Fat Grafting for Facial Filling and Regeneration

Plastic surgeons have come to realize that fat grafting can rejuvenate an aging face by restoring or creating fullness. However, fat grafting does much more than simply add volume. Grafted fat can transform or repair the tissues into which it is placed. Historically, surgeons have hesitated to embrace the rejuvenating potential of fat grafting because of poor graft take, fat necrosis, and inconsistent outcomes. This article describes fat grafting techniques and practices to assist readers in successful harvesting, processing, and placement of fat for optimal graft retention and facial esthetic outcomes.

Key points

  • Fat grafting is a well-established technique to restore volume and enhance the quality of skin in the aging face.

  • Harvesting by hand using 10-mL syringes is recommended to avoid traumatizing fat.

  • Sterile centrifugation at 1286 g for 2 minutes should be used for processing.

  • Blunt tip cannulas should be used to diffusely transplant fat and avoid intravascular injection.

  • Fat should be infused in small aliquots no greater than 0.1 mL per pass to encourage proximity to a blood supply and avoid fat resorption, necrosis, or oil cyst formation.

  • Varying the depth of fat injection brings about desired cosmetic results.

  • Maximal graft retention results from adherence to precise technique.

  • Improvements in the quality of the overlying skin can be quite dramatic.

Introduction

The key to fat grafting in the face is to appreciate and use the ability of fat to transform and rejuvenate the tissues into which it is placed. The first attempts of fat grafting to the face were performed to not only restore fullness but also improve the quality of the tissue into which the fat was grafted, including scars. In 1893, Gustav Neuber described the use of transplanted fat not only for filling but also the reconstruction of an ugly depressed facial scar. Even in this earliest description of fat grafting, the surgeon recognized the importance of the transformation of the tissues into which the fat was placed. In this first reported case, the grafted fat was noted to improve the scarring.

Holländer was the first to describe a technique for the injection of fat using a cannula in 1909. After 3 years, in 1912, he published more extensive descriptions of the injection technique and photographs of his results, in which he not only restored fullness to facial atrophy but also described the correction of adherent scars and adhesions and improvement in the tissues into which the grafted fat was injected.

With the arrival of liposuction in the early 1980s, plastic surgeons had a new source for soft tissue filler, the lipoaspirate from liposuction.

Unfortunately, the surgeons in the 1980s who first used fat grafting implanted the grafts into the face with a bolus technique, which had less-than-desirable reported results. In these reports, the surgeons described resorption of the fat without any other changes.

In the early 1990s, Coleman introduced the technique of processing the fat by centrifuging and separating out the unwanted components (oil, blood, local anesthetic, and other noncellular material) and placing the fat in tiny aliquots with each pass of the cannula. Placement of the fat in small aliquots ensured the proximity of the injected fat to a blood supply and anchored the fat into the recipient tissue. This technique has been given many names, such as structural fat grafting, LipoStructure®, or the Coleman technique.

With more reliable techniques and instrumentation, fat grafting and harvesting and injecting with cannulas gradually become more popular. As a result, attention has returned to approaching facial rejuvenation not only by cutting and lifting but also through the restoration of fullness.

During this resurgence of fat grafting for the correction of atrophy associated with aging, an exciting observation has been made by the surgeons placing fat under sun-damaged, aging, and scarred skin. There has been a transformation of the skin over time. The change observed is an improvement in the texture of the overlying skin, which includes one or all of the following: a decrease in wrinkling, a decrease in the size of pores, an improvement in skin color, an apparent thickening of the skin, an improvement in facial scarring, and a smoother, younger appearance.

In this article, the details of the Coleman technique, including harvesting, refinement, and placement methods are described to aid practitioners in obtaining long-term, consistent, and esthetically pleasing results for facial rejuvenation. Patient selection and indications for facial fat grafting, potential complications, postoperative care, and current and future research and trends will be discussed ( Table 1 ).

Table 1
Current research on fat grafting
Title Author Journal Summary
“Grading Lipoaspirate: Is There an Optimal Density for Fat Grafting?” Allen et al, 2013 Plastic and Reconstructive Surgery More of the highest-density fractions of lipoaspirate were preserved over time compared with lower-density fractions. High-density fractions contained more progenitor cells and larger concentrations of several vasculogenic mediators compared with the lower-density fractions
“Endogenous Stem Cell Therapy Enhances Fat Graft Survival” Butala et al, 2012 Plastic and Reconstructive Surgery Endogenous progenitor cell mobilization enhanced low-density fat neovascularization, increased vasculogenic cytokine expression, and improved graft survival to a level equal to that of high-density fat grafts
“Double-Blind Clinical Trial to Compare Autologous Fat Grafts Versus Autologous Fat Grafts with PDGF: No Effect of PDGF” Fontdevila et al, 2014 Plastic and Reconstructive Surgery The addition of plasma-rich growth factors to the adipose tissue graft did not improve outcomes
“Prevalence of Endogenous CD34 + Adipose Stem Cells Predicts Human Fat Graft Retention in a Xenograft Model” Philips et al, 2012 Plastic and Reconstructive Surgery Concentration of CD34 + progenitor cells within the stromal vascular fraction may be used to predict human fat graft retention
“Application of Platelet-Rich Plasma and Platelet-Rich Fibrin in Fat Grafting: Basic Science and Literature Review” Liao et al Tissue Engineering Part B Reviews This article provides a general foundation on which to critically evaluate earlier studies, discuss the limitations of previous research, and direct plans for future experiments to improve the optimal effects of platelet-rich plasma in fat grafting

Introduction

The key to fat grafting in the face is to appreciate and use the ability of fat to transform and rejuvenate the tissues into which it is placed. The first attempts of fat grafting to the face were performed to not only restore fullness but also improve the quality of the tissue into which the fat was grafted, including scars. In 1893, Gustav Neuber described the use of transplanted fat not only for filling but also the reconstruction of an ugly depressed facial scar. Even in this earliest description of fat grafting, the surgeon recognized the importance of the transformation of the tissues into which the fat was placed. In this first reported case, the grafted fat was noted to improve the scarring.

Holländer was the first to describe a technique for the injection of fat using a cannula in 1909. After 3 years, in 1912, he published more extensive descriptions of the injection technique and photographs of his results, in which he not only restored fullness to facial atrophy but also described the correction of adherent scars and adhesions and improvement in the tissues into which the grafted fat was injected.

With the arrival of liposuction in the early 1980s, plastic surgeons had a new source for soft tissue filler, the lipoaspirate from liposuction.

Unfortunately, the surgeons in the 1980s who first used fat grafting implanted the grafts into the face with a bolus technique, which had less-than-desirable reported results. In these reports, the surgeons described resorption of the fat without any other changes.

In the early 1990s, Coleman introduced the technique of processing the fat by centrifuging and separating out the unwanted components (oil, blood, local anesthetic, and other noncellular material) and placing the fat in tiny aliquots with each pass of the cannula. Placement of the fat in small aliquots ensured the proximity of the injected fat to a blood supply and anchored the fat into the recipient tissue. This technique has been given many names, such as structural fat grafting, LipoStructure®, or the Coleman technique.

With more reliable techniques and instrumentation, fat grafting and harvesting and injecting with cannulas gradually become more popular. As a result, attention has returned to approaching facial rejuvenation not only by cutting and lifting but also through the restoration of fullness.

During this resurgence of fat grafting for the correction of atrophy associated with aging, an exciting observation has been made by the surgeons placing fat under sun-damaged, aging, and scarred skin. There has been a transformation of the skin over time. The change observed is an improvement in the texture of the overlying skin, which includes one or all of the following: a decrease in wrinkling, a decrease in the size of pores, an improvement in skin color, an apparent thickening of the skin, an improvement in facial scarring, and a smoother, younger appearance.

In this article, the details of the Coleman technique, including harvesting, refinement, and placement methods are described to aid practitioners in obtaining long-term, consistent, and esthetically pleasing results for facial rejuvenation. Patient selection and indications for facial fat grafting, potential complications, postoperative care, and current and future research and trends will be discussed ( Table 1 ).

Table 1
Current research on fat grafting
Title Author Journal Summary
“Grading Lipoaspirate: Is There an Optimal Density for Fat Grafting?” Allen et al, 2013 Plastic and Reconstructive Surgery More of the highest-density fractions of lipoaspirate were preserved over time compared with lower-density fractions. High-density fractions contained more progenitor cells and larger concentrations of several vasculogenic mediators compared with the lower-density fractions
“Endogenous Stem Cell Therapy Enhances Fat Graft Survival” Butala et al, 2012 Plastic and Reconstructive Surgery Endogenous progenitor cell mobilization enhanced low-density fat neovascularization, increased vasculogenic cytokine expression, and improved graft survival to a level equal to that of high-density fat grafts
“Double-Blind Clinical Trial to Compare Autologous Fat Grafts Versus Autologous Fat Grafts with PDGF: No Effect of PDGF” Fontdevila et al, 2014 Plastic and Reconstructive Surgery The addition of plasma-rich growth factors to the adipose tissue graft did not improve outcomes
“Prevalence of Endogenous CD34 + Adipose Stem Cells Predicts Human Fat Graft Retention in a Xenograft Model” Philips et al, 2012 Plastic and Reconstructive Surgery Concentration of CD34 + progenitor cells within the stromal vascular fraction may be used to predict human fat graft retention
“Application of Platelet-Rich Plasma and Platelet-Rich Fibrin in Fat Grafting: Basic Science and Literature Review” Liao et al Tissue Engineering Part B Reviews This article provides a general foundation on which to critically evaluate earlier studies, discuss the limitations of previous research, and direct plans for future experiments to improve the optimal effects of platelet-rich plasma in fat grafting

Treatment goals and planned outcomes

The first step in facial rejuvenation is identifying the patient’s complaints and goals. The next step is a thorough analysis of the face, donor sites, and general patient selection criteria. Fat grafting can be a tremendous tool for facial rejuvenation; however, in the excessively sagging face with redundant loose skin, fat grafting alone may not give the patient an adequate change. The face should be analyzed in a systematic manner to assess the needs of each potential patient. In the youthful face, the skin of the forehead is tight and free of rhytids and the brow and glabella are unfurrowed. The upper eyelids and orbits are full. The cheeks are full and rounded with the fat pad hiding the zygomatic arch. The buccal cheek may have a slight hollowing but only appears gaunt in the thinnest patients. The nasolabial folds are soft and the lips full, pouted, and averted, with the lower lip slightly larger than the upper lip. The jaw line is sharp, with a well-defined chin.

As a person progresses toward middle age, lines and folds become apparent on the forehead and glabella. The temples begin to hollow, as do the orbits. As the upper eyelid loses fullness, the skin of the upper lid empties out. This process can result in sagging of the excess skin, or the skin can retreat into the orbit giving a hollow appearance. The lid-cheek junction elongates, because the inferior orbital rim becomes more prominent again because of volume loss. The tear trough deepens, as do the nasolabial and marionette folds. The zygomatic arch becomes more apparent as the malar fat pads deflate and the border of the mandible weakens with atrophy and becomes less defined because of relative ascent of the posterior and anterior jawline concomitantly with the descent of the jowl, often with the appearance of excess jowls. These changes become more apparent as aging continues.

Facial fat grafting reverses these changes by restoring volume and appropriate proportions to the face. Unlike traditional temporary fillers, fat has the potential for permanence and improving the quality of the overlying skin and repairing skin damage, thereby rejuvenating the face.

In the upper third of the face, forehead and glabellar rhytids can be smoothed and eliminated with both intradermal and superficial fat grafting. Orbital hollowing can be filled with well-placed fat, either alone or in combination with excision of the skin of the upper eyelid. The lower lid and the lid/cheek junction can be returned to a soft, full, youthful appearance with autologous fat augmentation; however, care should be taken to avoid complications in the lower lid. The tear trough deformity can also be reconstructed with carefully placed fat injections, while coverage of the zygomatic arch can be accomplished as well. The lips can be augmented with fat to restore the full, pouty look of youth, while a weak jawline can be corrected with fat grafting along the mandibular border. Finally, fat grafting is extremely valuable in correcting congenital and acquired soft tissue defects of the face, including HIV-related lipoatrophy and Perry-Romberg syndrome, linear scleroderma, surgical defects, and scarring and traumatic loss of soft tissue, as well as underlying bony injuries. Similar to the goals in the esthetic patient, fat grafting in the reconstructive realm aims to restore healthy, natural facial contours.

Preoperative planning

As with any procedure in plastic surgery, all candidates should undergo a thorough preoperative history and physical examination. Attention should be paid in the preoperative assessment to a patient or family history of bleeding or clotting disorders, previous miscarriage, and/or deep vein thrombosis or pulmonary embolism. In addition, all patients should be asked about the use of anticoagulants such as warfarin, Lovenox, aspirin, nonsteroidal antiinflammatory drugs, and certain vitamins and supplements known to adversely affect clotting.

Smoking and tobacco use negatively affect graft take. Thus, smoking status should always be documented in the preoperative workup. Although infection is rare with fat grafting, all patients should be asked about a history of methicillin-resistant Staphylococcus aureus infections and previous postsurgical infection.

Time should be spent inquiring about all previous surgical procedures, and patients should be asked specifically about previous cosmetic surgeries and noninvasive procedures. Patients may not consider injection of fillers or liposuction or minimally invasive liposculpting procedures relevant and may not initially recount these procedures unless specifically asked. Such procedures can greatly affect the quantity and quality of fat that can be harvested from a donor site. Patients should be questioned about weight changes and plans for future weight gain or loss. Throughout the preoperative assessment, it is important for the surgeon to gauge the mind-set and goals of the patient. Patients with unrealistic goals are more likely than not to turn into unhappy patients postoperatively.

Photographs of both the donor sites and the recipient sites from a wide variety of angles are critical in fat grafting. Photographs provide the surgeon and the patient with a blueprint for planning surgery, and the photos or tracings can be marked accordingly. In this regard, by reviewing preoperative photographs with the patient, previously unrecognized defects and asymmetries may be pointed out and documented in the medical record. In addition, by comparing preoperative photographs to pictures from the patient in his or her 20s or 30s, the patient is better able to identify areas of concern and possible correction. Using this information, all areas of planned augmentation, cannula entry points, and projected size of grafts can be documented on the preoperative photographs to better prepare the patient for postoperative results. Finally, initial photographs provide a way to compare preoperative appearance with postoperative results.

These preoperative conversations and planning sessions are the basis for informed consent. In addition to spending time analyzing photographs, during a consultation, it is also important to prepare the patient for any possible complications before the day of surgery. Surgical plans, desired outcomes, risks, and benefits should be reviewed again the day of surgery to address any last-minute patient concerns.

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Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Fat Grafting for Facial Filling and Regeneration
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