History

With renewed interest in volumetric enhancement for facial rejuvenation, fat grafting is once again gaining popularity. Fat grafting has been performed successfully for soft tissue augmentation since 1893, when Neuber first introduced the technique. This was followed by Eugene Hollander, who in 1909 described a technique to transplant fat using a needle and syringe and Conrad Miller, who in 1926 claimed that grafting fat through hollow metal cannulas gave a more natural and longer lasting correction than paraffin. In 1986, after the introduction of body contouring by suction curettage, Teimourian and Illouz described the injection of semi-liquid fat into liposuction deformities and Chajchir described injecting suctioned fat into the face. Some of the initial results were positive,^1,2 however many were not^3,4 and in the 1980s, many well-respected plastic surgeons felt that fat grafting was unreliable and denounced the procedure. As techniques improved so did the results and surgeons began to realize that grafted fat could result in long-lasting contour changes.^5,6 The standard for fat grafting is now the Coleman technique, which emphasizes gentle handling of tissues to make fat grafting reliable and predictable.

Evaluation

Anatomy

The anatomy of an attractive face will vary depending on culture and personal preferences, but the face of youth is generally full, smooth, and well-defined. Most would consider an attractive face not only youthful, but also symmetric, proportional, and free of anything unusual or distracting, such as scars or growths. The ideal facial surface anatomy therefore begins with a smooth forehead and full temple. The upper eyelids should not have excess skin, but should have fullness beneath the brow and a short distance between the ciliary margin and the lid crease. The lower eyelids should have smooth skin and minimal hollowing. The lid–cheek junction should be relatively flat and not elongated. The cheeks should be round, but slightly angular and the buccal cheek should not be significantly depressed. Slight nasolabial folds may be present with a defined cheek mass, however deep folds or creases within the folds are not desirable. The lips should be full and well-shaped, with the lower lip slightly larger than the upper lip. The jaw line and chin should be well-defined and smooth.

With age, the temples begin to hollow and the upper and lower eyelids deflate. In the temples, this results in increased visibility of the bony skeleton. In the eyelids, not only does the bony orbit become more obvious, but there is also an apparent excess of skin. The anterior cheeks begin to flatten which accentuates the appearance of the nasolabial folds and the lips become thinner and invert. The anterior chin flattens and the perimental region loses volume, accentuating the presence of jowls. The jaw line becomes less sharply defined, giving a wavy appearance to the previously angular mandibular border.

As the loss of facial volume depletes further, the secondary effect is that of descent of the overlying skin. A comparison of photographs of the patient at a younger age gives us valuable clues as to the individual aging process and the goals for surgical rejuvenation. If there is tremendous descent of the facial skin, a skin tightening/repositioning procedure is often needed. If the descent is more moderate, however, often the restoration of the underlying volume alone can reposition of the skin and improve the facial contours.

Technical steps