Structural fat grafting is a powerful tool for correcting one of the primary processes of facial aging: the gradual loss of facial soft tissue volume, which primarily represents the atrophy of facial fatty tissue. The importance of restoring facial fullness cannot be emphasized enough, for without it, very few facial cosmetic surgical procedures are truly rejuvenating. As we age the skeletal features of the face become more obvious, and create subtle visual clues that tell the observer 'this is an older person'. Fat atrophy is often very obvious when it appears as hollowness in the temple area and as flattening of formerly full cheeks, but can also exist as more subtle changes that still convey an appearance of advancing age, such as the development of a hollow in the space between the upper lid and eyebrow, or as indentations in a formerly smooth and gently curving jawline.
Lifting skin and trimming the excess has been the standard approach to the treatment of facial aging for centuries, but when performed without some means of restoring the youthful fullness of facial soft tissues, the result is an older-looking person with tighter skin. The word 'rejuvenation' means literally 'to restore youthfulness' or 'to make young again', so if the goal of surgery is to rejuvenate the face then it cannot be accomplished solely by means of redraping the skin and removing the excess.
In my practice fat grafting is not an afterthought that is thrown into the surgical plan for the occasional patient. It is a key component of almost every major facial rejuvenation surgery that I perform. It is in fact that very first part of the surgical procedure for my patients undergoing a full facial rejuvenation surgery.
Fat grafting also gives the surgeon the ability to provide a minimally invasive, quick recovery solution for some of the earliest signs of facial aging, in many patients long before they could or should consider a more involved (and much longer recovery) procedure like a facelift. Most people show evidence of facial soft tissue atrophy in their thirties, long before they develop the degree of skin laxity that warrants skin redraping and removal. So younger patients now have a means for 'turning the clock back' by maintaining or restoring facial fullness through structural fat grafting. These enhancements look beautiful and natural, not like surgery, and over and over I hear fat grafting patients tell me that "none of my friends or co-workers can figure out why I look so great".
As with any cosmetic surgical procedure, there can certainly be 'too much of a good thing'. Over-grafting of fatty tissue will distort facial features and produce unnatural proportions that look like surgery rather than appearing to turn back the clock. An important part of my preoperative evaluation is reviewing photographs with patients from their twenties and thirties (and from their forties for patients in their sixties and seventies). Such photographs are invaluable in confirming the manner in which a face has aged, and in planning a surgery that is designed to help a patient look more like their youthful self.
Temporary injectable solutions
A number of 'soft tissue fillers' are available for temporarily improving facial areas that have lost volume, are naturally thin or hollow, or have developed noticeable and bothersome lines and creases. The most popular fillers currently are hyaluronic acid products like Juvederm® and Restylane® which can be used to, among other things, plump up thin lips and to fill out nasolabial folds (lines that run from beside the nostrils to the area beside the corners of the mouth) and marionette lines (lines that run from the corners of the mouth towards the jawline). In this practice we have performed thousands of injections with these safe and reliable hyaluronic acid fillers. They are well-tolerated by almost all patients and they produce very few post-injection problems. The improvement generally lasts from four to eight months, the average being about five to six months. Of the available hyaluronic acid soft tissue fillers, I have been most pleased with the performance of Juvederm®.
Other injectable fillers are currently available which attempt to produce a longer-lasting soft tissue augmentation by incorporating substances that are more slowly metabolized or that cannot be metabolized by the body. These are sometimes referred to as 'semi-permanent' fillers. Some incorporate non-degradable biologic materials (e.g. Radiesse®, which contains calcium hydroxyapatite, the mineral component of bone) or non-biologic (synthetic) materials (e.g. ArteFill®, which contains polymethyl methacrylate, also known as Lucite) that are designed to persist in the body permanently. Another is Sculptra®, which consists of a synthetic polymer called poly-L-lactic acid, which is also used as an absorbable suture material.
Unfortunately, the body treats these materials as foreign objects, and as a result the placement of non-degradable and synthetic materials may lead to inflammation, infection, migration and granuloma (an inflammatory cyst) formation - none of which are problems that you want to experience near the skin surface in your face. In general, the 'semi-permanent' injectables containing these materials are less likely to produce a result that looks and feels natural, and because of the potential complications I feel that they should never ever be injected anywhere close to the skin surface. We do not use any of these injectables in my practice.
If you are looking for a longer-lasting result than you are getting with Juvederm® or Restylane®, we have a much better solution for you: you own fat, currently residing somewhere that you don't need it. The improvement is designed to be permanent, and your body will not treat it as a foreign object. Your immune system won't attack it. The cost is about the same as several syringes of a 'semi-permanent' filler. And the quality of your facial skin may, in fact, actually improve in the areas where fat is grafted.
The ideal soft tissue 'filler'
One guiding principle of reconstructive plastic surgery is short and simple: "Replace like with like." Specifically, where tissue is missing, restore the defect with the same tissue whenever possible. If bone is missing, use a bone graft. If muscle is missing, use a muscle flap. So if fat is missing, the ideal solution is obvious.
Whether the goal is to restore volume to the lips or cheeks or temples, or to fill in a crease or depression such as the nasolabial folds or marionette lines (or all of the above), the ideal material is quite clearly the material that one wishes were there in greater abundance in the first place: your own fat. To be the ideal filler material it must also make sense from a cost perspective, which it does. The fat supply, from the standpoint of the volumes required for facial enhancement, is essentially limitless. A multi-area facial enhancement by fat grafting costs about the same as several syringes of ArteFill, Radiesse or Sculptra. And fat has the distinct advantages of not inciting an immune response, producing a more natural soft tissue consistency, and being well tolerated immediately below the skin (even within the deep dermis itself). So in my practice, there really is no place for the 'semi-permanent' soft tissue fillers.
The process is actually quite straightforward: fat is harvested from the abdomen, thighs, hips or buttocks using specially-designed instruments and a specialized technique, processed (by centrifugation, which eliminates all components of the harvested material which are not viable fat), and meticulously introduced into the facial areas to be enhanced using a second, smaller set of fat transfer cannulas. This procedure does not require an operating room and deep sedation or anesthesia - it can be performed in the office procedure room under local anesthesia and oral sedation.
A number of terms are currently used to describe varying techniques for harvesting and delivering fat in small quantities to produce long-lasting soft tissue augmentation: structural fat grafting, microfat grafting, lipostructure, orbital pearl fat grafting, etc. These terms all describe techniques for harvesting living fatty tissue with minimal trauma, refining the fat (in most cases) in some manner such as by centrifugation, and meticulously introducing the fat into the recipient area a small amount at a time to produce new soft tissue structure.
When is a graft truly a graft?
For fat grafting to truly represent 'grafting', the grafted tissue must gain a blood supply in its new location which provides a source of oxygen and nutrients and allows the tissue to persist indefinitely. If the grafted fat does not acquire a blood supply in the first few weeks after surgery, the body will gradually break it down and dissolve it, and no long-term benefit will be achieved in terms of soft tissue augmentation. Successful fat grafting surgery therefore requires a great deal of focus and attention to detail, to ensure that the fat which is harvested is viable tissue (i.e. not damaged by the harvesting process), and that the fat is delivered in such a way that the potential for ingrowth of blood vessels is maximal. If this process of blood vessel ingrowth (neovascularization) does not occur, then the injected tissue cannot truly be considered a 'graft' and is instead just another 'soft tissue filler' of limited duration.
Fat grafting has been performed by plastic surgeons for decades, but it is just in the last ten years or so that techniques and instruments have been refined to the point that it can be accomplished reproducibly and reliably, making it an increasingly important part of facial rejuvenation surgery. The term 'structural fat grafting' refers to a specific surgical technique in which small amounts (less than 0.1 cc at a time) of fat are carefully microinjected in a series of discrete layers to gradually 'build' new soft tissue structure. As there is space between each microinjection, new blood vessels are able to grow into the grafted fat, allowing it to persist long-term.
Structural fat grafting requires specialized training and specialized surgical instruments, as well as patience, finesse and attention to detail on the part of the surgeon. When performed properly, permanent and natural-appearing improvements in facial contours are possible. This revolutionary technique provides a means for restoring a youthful facial appearance that cannot be accomplished by means of traditional facial cosmetic surgery techniques, which have in the past focused primarily on skin excision for the purpose of 'tightening' facial features.
Enhancing the upper lid and brow
One of the most remarkable and rewarding enhancements I have been able to provide patients using this technique is the creation or restoration of soft tissue fullness in the interval between the upper lid crease and the eyebrow. I refer to this location as the 'brow-upper lid junction'. Hollowness in this area projects an image of advancing age, or exhaustion, or illness - and sometimes all of the above. Fullness in this area projects a sense of youth and vitality. Just look at the 20-something models you see in fashion magazines; in almost all of them you'll find that the upper lid is mostly or completely concealed by the soft tissue fullness immediately below the brow.
Careful placement of structural fat into this area can produce a dramatic rejuvenating effect, but one that no observer can ever identify as a surgical change to the eye area - it looks not only youthful but also completely natural. The medical term for the area around the eye is the orbit, so the treatment described above is sometimes referred to as 'orbital fat grafting' or 'peri-orbital fat grafting'.
Correcting hollowness following upper and lower blepharoplasty
Many of my brow-upper lid junction structural fat grafting patients have come to my practice for the correction of hollowness created by the over-zealous removal of fat during an upper blepharoplasty surgery. I am continually amazed at how many cosmetic surgeons practice 1970's-era blepharoplasty surgery in the 21st century. I almost never remove upper lid fat during blepharoplasty surgery, and in many cases I actually add fat at the brow-upper lid junction. Fortunately, essentially all cases of post-blepharoplasty hollowness can be improved dramatically by structural fat grafting. It is a more challenging procedure, as scar tissue must be overcome to create space for the grafted fat, and in many cases it takes more than one fat grafting procedure to restore adequate fullness in these patients.
Lower lid hollowness following an overly aggressive lower blepharoplasty can likewise be improved. One must exercise care and caution, as lower lid skin and the underlying soft tissues are usually quite thin, and thus the lower lids are less able to conceal grafted fat. Fat grafting must be preformed conservatively here, with a plan for secondary and occasionally tertiary fat grafting procedures depending on the 'take' of the initial fat grafting surgery.
Many patients referred to me for treatment of these frustrating and difficult post-blepharoplasty problems have reported more than just a cosmetic improvement. Excessive removal of skin and fat during upper and lower blepharoplasty can impair normal lid function and cause or aggravate dry eye syndrome. In some cases the fat grafting procedure will restore suppleness and flexibility to peri-orbital soft tissues, make eyelid closing easier, and improve the truly irritating and aggravating symptoms of dry eye syndrome.
Other applications for facial rejuvenation
The loss of soft tissue volume with aging occurs in a predictable pattern in most patients. Most people experience some deflation of the cheek fat pad in their thirties, and lip volume may also begin to thin around this time. Nasolabial folds begin to deepen. In their forties most people experience some loss of fatty fullness in the temples and along the jawline, particularly in the area just lateral to the chin. All of these areas are effectively 'reinflated' and thus rejuvenated by means of structural fat grafting. In many cases patients in their thirties and forties can be treated by fat grafting only, and do not require any incisional surgical procedure to remove or 'tighten' skin.
For patients in my practice undergoing major facial rejuvenation surgery such as facelifts, structural fat grafting is one of the most important parts of the procedure and it is what I perform first. All areas of facial hollowness are restored to a more youthful fullness before any incision is made to address skin laxity and the need for some 'redraping' of the skin and deeper soft tissues. The eye area is filled out and the temples are restored to fullness before blepharoplasty or browlift is performed. The result is a patient that looks like a younger version of themselves, not like a person who has obviously just had a facelift.
I have also treated a number of patients who have experienced facial fat atrophy as a result of procedures which can heat the facial deep soft tissues excessively such as IPL or Thermage. Most of these patients come to my practice not only with areas of fat atrophy, but also with the frustration that their facial skin in the affected areas has lost its youthful quality. Remarkably, structural fat grafting has provided these patients not only with a correction of the soft tissue contour problem, but also with an improvement in the quality of the overlying skin.
A 'stem cell' effect?
As I have just mentioned above, many plastic surgeons who perform structural fat grafting report that patients often describe a variety of improvements in their facial skin following fat grafting surgery. This observation has led to the use of fat grafting in reconstructive surgery, for instance in the management of chronic wounds such as those seen in some patients following radiation treatment for cancer. Fat grafting into the tissues below a chronic, non-healing wound has been shown to stimulate successful wound healing in a number of studies.
So what is responsible for this effect? Many of us suspect that it is produced by 'stem cells' which are known to be present in abundance in human adipose (fatty) tissue. Stem cells are very dynamic human cells which have the capacity to be transformed into any number of cell types (fat, muscle, skin, fascia, etc), and which are capable of producing a variety of proteins which promote the repair of damaged cells and tissues.
Much of the evidence has been anecdotal, i.e. the personal observations of physicians made while treating patients in their usual clinical practice, outside the setting of a specific scientific study. A great deal of basic science research is now being done to specifically determine cause and effect, and it is certain that over the next few years we will gain a much clearer understanding of the healing properties of fatty tissue and stem cells.
Be aware that the term 'stem cell' is increasingly being used in what I feel may be an irresponsible manner - as a marketing gimmick to attract patients to a particular practice or surgeon. Nobody has an exclusive claim or right to the use of stem cells, and as yet no one has demonstrated an objective, quantitative method for measuring any 'stem cell effect' in facial rejuvenation surgery, if it is truly present. I believe that this effect exists, but it currently is not objectively and reproducibly measurable and therefore should not be used to 'sell' surgery.