Fat Transfer for Facial Volume Rejuvenation
For over a century, surgical physicians have utilized fat for the treatment of diseases affecting soft tissue, contour abnormalities and scars. Autologous fat transplantation has regained popularity in recent years for its use in facial rejuvenation, especially with the advent of tumescent anesthesia, which has facilitated accessibility to fat for transplantation. The procedure can be used to treat volume loss of the malar eminence, submalar region, nasolabial crease, infraorbital rim, temporal fossa, jawline, glabella, lateral brow, perioral area and lips.
Most recently, stem cell fat grafting has gained a lot of popularity for the claim that it is more permanent than traditional fat transfer. However, it should be recognized that the use of stem cells does not revitalize aging facial skin. Often times the results of a stem cell fat grafting can be very disappointing — correction is often transient and not consistent from patient to patient. Fat transfer is an excellent, safe technique that can be performed in an office setting and used in combination with other restorative procedures such as face and jawline lifts and laser treatments for intervening in the aging process.
The Aging Face
The aging face is the result of many factors, including volume loss, redistribution of facial fat, skin laxity and anatomic changes in the supporting structures. Facial bone resorption and remodeling contributes to the flattened appearance of the face. These changes can be caused by several different factors, including the normal genetic aging process, cigarette smoking, sun damage, gravity, alcohol and the repetitive use of facial muscles.
The youthful face is full of fat, providing a sound platform for the skin to drape over. With time, the fatty layer redistributes and atrophies, causing a defective overlying contour with skin laxity. This can contribute to the prominence of the transverse forehead creases, vertical glabellar creases, buccal fat pad atrophy, radial creases of the upper lip, double chin and jowl formation we often see in the aging face. Other signs of aging include ptosis of the brow and upper lid redundancy, crow’s feet formation, a drooping nasal tip, deepened nasolabial folds, descending oral commisures, infraoral creases and wattles of the neck.
The importance of volumetric facial rejuvenation has become a popular topic in recent literature. Volumetric facial rejuvenation is based on analysis of the esthetics of the attractive, youthful face contrasted with the typical aging face. Whereas traditional rejuvenation techniques emphasized removal of fat and skin, volumetric facial rejuvenation stresses the importance of filling areas of volume loss to produce a more natural, youthful appearance. This can be achieved using absorbable and non-absorbable injectable fillers, alloplastic and allogenic grafts, silicone implants and autologous fat transfer. In our experience, we have been especially successful using autologus fat transfer.
Autologous fat for volume restoration has many benefits. It is biocompatible, inexpensive, abundant, host-compatible and readily available and can be easily harvested on repeat occasions. Many researchers have described the importance of the volume restoration of the midface in rejuvenation. Fat transfer can be used to treat these area and many more, such as the infraorbital rim, temporal fossa, jawline, glabella and lateral brow.
Our Fat Transfer Surgical Approach
The technique of fat transfer involves very basic equipment. The setup includes an infusion catheter attached to a 60-cc syringe that holds 0.25% xylocaine with 1:400,000 epinephrine. This is made by diluting 10 cc of 1% xylocaine with 1:100,000 epinephrine and 30 cc of normal saline. A #11 blade is used to make a 1-mm diameter opening in the corium, which gives access to the subcutaneous plane.
The donor site is often chosen based on patient preference. Ideally, it would involve an area that is relatively metabolically resistant to weight fluctuations (ie, areas of the body in which the patient notices a persistent collection of fat even after losing weight). The hip, buttock region, lateral thigh, or the lower abdomen are all acceptable. In males, the donor region is often limited to the lateral flanks or “love handles.”
A wide area of skin overlying the donor site is prepped with betadine. The center of the area is grasped in a pinching fashion and a puncture is made with a #11 blade. The dilute xylocaine mixture is injected in a radial fashion into the subcutaneous plane via an infusion catheter. The tip of the infusion cannula is constantly palpated and monitored with the operator’s hand as the infusion is carried out. This is virtually painless and produces a tumescence of the donor site. The patient’s comfort can be enhanced by appropriate “vocal” anesthesia. A sterile icepack is then applied to the region for 20 minutes, adding to the tissue firmness. After adequate chilling a 14-gauge accelerator extraction cannula (Byron Instruments) is attached to a 10-cc syringe and inserted into the donor area. The cannula is advanced along the subcutaneous plane parallel to the overlying skin. The syringe plunger is withdrawn and stabilized in the grasp of the “working” hand. With a gentle in-and-out motion directed in a radial fan-shaped pattern, the syringe quickly fills with adipose tissue. This is, in essence, a blunt lateral punch extraction of the subcutaneous adipose tissue.
Normally, only 15 cc to 20 cc are needed, and after filling the required syringes, the syringes are capped and placed standing in the upright position (tip downward) for 10 minutes. This allows the serosanguineous fluid to separate from the fat. The fluid is mostly local anesthetic with small amounts of blood present. This admixture, which drains to the base of the syringe by gravitational pooling, is discarded. In effect this fluid washes the fat. One can see the intact fat lobules that compose the final donor material. In our experience, no additional washing or manipulation of the fat is needed and may even be detrimental to the survival of the intact fat lobules.
We typically place a small wheal of local anesthetic at each injection point of the face. The fat graft is then placed by injection, through a 1.5-inch, 18-gauge needle using the same syringe. The 18-gauge needle is directed into and parallel with the surface of the skin, sliding just along the dermal-subcutaneous junction analogous to the linear threading technique used for bovine collagen injection. If the grooves are quite deep we will often create a small tubular pocket to place the fat in, making minute 1-mm side-to-side “windshield wiper-like” motions. This not only creates the tubular pocket for the placement of fat but lyses the bound-down connective tissue. We have found the key to accurate placement is using a “lateral pinch technique” where manual pressure is applied bilaterally along the edges of the defect to be filled. The linear or curvilinear placement of the first three or four fingers of the operator on one side of the defect mirrored by the placement of the assistant’s fingers creates a walled chamber for the infused donor fat. This simple maneuver allows total control of fat deposition and has been free of complications. If additional injection pressure on the syringe is required, the described technique prevents an overspill of the fat into unwanted areas. Occasionally, a fibrous lobule of fat will block the entrance to the needle; simply changing the needle is all that is required to fix this. We have found the use of “injection guns” cumbersome and totally unnecessary.
Once the donor tissue is placed, if necessary, it can be smoothed or worked into exact position, although linear threading using the lateral pinch technique rarely makes this necessary (Figures 1-3).
Infection is a rare but potentially serious complication of the procedure. Fat transplantation should be conducted in a sterile manner and the clinician may consider prescribing prophylactic antibiotic treatment in all patients. There have been rare reported cases of Staphylococcus, Streptococcus, Pseudomonas and Mycobacterium infections following fat transfer. The physician should preoperatively screen for and treat any active or recurrent infections, particularly of the skin, dental, ocular or sinus regions. After having performed thousands of fat transfer procedures over more than 20 years of practice, we have never encountered infection as a complication.
Vascular occlusion following intravascular injection of fat is a serious complication. There are reported cases of blindness following injections of the glabellar region and fatal stroke and occlusion of the middle cerebral artery following fat transplant. Ischemia can be recognized by immediate blanching of the skin and should be treated immediately by putting the patient in Trendelenburg position and applying nitroglycerin paste to the area. To prevent intravascular injections, the physician may consider using small 1-cc syringes with low injection pressures for fat transfer, epinephrine in the anesthesia to promote vasoconstriction, blunt-tipped cannulas and withdrawal prior to all injections.
Common complications of facial fat transfer include mild bruising and edema of both the donor and recipient sites which may persist for approximately 12 to 72 hours. The biggest disadvantage to using a large bore needle (usually 18-gauge) is that it can lead to significant bruising (along with the highly variable duration of correction) at the donor site. The most common area for this is in the lips. Patients should apply ice postoperatively for 15 to 20 minutes three times during the first 12 hours to help prevent bruising and to prevent hematoma formation. The patient should also cleanse the face gently postoperatively to avoid further edema and bruising. Exercise and exertion should also be avoided during the first 24 hours to decrease these side effects. Pain or discomfort is rare but can be treated with mild analgesics.
Migration of fat, overcorrection, undercorrection and tissue irregularities from the procedure are important cosmetic concerns. The use of blunt cannulas can potentially damage underlying structures, such as muscles, nerves, glands and blood vessels. Microcalcifications can form in the face from trauma during the procedure and can be seen on x-ray.
The main advantage of the syringe technique for fat transfer is that it provides a fully-closed procedure for the patient, whereby the removal of fat is sterile. The use of a syringe-needle unit or syringe-cannula unit for tissue transplantation causes minimal tissue damage as the operation is performed without power-assisted vacuum. The smaller the graft used in fat transfer, the greater the chance it will survive. We limit the amount of fat injected at any one point to 2-mm3 aliquots. This has been found in studies to be the optimal size of droplet to maximize graft survival with the demands of neovascularization and metabolic influx.
It has been estimated and accepted that 25% to 50% of cells survive the fat transfer process; one procedure is often not enough to have long-term results. Patients should be prepared to have a maximum of 4 to 5 injections in a given treatment area, each separated by 3 months. This is especially true for non-facial areas, such as the breasts, where large volumes are needed. Overcorrection of an area is often performed by the surgeon to prepare for fat resorption. The result of small and repeated implantations is minimal downtime for the patient and maximum corrective benefits.
Our most common use of the fat transfer is in conjunction with face lifting and jawline tuck procedures. We find that fat transfer complements the results of these procedures by adding volume restoration. In addition, the neck and jowl provide ample donor fat during this combination procedure. We also believe that there is nothing more successful than fat transfer for rejuvenation of the aging hands, especially in combination with the Nd:Yag laser for lentigines. In our experience, not all patients are candidates for the fat transfer procedure, since slender and/or athletic patients have little donor material. We rarely use fat transfer for lip restoration due to occasional lumpiness, but instead use other reliable, long-lasting filler materials more well-suited for this area.
The technique of fat transfer is rapidly becoming the treatment of choice for facial rejuvenation, particularly for areas such as the malar eminence, submalar region, nasolabial crease, infraorbital rim, temporal fossa, jawline, glabella, lateral brow and perioral area. Using the body’s own living tissues for augmentation and restoration is a century-old concept that continues to create a youthful result in an outpatient setting.
Dr. Bisaccia is a practicing dermatologist and Clinical Professor of Dermatology at the Columbia University of Physicians and Surgeons in New York City. Dr. Patel is a Fellow in an ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologic Surgeons in Morristown, NJ. Dr. Scarborough is a practicing dermatologist and Assistant Clinical Professor of Medicine, Division of Dermatology, at the Ohio State University Hospital in Columbus, Ohio.
Disclosure: Drs. Bisaccia, Patel and Scarborough disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article.