative Photos
Multiangles of standard photos, including frontal, lateral, 45-degree lateral, 90-degree lateral, head up, head down, and additional specialized angles, should be taken. These photos help to visualize the facial defects and guide the placement and thickness of the filler.
2. Three-Dimensional (3-D) Laser Scan and Volumetric Analysis:
Utilizing advanced technology, a 3-D laser scan and volumetric analysis can be performed to assess facial symmetry. Specialized software is used to analyze facial models, quantify volume discrepancies, and determine the precise quantity of fat to be injected.
3. Preparing Pathologic Soft Tissue Defects
In cases where patients have pathologic soft tissue defects, such as radiation damage or scleroderma, the skin may be tight or thin with limited elasticity. To improve the recipient space, patients may be instructed to stretch the skin using small vacuum instruments or other tools for a period of one to three months before the procedure.
4. CT Scans for Romberg Disease Patients:
Patients with Romberg disease may undergo CT scans during their initial visit. These scans help evaluate the degree of atrophy in the bone, muscle, and fat tissue, as well as assess the occlusion of their teeth.
Surgical Procedure
Before Liposuction
Patients are asked where they have excess fat and which areas they want to reduce. Elderly women often have excess fat in the belly, while younger patients may have fat harvested from the bilateral gluteal groove to lift the gluteal area and elongate the leg.
Fat Grafting: 3L3M Technique
The authors prefer manual or syringe suction for fat harvest, using a tumescent anesthetic fluid containing lidocaine and epinephrine. They use a 20-mL syringe for gentle suction, keeping air in the syringe to create less negative pressure. The authors may choose a suction cannula with multiple side holes of varying diameters depending on the purpose of filling.
After acquiring the fat, the authors wash it with saline to remove lidocaine, epinephrine, cell debris, and red blood cells. They allow the fat and saline mixture to settle, removing the clear liquid part and transferring the middle layer of fat into smaller syringes. The top layer of oil is used to lubricate the injection cannula. The entire procedure is controlled within a specific temperature range and time limit.
Before the fat grafting, proper recipient site preparation is done, including design considerations using 3D simulation or photos. The recipient site should not have been injected with other fillers within the past six months. The skin should be infection-free, without ulcers, and have good elasticity.
Temporal Hollowing Augmentation
Specific techniques, such as temporal hollowing augmentation, can use the targeted fat grafting technique. Before fat grafting, the temporal hollowing region is marked by 4 borders: superiorly, anteriorly, inferiorly, and laterally.
A small incision is made at the junction of the hairline and temporal line on the medial side of the head. An 18G blunt-tipped infiltration cannula is inserted through this incision and advanced along the surface of the skull until it reaches the loose areolar tissue layer.
Within this layer, the fat graft is placed in the upper and lower temporal compartments using a multiplane, multitunneling technique. The infiltration cannula is then withdrawn from the space beneath the superficial temporal fascia and further advanced into the subcutaneous fat layer in the temporal region. Precise grafting is done to the lateral temporal cheek fat and lateral orbital fat compartments to correct any skin irregularities caused by deep plane injection.
To achieve a round and convex facial contour, the infiltration cannula can also be inserted into the subcutaneous fat layer in the forehead to adjust the contour between the temporal and forehead regions. This technique allows for precise fat placement and contouring in the temporal area.
Incision: Midface Fat Graft
The recommended incision for the procedure is described in two options.
The first option is a paraoral commissure incision made on the lip mucosa, adjacent to the oral commissure, to minimize scar formation. The second option involves making a punch incision following the nasal labial fold using a 16G needle, followed by the placement of a small cannula to avoid scarring.
The recommended injection technique involves using an 18G cannula connected to a 1-mL syringe. The cannula is accurately placed beneath the lip mucosa or subcutaneously initially, and then used to place the autologous fat in different layers during subsequent procedures.
When placing fat in the deep fat compartment, the cannula is advanced between the mucosa and the orbicularis oris muscle, with the root of the canine tooth as a bony marker. The lateral part of the deep medial cheek fat compartment is approached by advancing the cannula close to the maxilla with guidance from the first molar tooth. The medial part of the suborbicularis orbital fat compartment is accessed by advancing the cannula along a trajectory connecting the first molar and the lateral limbus of the ipsilateral cornea.
Special attention is given to avoiding proximity to the maxilla when the cannula is around the level of the nasal ala. For augmentation of the middle and lateral cheek fat compartments, the cannula is directed to the lower one-third of the masseteric ligament where the fibrous structure is weak. An alternative incision in the sideburn region may also be used to prevent injury to blood vessels or nerves in the masseteric ligament.
See below the figure demonstrating targeted fat grafting for temporal hollowing augmentation. (From Xie et al, 2020)
Post-Operative Care
Following the procedure, a compression dressing is applied to the treated area and kept in place for 5 to 7 days. If patients are not satisfied with the initial augmentation outcome, a second surgical procedure can be performed after 3 to 6 months to further enhance the contour.
Expected Outcome & Complication Management
The targeted fat compartment volume restoration technique for fat grafting resulted in smoother and less concave curvilinear lines in the temporal region and midface. The procedure achieved a pleasing elevation of the anterior projection of the temporal region and midface.
Minor complications such as chronic edema, headache, and skin irregularity were observed but resolved without treatment. Overcorrection was the most commonly reported major complication, which can be treated with liposuction.
See below the figure showing the preoperative and postoperative photographs after fat grafting in the temporal region and midface. (From Xie et al, 2020)
Conclusion
Based on anatomic studies and clinical applications, the compartment-based fat grafting is proven to be a safe and effective procedure for facial contouring for temporal region and midface. Targeted restoration of facial fat compartments through fat grafting is able to achieve a natural and youthful appearance while avoiding complications. It identifies specific regions of the face, such as the temporal hollowing region and midface, where fat compartments are located. These compartments are divided into superficial and deep planes. A specific sequence is recommended for fat grafting, starting with the deep facial fat compartments followed by the superficial compartments, and proceeding from the medial to lateral parts and the upper to lower sides. Various neurovascular structures pass through these compartments. A unique entry site for fat placement in the temporal region and a multiplane, compartment-specific approach, is recommended for midface fat grafting. The paraoral commissure incision is suggested for accessing the compartments in the midface.
Reference
Fat Grafting for Facial Contouring (Temporal Region and Midface) (2020)
Fat Grafting for Facial Rejuvenation (2020)
The Science of Fat Grafting (2020)
Modern Fat Grafting Techniques to the Face and Neck (2021)
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