Introduction

With renewed interest in volumetric enhancement for facial rejuvenation, fat grafting is once again gaining popularity. It has been used successfully for soft tissue augmentation since 1893¹ and in 1909 Eugene Hollander described a technique to transplant fat using a needle and syringe.² In 1926 Miller claimed that grafting fat through hollow metal cannulas gave a more natural and longer lasting correction than paraffin.³ Soon after the introduction of suction curettage of body fat for contouring, Teimourian and Illouz described the injection of semi-liquid fat into liposuction deformities^4,5 and Chajchir described injecting suctioned fat into the face.⁶ Although some of the initial results were positive^7,8 many were not.^9,10 Illouz compared the longevity of grafted fat in the face to that of collagen.⁴ In the 1980s, many well-respected plastic surgeons denounced fat grafting based on negative results.^11,12 As techniques changed, more positive results were obtained and surgeons began to realize that grafted fat could result in long-lasting contour changes.^13–16 The technique developed by Coleman began in 1987 and evolved over the next few years to become a standard for fat grafting. It emphasizes basic sound surgical techniques with the gentle handling of tissues to make fat grafting predictable and reliable.

Indications and Contraindications

Fat Grafting For Facial Rejuvenation

The face of youth is full, soft and well defined. While traditional aesthetic facial procedures that involve cutting and pulling of the skin are sometimes beneficial, they do not replace the facial volume that diminishes with age. Fat grafting offers a permanent correction of the loss of volume that occurs over time. The idea of what is attractive will vary from culture to culture and person to person, but facial fullness is generally associated with youth. The attractive face, therefore, has a smooth brow and temples, full upper eyelids without excess skin, smooth lower eyelids, round but angular cheeks, minimal nasolabial folds, full lips, and a well defined chin and jaw line. The aging process results in predictable changes. With time, the temples begin to hollow and the upper and lower eyelids deflate, leaving behind either excess skin or hollowing of the orbit. A break occurs in the anterior cheek, flattening this area and accentuating the nasolabial folds, and the lips begin to invert. The anterior chin flattens and the jaw line becomes less defined and angular. The overall result appears as descent of the skin, but often by restoring the underlying volume alone, an apparent repositioning of the skin can be achieved. The use of photographs of patients at a younger age is extremely helpful in understanding the aging process and what is needed to restore a youthful face.

The cheek is a relatively easy area to visualize in three dimensions. The immediate, intraoperative results of cheek augmentation with fat are the most similar to what will be seen as the final result.¹⁷ This is a good area to begin learning and practicing making three-dimensional changes in the face. On the other hand, the lower eyelid is one of the most difficult areas for structural fat grafting. Irregularities, lumps, and excess fat can easily be seen through the thin eyelid skin when the swelling resolves. The lower eyelid should be approached with caution and only after gaining confidence in other more forgiving areas of the face.

Augmentation of the lips is a relatively simple procedure, but the anatomy of an attractive lip is often ignored and the lips are filled like tubes or sausages. A youthful, attractive upper lip has a distinctly protuberant white roll that tapers off from the Cupid’s bow and becomes less obvious laterally. Under the Cupid’s bow, the vermillion of the lip has a well-centered, distinct tubercle. The width of the upper lip comes from the less-distinct fullness laterally. Between the central tubercle and the lateral fullness, there is often a concavity or slight depression.

The lower lip has a slightly protuberant rim, which is less distinctive than the white roll of the upper lip. The fullness and depressions of an attractive lower lip are opposite to those of the upper lip, with a central cleft and more fullness laterally. The amount of vermilion visible is much greater in the lower lip than in the upper lip (Fig. 15.1).^18,19

Fig. 15.1 Facial aging example

33 year old woman who presented complaining that her lower eyelids were no longer smooth and that her right cheek was indented. Fat was placed into the lower eyelids and cheeks bilaterally. Preoperative photo (upper) and post-operative photo (lower) 2 years and 9 months after the procedure.

Fat Grafting for Change in Facial Proportion

The younger patient will present not with the typical signs of aging, but requesting a change in the contours of the face. The most commonly requested changes in facial proportion are for cheeks that are more prominent, full and angular; a chin that is more prominent anteriorly; and a mandibular border that is more angular and well defined. Again, the cheek is an easier place to start learning fat grafting. The natural cheek prominence should be identified as the malar prominence and the fullness should extend laterally toward the base of the helix. Some fullness should also be placed over the anterior cheek, creating a slight ‘apple’ effect.

Augmentation of the chin is accomplished by first placing fat over the entire anterior prominence of the mandible.²⁰ The shape of the chin is then sculpted by placing additional fat in two small balls, leaving a slight central cleft between them. This creates not only a more prominent chin, but also a shapelier chin.