The search for the ideal filler goes on, but injecting the patient’s own fat can provide the best result
There has been a paradigm shift in the approach to facial aging. This consists of a trend away from subtractive facial-surgery techniques and a newer focus on restorative procedures. As the face matures over time, facial-fat loss and volume depletion contribute to an aged and sunken facial appearance.
To restore lost facial volume and contour, aesthetic surgeons have been searching for the ideal filler to rejuvenate it and to correct wrinkles, scars, depressions, and creases. To date, no filler has been deemed perfect; all soft-tissue fillers currently on the market have disadvantages.
Fat transfer (taking fat from an area of a patient’s body where it is plentiful and transferring it to an area of volume loss) can be a good way to replace this lost fullness. For more than a century, free autologous fat transfer—also referred to as facial fat rejuvenation, fat grafting, free fat transfer, autologous fat grafting/transfer/transplantation, liposculpture, lipostructure, microlipoinjection, and fat injection, as well as by numerous trade names—has been performed to correct facial defects.
Transferring a patient’s own fat has always been an attractive idea because there are no allergic reactions; the fat is readily available and inexpensive; and a variety of conditions, including facial-volume loss, atrophic aging of the hands, postsurgical defects, and posttraumatic defects, can be treated. When performed appropriately, the procedure can yield satisfying cosmetic results.
Some of the many benefits of fat transfer include minimal pain or discomfort, short recovery time, minimal risk, the ability to treat all skin types, long-lasting results, cost-efficiency (especially in combination with other procedures), and the elimination of the risk of allergy or rejection. The main disadvantages of fat transfer in the past have been the unpredictability of the volume of transferred fat that the patient’s body will resorb and the length of time the fat will remain in place.
New techniques used to harvest and implant the fat, however, have improved post-transfer fat survival. In fact, fat transfer is commonly used now to enhance the results of other cosmetic surgeries, such as facelifts.
The Fat-Transfer Procedure
Fat transfer is actually two procedures performed in a single session that lasts approximately 1 hour. The first procedure is fat harvesting. A small amount (about 30 to 60 mL) of fat is removed from the locally anesthetized donor site. The anesthetic solution not only makes the procedure nearly pain free, but also minimizes the likelihood of later bruising and bleeding at the donor site.
The preferred donor sites are the abdominal and trochanteric regions, where fat cells have a high concentration of antilipolytic receptors and are therefore less likely to be resorbed. Conversely, the adipose tissue found in the face, arms, and upper torso has a high concentration of lipolytic receptors, making these locations poor harvest-site choices.
Traditional fat-transfer methods entail centrifugation and manual processing of the harvested fat to prepare it for transfer. These techniques are not only time-consuming, but are potentially damaging to the adipocytes.
Another option is to use disposable sterile devices that allow the surgeon to harvest, filter, wash, and transfer fat cells gently, in a controllable, time-saving, simple manner. Instead of centrifugation, these systems use filtration with low-vacuum suction during harvesting, allowing the delicate fat cells to be reimplanted quickly, without multiple transfers and excessive handling.
These systems are intended to enhance the predictability of outcomes and to improve the quality and viability of the tissue that is reinjected. Their use has advanced the simplicity, predictability, and portability of the fat-transfer technique to allow it to compete with the newer generations of facial fillers.
After the fat has been prepared, it is injected into the recipient site. The area to be augmented is first given a local anesthetic. The freshly harvested fat is then carefully injected into the desired area in very tiny amounts until the desired volume is reached. Modern microdroplet or threading injection techniques have improved the results by increasing the longevity of the grafted material.
In addition to injection technique, injection location is an important feature of successful fat transfer. A multilevel volume-enhancement approach yields the best outcome. Layering injections into deep tissues on top of the bone and periosteum and into muscle, and then moving outward into more superficial areas, will restore facial volume in a three-dimensional manner.
Rather than simply filling in lines, fat transfer can improve the structure and support of the face. The average facial correction uses 10 to 60 mL of injected fat, but this volume can be tailored to each patient’s needs, age, and volume loss. No sutures are generally needed at the donor or the recipient site.
It is best to harvest more fat than is needed at the time of the first procedure and to freeze the excess fat for later injections (to avoid additional harvesting procedures). Occasionally, no matter how many times a particular area is grafted, the fat will be resorbed. Also, because not every area responds well to fat transfer, the transferred fat lasts longer in areas of minimal movement. Therefore, fat transfer is quite successful for the correction of sunken cheeks; this area is relatively immobile.
Fat transfer to lips, smile lines, and the area around the mouth is often less than ideal because of excessive movement in these areas. Other soft-tissue fillers or skin treatments can be used to achieve the desired cosmetic enhancement. Facial-fat transfer can also be effectively combined with other facial-rejuvenation procedures, however, to provide optimal aesthetic results for the right candidate.
Candidates for Fat Transfer
Many areas of the face and body can be treated with fat transfer, but the most common treatment indications are hollow-appearing eyes and visible tear troughs, overly aggressive removal of fat pads during lower blepharoplasty, facial scars and depressions, and aggressive buccal fat removal or natural loss of fat in the lower cheeks. Fat transfer can also be used on the temple areas and temporal fat pads, upper malar and submalar areas, chin, lips (although it is not a defining filler), jawline, forehead, buttocks and hips, sternum, outer brow, and glabella, as well as between the upper lip and nose, on the bridge of the nose and lateral fatty pads, and anywhere else that fat is needed or wanted.
Fat transfer to the breasts, however, is not recommended, because it would make mammographic detection of breast cancer much more difficult.
Good candidates for fat transfer are in good health, have no active diseases or preexisting medical conditions, and have realistic expectations. Appropriate fat-transfer sites include areas where there is fat atrophy associated with trauma or aging. Fat transfer alone is suitable for a younger patient or for one who is not interested in a facelift. It is also useful for revising unsatisfactory facelifts (or other poor surgical outcomes), especially where indentations need to be filled or where overly tight areas need to be softened. Fat transfer is an excellent adjunct to the midface or full facelift, enhancing facial rejuvenation.
After childbirth, some women experience facial-volume loss, showing flattened cheeks and increased prominence of the nasolabial folds and orbital rims. These younger women can be good candidates for fat transfer. The procedure can also be used in older patients with mild to moderate facial laxity to fill deeper folds and lines and to reduce skin redundancy.
Fat transfer is also an excellent option for volumetric correction of the hands. Often, a patient undergoes cosmetic procedures to rejuvenate the facial appearance, but the hands continue to reveal the patient’s actual age. Fat transfer to the dorsum of the hand can make the face and hands look more compatible. Fat transfer can also be an effective means of correcting damage resulting from overtreatment effects or damage associated with radiofrequency tissue tightening or laser therapy.
Recovery Time and Complications
Recovery time after a fat transfer is very short. In most cases, patients can return to their normal activities almost immediately. Although fat transfer is associated with minimal morbidity, it remains a surgical procedure, and that fact should not be glossed over.
The major complications associated with fat transfer are infection and bruising, both of which can easily be remedied; many surgeons prescribe antimicrobial prophylaxis to prevent infection. There are also risks of asymmetry and contour irregularities, as well as the remote possibility of permanent discoloration due to the rupture of superficial blood vessels at the treatment site during an injection. Calcification, another rare complication, would cause hard micronodules to appear under the skin.
Fat embolism is a rare and serious complication that can occur when fat is mistakenly injected into a blood vessel. Extreme overcorrection or impeded graft vascularization can result in irregularity of the graft material, fatty cysts, or fat necrosis.
Because the patient’s own fat is transferred, there is no risk of allergic reaction or graft rejection. Possible complications, however, can include donor-area irregularities in the lower abdomen, upper hips, or outer thighs.
One of the major challenges of performing autologous fat transfer is ensuring that patients understand that complete permanence may not be a realistic expectation. The length of time that fat lasts after transfer is unpredictable. At times, the transferred fat disappears within several months; often, it can remain much longer, even for years. It is not uncommon for patients to require as many as three injections before desirable results are sustained.
Patients should be evaluated for factors that adversely affect graft viability. Smoking cessation is crucial, because smoking can significantly decrease the longevity of the grafted fat. The survival of newly grafted fat tissue is severely compromised by the vascular constriction induced by smoking.
Patients taking blood thinners may also experience poor results, because the medication may induce hemorrhage into the transfer area. Patients with eating and body-image disorders may be dissatisfied with the fat-transfer procedure if their unhealthy pursuit of a lower-than-ideal body weight undermines the desired volume enhancement.
Many variables are involved in fat-transfer graft survival. These include fat-cell-removal techniques; fat-handling techniques; the use of centrifugation, emulsions, or serums (including vitamin C complex, plasma, patient-derived plasma emulsion with vitamin C complex, oxygen-rich serums, and albumin); reimplantation techniques; the patient’s metabolism; the mobility of the recipient site; the patient’s postprocedural care of the treated area; and the level of vascularization and angiogenesis at the graft site.1–3
Some studies show improved survival of fat-transfer tissue if hyperbaric oxygen therapy is used.4 Patients who have compromised tissue vascularity, infection, trauma, or disease have reportedly gained increased cell life due to oxygenation of the deeper or traumatized tissues. This has been shown to help stop necrotic tissue spread, even in its advanced stages. There are many unanswered scientific questions concerning fat-transfer viability and techniques. Further research is needed to improve fat-survival rates and expand the knowledge of fat transfer.
As part of the shift from tightening to volume replacement as the primary strategy for treating the aging face, fat transfer is clearly becoming an increasingly important component of cosmetic facial rejuvenation. PSP
Benjamin Bassichis, MD, FACS, is a double board-certified facial plastic and reconstructive surgeon and director of the Advanced Facial Plastic Surgery Center in Dallas. He is also a clinical assistant professor at the University of Texas-Southwestern Medical Center in Dallas. He can be reached at (972) 774-1777 or via his Web site, www.advancedfacialplastic.com.
1. Johnson GW. Body contouring by macro injection of autogenous fat. Paper presented at: First World Congress of the American Academy of Cosmetic Surgery; October 1986; New Orleans.
2. Har-Shai Y, Lindenbaum E, Gamliel-Lazorovich A, Beach D, Hirshowitz B. An integrated approach for increasing the survival of autologous fat grafts in the treatment of contour defects. Plast Reconstr Surg. 1999;4: 945–954.
3. Narins RS, Tope WD, Pope K, Ross CE. Overtreatment effects associated with a radiofrequency tissue-tightening device: Rare, preventable, and correctable with subcision and autologous fat transfer. Dermatol Surg. 2006;32: 115–124.
4. Shoshani O, Shupak A, Ullmann Y, et al. The effect of hyperbaric oxygenation on the viability of human fat injected into nude mice. Plast Reconstr Surg. 2000;106:1390–1398.