A modern paradigm shift in facial rejuvenation focuses on volume restoration in addition to facial recontouring. The concept of facial volume restoration has long been advocated1–3 and ultimately accepted into common practice with our improved understanding of facial aging.4 Landmark anatomical studies5 made the development of the “lift-and-fill” technique possible,6 combining reliable, anatomical compartment volume augmentation with superficial musculoaponeurotic system manipulation.
Deep compartments include nasolabial and deep malar compartments; more superficial compartments include middle malar, superior cheek, temporal, perioral, submental, and ear lobules (Fig. 1). These fat compartments provide topographic guidance to optimize injection outcome. The goal of this communication is to clearly delineate the senior author’s (R.J.R.) technique of fat injection for facial rejuvenation.
Fat Harvest and Processing
Fat harvest is accomplished using manual low-pressure lipoaspiration using a blunt 3-mm cannula. Inner thighs and abdomen are the ideal donor sites, and contain the highest concentration of stromal vascular cells and cause the least amount of pain, as shown in previous studies and clinical experience.7 The lipoaspirate is then processed using centrifugation at 2250 rpm for 1 minute. The supernatant and infranatant are discarded before transferring fat graft into 1-cc syringes. Fractionated fat is used for periorbital injections. Fat is processed by means of mechanical emulsification by pushing centrifuged fat between two 10-cc syringes through a 2-mm filter 60 to 80 times. This results in fragmentation of adipose tissue structure, as described previously.8
Facial fat augmentation always begins with proper preoperative marking, clearly delineating areas of volume preservation and loss. In addition, precise facial analysis, focusing on facial symmetry, is essential for optimal outcome. A 14-gauge needle creates entry for a 2-mm blunt-tip Coleman cannula. A single entry point adjacent to the alar base provides access to the deep and superficial cheek compartments. Injections always begin deep, addressing nasolabial and deep malar compartments, followed by superficial superior and inferior malar compartments. Filling superior cheek compartments along the zygomatic arch corrects asymmetry in facial width and creates youthful contours. Injection is performed in an antegrade and retrograde manner. Approximately 1 to 3 cc is injected into each compartment, followed by gentle massage. [See Video 1 (online), which demonstrates facial fat augmentation in the malar region.]
Enhancement of superficial chin compartments begins with an access port along the intersection of lines drawn from the oral commissure and the lateral canthus. A single port allows injection of the compartment in a radial fashion in the subcutaneous plane. [See Video 2 (online), which demonstrates facial fat augmentation in the chin/mandibular border.] Approximately 1 to 2 cc is injected into each side. Fat augmentation of the chin alone is often adequate for treatment of microgenia requiring less than 2 cm of advancement. More severe cases usually require either genioplasty or implant. In these cases, fat injection can serve as an excellent adjunct technique to blend and smooth out the contour.
A single entry point just anterior to the mandibular angle allows for deep augmentation of the mandibular border along the body and ramus in the supraperiosteal plane, creating a well-defined aesthetic jawline. For male patients, the entry point can be moved posteriorly to provide better access for augmentation of the mandibular angle, which is key for a masculine mandibular contour. Approximately 1 to 3 cc is injected again in anterograde and retrograde fashion, with improvement of aesthetic line as the endpoint [see Video 2 (online)].
Temporal and Forehead
Temporal and forehead fat grafting addresses age-related hollowing, and has the added benefit of mildly lifting the brows. Temporal injection is performed using a single-port access within the temporal hairline. The key principle is disrupting the temporal fusion line to allow uniform fill. This typically requires 1 cc of fat graft. Another 1-cc injection is then needed to correct the hollowing in a radial fashion just lateral to the lateral brow. [See Video 3 (online), which demonstrates facial fat augmentation in the temporal/forehead regions.] The central forehead injections must correct three distinct compartments: the glabella and the two superior brow regions. Injection is performed in the subcutaneous plane using a port either in a crease in the midforehead for those with a tall forehead, or in the hairline for those with a shorter forehead. Injection of the superior brow regions not only corrects age-related changes, but also often provides the illusion of more-lifted brows. A second stab incision along the medial brow line allows additional access to the superior brow and disruption of the temporal fusion line from the medial aspect and full correction of temporal hollowing.
Upper Lip, Earlobe, and Nose
A 21-gauge needle on a 1-cc syringe can be used superficially, with minimal vascular trauma. Perioral rejuvenation focuses on respecting and enhancing aesthetic landmarks. Small aliquots around the commissures in a cross-radial fashion and into the philtral columns provide subtle but vital restoration of youthful features. The senior author does not recommend injection into the vermillion lips because of the unpredictable nature of fat graft take within the lip.
Ear lobes are often a forgotten but nonetheless important aspect of facial rejuvenation. Deflated and wrinkled ear lobes can appear incongruent next to fully rejuvenated face and neck, and can serve as a telltale sign for surgical intervention. Fat augmentation is the ideal method for correction, as it is simple and long-lasting. A 21-guage needle is used for direct injection into the lobule with correction of the deformity as the endpoint. [See Video 4 (online), which demonstrates facial fat augmentation of the ear lobules.]
Nasal injection can also be performed similarly using the simple method to correct minor age-related atrophy and loss of tip projection and rotation. The key point is to keep in the midline and on the dorsum to avoid vascular compromise. Small aliquots go a long way.
Periorbital rejuvenation is almost always performed in conjunction with blepharoplasty. Again, accurate preoperative assessment is essential. Correction of age-related periorbital changes rarely requires removing fat from the fat compartments. Instead, volume restoration is often key. The senior author has previously demonstrated in his studies that fractionated fat is ideal for the periorbital region.8 Injection is performed through three separate access points in an equilateral triangle configuration using a blunt cannula. The sequence of injection commences inferiorly into the cheek-orbital rim junction, disrupting the orbital retaining ligament in the suborbicularis plane, superiorly along the medial superior orbital rim in the supraperiosteal plane, and along the lateral orbital rim and canthus. [See Video 5 (online), which demonstrates facial fat augmentation in the periorbital regions using fractionated fat.] Approximately 3 cc is injected in each side. This effectively correct any age-related hollowing of orbit.
Volume restoration with autologous fat of the facial fat compartments is essential for facial rejuvenation. It can be used independently or as an adjunct to rhytidectomy and blepharoplasty (Fig. 2). Accurate preoperative facial analysis, knowledge of fat compartment anatomy, and precise intraoperative techniques are needed for successful outcomes. Deep facial compartments are always restored first because they are the foundation of facial volumization. Preoperative bony contour and distribution of fullness dictate the contour and volume of grafting. When used as an adjunct to rhytidectomy, superficial musculoaponeurotic system manipulation serves as final refinement of facial contour. When used properly, fat augmentation is a powerful tool to ensure optimal restoration to youthful appearance.
Patients provided written consent for the use of their images.
1. Coleman SR. Facial augmentation with structural fat grafting. Clin Plast Surg. 2006;33:567–577.
2. Stuzin JM. Restoring facial shape in face lifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362–376; discussion 377–378.
3. Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg. 1993;91:463–474; discussion 475–476.
4. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg. 2007;120:1367–1376; discussion 1377.
5. Rohrich RJ, Pessa JE. The fat compartments of the face: Anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219–2227; discussion 2228–2231.
6. Röhrich WG, Hardiess G, Mallot HA. View-based organization and interplay of spatial working and long-term memories. PLoS One. 2014;9:e112793.
7. Geissler PJ, Davis K, Roostaeian J, Unger J, Huang J, Rohrich RJ. Improving fat transfer viability: The role of aging, body mass index, and harvest site. Plast Reconstr Surg. 2014;134:227–232.
8. Rohrich RJ, Mahedia M, Shah N, Afrooz P, Vishvanath L, Gupta RK. Role of fractionated fat in blending the lid-cheek junction. Plast Reconstr Surg. 2018;142:56–65.