Fat Grafting Technique
All articles described, to some extent, the methods of preparing and grafting the adipose tissue (Table 2).9 , 35 , 36 , 38–52 Eleven out of 14 studies used a local form of anesthesia,9 , 36 , 38–42 , 44–46 , 48 , 49 , 51 , 52 and 3 authors preferred general anesthesia.35 , 47 , 50 The abdomen was the primary donor site in most studies with fat from the thigh and flank area used in cases of insufficient supply. The infiltration cannula size was poorly reported, with 3 studies35 , 40 , 46 reporting using 1-, 2-, or 3-mm cannulas, respectively, and the infiltration solution varied widely among studies. Ten studies9 , 35 , 40 , 41 , 45–50 (additionally) used some form of local anesthetic in combination with different solutions of epinephrine and saline before harvesting by way of manual aspiration in 16 of the 18 reporting studies. Harvesting was done by 2–3 mm cannulas, mostly blunt with 2–3 holes and attached to 10–60 ml Luer lock syringes. Preparation of the adipose tissue was done solely by centrifugation in 5 studies9 , 36 , 44 , 45 , 50 ranging from 1,000 to 3,000 rpm over 1–3 minutes spans, with the studies of Asilian et al.48 and Botti et al.35 comparing centrifugation and washing between groups. Furthermore, 6 studies38–41 , 43 , 51 used combinations of preparations in a none-comparative study design. Stromal vascular fraction (SVF), platelet-rich fibrin (PRF), and platelet-rich plasma (PRP) were used to supplement the fat in 4 studies, 2 by comparative design.36 , 45 The injection cannula sizes ranged from 1 to 3 mm (14–23 gauge) and were mostly blunt with 2 studies reporting using lateral openings35 , 48 and 1 study using a ratchet gun for precise fat distribution.46 For the injections, most studies described a retrograde injection technique. The primary site of injection was the subcutaneous space with additional injections most often performed above or just beneath the superficial muscular aponeurotic system (SMAS). The number of AFT sessions was reported in 11 studies9 , 36 , 39–41 , 45–47 , 49 , 51 , 52 and varied from 1 to 4 with an mean interval of 4.25 months.39–41 , 47 , 49 , 52 Postoperative management varied greatly among the 9 reporting studies35 , 39 , 41 , 43–46 , 48 , 52 and was even contradictory with Ibrahiem et al.52 recommending massage, as opposed to other studies.
Meta-analysis was performed over the 12 reporting studies.36 , 39 , 41–47 , 49 , 50 , 52 To determine the amount of heterogeneity between studies, Cochran’s Q was calculated (101.45, P < 0.0001) and quantified with I2 (tau2 = 2.0747; H = 3.81 [2.98, 4.87]; I2 = 93.1% [88.7%, 95.8%]). According to the Cochrane’s Handbook for Systematic Reviews of Interventions53—in the case of between-trial heterogeneity—the random-effects meta-analysis weights the studies relatively more equally and is therefore used in the following description. The overall complication rate was 6% (95% CI: 3.0–14.0) after a mean follow-up of 15.8 months in 1,205 patients (see Tables, Supplemental Digital Content 2, which displays different data charts including overall complications and infections, http://links.lww.com/PRSGO/A629). Hematoma/ecchymosis most reported (5%, 95% CI: 2.0–15.0), followed by fat necrosis/oil cysts (2%, 95% CI: 1.0–5.0), irregular fat distribution and scars (both 2%, 95% CI: 1.0–4.0). Infections were reported in 1% (95% CI: 0.0–4.0) of 728 patients in 6 studies.
Objective measurements of the volumetric result are imperative to demonstrate the efficacy of AFT. However, the face consists of multiple anatomical units greatly varying in important features like density causing great heterogeneity in comparing results. Five studies36 , 38 , 40 , 45 , 51 were included in the volumetric analysis (Table 4). The methods of determining volume retention varied greatly between studies. Supplements added to the fat graft were reported in 3 studies. As great heterogeneity between studies in regard to injection site and volumetric assessment exists, no pooling of data could be achieved, and volume retention varied greatly from 13% to 68% over a mean of 12.2 months.
A total of 9 studies9 , 35 , 36 , 39 , 41 , 44 , 46 , 48 , 52 reported on patient and/or surgeon satisfaction either on a visual analog scale (VAS) or a 2-4 point Likert scale (Table 5). Meta-analysis for patient satisfaction was performed after conversion to a dichotomous scale (see Tables, Supplemental Digital Content 3, which displays patient satisfaction results, http://links.lww.com/PRSGO/A630). To account for between-trial heterogeneity (Cochran’s Q: 35.26-6<0.0001/I2: tau2 = 0.4391; H = 2.42 [1.72, 3.41]; I2 = 83.0% [66.3%, 91.4%]), the random-effect model was used for reporting patient satisfaction. Furthermore, overall scores were used only postoperatively, and when satisfaction rates were compared between study groups,48 a mean over the total cohort was calculated. The satisfaction rate over a total cohort of 630 patients in 6 studies36 , 41 , 44 , 46 , 48 , 52 was 81% (95% CI: 70.0–89.0). It should be noted that Asilian et al.48 compared 2 groups of patients according to preparation method (centrifugation vs filtering/washing), and both groups were included in the analysis. Surgeons reported a good cosmetic outcome in 89%, and the overall postoperative mean VAS score among 88 patients in 2 reporting studies9 , 35 was 79.5.
This study was performed to obtain a comprehensive overview of the available evidence on the outcomes of AFT in facial rejuvenation with objective outcome measures and a clear description of the technique applied. The first remarkable issue is the small number of studies to evaluate AFT in rejuvenation of the face. Although AFT is used widely all over the world, the number of well-designed studies is limited.
As is the case in AFT for other indications—such as the breast—the techniques used for harvesting, preparation, and reinjection of the fat varied greatly among authors. The most important aim in this continuing search for the golden standard in AFT is improving the volume retention, which is believed to be influenced by almost all the AFT aspects. Whether shear stress of the adipocytes caused by cannula size (either during harvesting or injection) or high osmolality of the infiltration solution plays a role remains a matter of debate. Both have been shown to vary greatly in this systematic review but have also been shown to matter significantly to the long-term volume retention.54 Two recently published in vitro studies55 , 56 shed some light on this interesting topic with Hivernaud et al.56 reporting on—among others—adipose tissue resorption variances between different combinations of harvesting (ie, manual, power-assisted, or water-assisted lipoaspiration) and preparation (ie, decantation, centrifugation, or filtration). They found that both in the in vitro and in the murine models, greater efficiency (in terms of retaining tissue volume) was achieved with manual aspiration, soft centrifugation (400 g for 1 min), and washing steps. Although the majority of studies in this systematic review used manual aspiration, the centrifugation settings and times were considerably higher. Secondly, Streit et al.55 further studied the differences in morphology between fat samples obtained through decantation, centrifugation, and membrane-based tissue filtration and found the highest numbers of adipose-derived stem cells in the upper fraction of centrifuged lipoaspirates but the maximal concentration of adipose fraction after membrane-based tissue filtration. In conclusion, both studies seem to suggest superiority of manual aspiration and centrifugation and/or washing procedures—in line with both the British and German clinical guidelines57 , 58—but longer follow-up for the former, and affirmation in clinical practice for the latter study is necessary to make conclusive statements. As was stated in the recent systematic review of Shim et al.,59 the same can be said for harvest location, because multiple studies have shown a great varying degree in adipocyte number, volume, and morphology and also adipocyte-derived stem cells depending on where the fat is harvested.
Complications after dermal fillers are usually divided into early and late events and again into minor and major.8 One of the advantages of AFT over other facial fillers in both early and late events is the absence of hypersensitivity reactions and granuloma formation, respectively. Furthermore, when comparing AFT with the use of hyaluronic acid (HA) fillers, major complications such as necrosis and blindness—which have both been described after HA injection60–63—were not reported. The most reported complication after AFT for facial rejuvenation—hematoma/ecchymosis—was reported in 5% (95% CI: 2.0–15.0) of the total cohort, which is in line with that reported in studies using other dermal fillers.64 Late onset complications such as fat necrosis (2.0%, n = 629) have been reported but are among the other complications10 , 11 minimal.
As stated before, the long-term volume retention is crucial in defining AFT as a biocompatible permanent filler in general and in verifying its superiority over other fillers. Three studies40 , 45 , 51 reported an overall volume retention ranging from 40% to 68% over a follow-up of 6 to 12 months without specifying the injected locations. The remaining studies36 , 38 while specifying the locations (nasolabial/marionette fold and cheek/malar, respectively) reported much lower volume retentions, ranging from 13% to 19% over a follow-up of 12 months indicating the importance of the location in regard to the long-term retention of the reinjected fat. However, because of the great heterogeneity among studies—especially when it comes to the different injected facial zones—no definitive conclusion could be made with regard to overall volume retention after AFT for facial rejuvenation. Supplements were used in 2 studies that reported on volume retention36 , 51; however the injected facial zones, the method of measuring volume retention, and the supplements used (PrP/PrF vs SVF) all varied, so no beneficial effect could be reported. Therefore, the aim of further studies should be toward facial location-specific volumetric assessment using objectifiable tools like 3D imaging (such as the VECTRA XT 3D imaging system), CT, or MRI.
The patient and surgeon satisfaction rates in the included studies were considered acceptable and in line with other publications and a recently published study on quality of life after minimally invasive facial cosmetic procedures.65 However, only standard visual analog scales, and also Likert scales, were used without the inclusion of validated questionnaires like the FACE-Q.66 Also satisfaction scores per facial zone are only reported in 1 study35 on VAS, ranging from 6 in the lips to 9 in the eyelids and malar region. Therefore, further studies should focus on incorporating the FACE-Q into the study design and report per facial zone.
This systematic review has several limitations. Only low-level evidence studies (OCEBM III) and mainly retrospective studies without a control group were found. The 3 studies that used a comparative study design failed to report on some important aspects like allocation concealment and blinding, as is illustrated in Figure 2. The use of validated measurement tools to assess patient-reported outcomes is lacking, and objectifiable data on volume retention are generally absent. Heterogeneity between studies in reported outcomes and nomenclature regarding specific facial zones and complications makes it difficult to draw conclusions. This was partly resolved by combining similar terms under 1 common nominator (eg, bruising and ecchymosis), but this may have introduced some bias. More important is the fact that several studies neglected to specify the complications and only sufficed with the annotation that there were none. These studies67 , 68 were therefore excluded, and this adds further to a possible reporting bias. Finally, the very definition of a complication of AFT in facial rejuvenation is a complicated matter and a clear consensus whether, for example, postoperative pain qualifies as a complication or part of the normal postoperative course is still lacking. A strong example thereof is the 38% rate of hematoma in the study of Zeltzer et al.,47 which deviates significantly from the reported rate in the rest of the studies, and while the authors tried to correct this by using a random-effect model, the reader should be cautious in interpreting these results. Therefore, on a methodological basis, the focus for further studies should be, first, to define complications and, second, to adhere to this definition when reporting on complications. In reporting on patient/surgeon satisfaction, the authors took certain liberties in translating Likert scales to dichotomous (satisfied vs dissatisfied) data by categorizing “moderately satisfied”—in a 3-point Likert scale—under “satisfied,” because the patients might answered differently when presented with an actual dichotomous question. This should be kept in mind when interpreting these results.
The aim of this study was to complement the broad database of descriptive reviews and expert opinions on the subject of AFT for facial rejuvenation with the addition of a more comprehensive, systematically reviewed overview of the recent literature, including meta-analysis of complications and satisfaction. The authors believe this systematic review accomplishes that by the inclusion of structured tables on important outcomes and also the exclusion of case series and case reports and studies with insufficient follow-up periods.
This systematic review provides an updated overview of the important outcomes of AFT for facial rejuvenation. Although the evidence in this review is still limited and plagued by the same heterogeneity that is often found in reporting on AFT for other indications, still, this technique is regarded as a promising method in facial rejuvenation. Although AFT has a number of obvious advantages over other dermal fillers in terms of biocompatibility, such as the absence of hypersensitivity reactions and the risks of granuloma formation, other complications such as fat necrosis have to be taken into account. Furthermore, the great variation in reported volume retentions in this systematic review suggests further studies are needed to clarify the facial-unit-specific, long-term preservation of the achieved volume before AFT can rightfully be called a true permanent filler. However, in achieving these goals, proper research should evaluate whether AFT is the superior biocompatible next-generation facial filler.
The authors would like to thank Mr. Quinten de Bakker, from the medical library, VieCuri Medical Center, Venlo, the Netherlands for his widespread assistance in the search process.
1. Champaneria MC, Workman AD, Gupta SC. Sushruta: father of plastic surgery. Ann Plast Surg. 2014;73:2–7.
2. Zins JE, Moreira-Gonzalez A. Cosmetic procedures for the aging face. Clin Geriatr Med. 2006;22:709–728.
4. Levy LL, Emer JJ. Complications of minimally invasive cosmetic procedures: prevention and management. J Cutan Aesthet Surg. 2012;5:121–132.
6. Newman J. Review of soft tissue augmentation in the face. Clin Cosmet Investig Dermatol. 2009;2:141–150.
7. Ahn CS, Rao BK. The life cycles and biological end pathways of dermal fillers. J Cosmet Dermatol. 2014;13:212–223.
8. Lee SK, Kim SM, Cho SH, et al. Adverse reactions to injectable soft tissue fillers: memorable cases and their clinico-pathological overview. J Cosmet Laser Ther. 2015;17:102–108.
9. Tepavcevic B, Radak D, Jovanovic M, et al. The impact of facial lipofilling on patient-perceived improvement in facial appearance and quality of life. Facial Plast Surg. 2016;32:296–303.
10. Boureaux E, Chaput B, Bannani S, et al. Eyelid fat grafting: indications, operative technique and complications; a systematic review. J Craniomaxillofac Surg. 2016;44:374–380.
11. Gir P, Brown SA, Oni G, et al. Fat grafting: evidence-based review on autologous fat harvesting, processing, reinjection, and storage. Plast Reconstr Surg. 2012;130:249–258.
12. Asken S. Facial liposuction and microlipoinjection. J Dermatol Surg Oncol. 1988;14:297–305.
13. Buckingham ED. Fat transfer techniques: general concepts. Facial Plast Surg. 2015;31:22–28.
14. Butterwick KJ. Fat autograft muscle injection (FAMI): new technique for facial volume restoration. Dermatol Surg. 2005;31(11 Pt 2):1487–1495.
15. Chen HH, Williams EF. Lipotransfer in the upper third of the face. Curr Opin Otolaryngol Head Neck Surg. 2011;19:289–294.
16. Coleman SR, Katzel EB. Fat grafting for facial filling and regeneration. Clin Plast Surg. 2015;42:289–300, vii.
17. Cook T, Nakra T, Shorr N, et al. Facial recontouring with autogenous fat. Facial Plast Surg. 2004;20:145–147.
18. Donofrio LM. Techniques in facial fat grafting. Aesthet Surg J. 2008;28:681–687.
19. Ellenbogen R. Fat transfer: current use in practice. Clin Plast Surg. 2000;27:545–556.
20. Fournier PF. Facial recontouring with fat grafting. Dermatol Clin. 1990;8:523–537.
21. Glasgold M, Glasgold R, Lam S. Autologous fat grafting for midface rejuvenation. Clin Plast Surg. 2015;42:115–121.
22. Handa T. Lipoinjection for periorbital rejuvenation. Jpn J Plast Reconstr Surg. 2005;48:31–38.
23. Kranendonk S, Obagi S. Autologous fat transfer for periorbital rejuvenation: indications, technique, and complications. Dermatol Surg. 2007;33:572–578.
24. Metzinger S, Parrish J, Guerra A, et al. Autologous fat grafting to the lower one-third of the face. Facial Plast Surg. 2012;28:21–33.
25. Minton TJ, Williams EF. Lipotransfer in the upper third of the face. Facial Plast Surg. 2010;26:362–368.
26. Scarborough DA, Schuen W, Bisaccia E. Fat transfer for aging skin: technique for rhytids. J Dermatol Surg Oncol. 1990;16:651–655.
27. Moher D, Liberati A, Tetzlaff J, et al; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62:1006–1012.
28. Endnote (Clarivate Analytics). X7 (computer program); 2013.
29. Savović J, Weeks L, Sterne JA, et al. Evaluation of the Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials: focus groups, online survey, proposed recommendations and their implementation. Syst Rev. 2014;3:37.
30. Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.
31. Higgins JP, Altman DG, Gøtzsche PC, et al; Cochrane Bias Methods Group; Cochrane Statistical Methods Group. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.
32. R: A Language and Environment for Statistical Computing
(computer program), 2008.Vienna, Austria: R Foundation for Statistical Computing.
33. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21:1539–1558.
34. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986;7:177–188.
35. Botti G, Pascali M, Botti C, et al. A clinical trial in facial fat grafting: filtered and washed versus centrifuged fat. Plast Reconstr Surg. 2011;127:2464–2473.
36. Keyhan SO, Hemmat S, Badri AA, et al. Use of platelet-rich fibrin and platelet-rich plasma in combination with fat graft: which is more effective during facial lipostructure? J Oral Maxillofac Surg. 2013;71:610–621.
37. Howick J. The Oxford 2011 Levels of Evidence. Oxford Centre for Evidence-Based Medicine; 2011.
38. Gormley DE, Eremia S. Quantitative assessment of augmentation therapy. J Dermatol Surg Oncol. 1990;16:1147–1151.
39. Eremia S, Newman N. Long-term follow-up after autologous fat grafting: analysis of results from 116 patients followed at least 12 months after receiving the last of a minimum of two treatments. Dermatol Surg. 2000;26:1150–1158.
40. Dasiou-Plakida D. Fat injections for facial rejuvenation: 17 years experience in 1720 patients. J Cosmet Dermatol. 2003;2:119–125.
41. Xie Y, Zheng DN, Li QF, et al. An integrated fat grafting technique for cosmetic facial contouring. J Plast Reconstr Aesthet Surg. 2010;63:270–276.
42. Monreal J. Fat grafting to the nose: personal experience with 36 patients. Aesthetic Plast Surg. 2011;35:916–922.
43. Ransom ER, Antunes MB, Bloom JD, et al. Concurrent structural fat grafting and carbon dioxide laser resurfacing for perioral and lower face rejuvenation. J Cosmet Laser Ther. 2011;13:6–12.
44. Tsai FC, Liao CK. Clinical outcomes of patients with prominent nasolabial folds corrected by the technique: dermo-fascial detachment and fat grafting. J Plast Reconstr Aesthet Surg. 2011;64:307–312.
45. Li J, Gao J, Cha P, et al. Supplementing fat grafts with adipose stromal cells for cosmetic facial contouring. Dermatol Surg. 2013;39(3 part 1):449–456.
46. Rusciani Scorza A, Rusciani Scorza L, Troccola A, et al. Autologous fat transfer for face rejuvenation with tumescent technique fat harvesting and saline washing: a report of 215 cases. Dermatology 2012;224:244–250.
47. Zeltzer AA, Tonnard PL, Verpaele AM. Sharp-needle intradermal fat grafting (SNIF). Aesthet Surg J. 2012;32:554–561.
48. Asilian A, Siadat AH, Iraji R. Comparison of fat maintenance in the face with centrifuge versus filtered and washed fat. J Res Med Sci. 2014;19:556–561.
49. Le TP, Peckinpaugh J, Naficy S, et al. Effect of autologous fat injection on lower eyelid position. Ophthal Plast Reconstr Surg. 2014;30:504–507.
50. Bernardini FP, Gennai A, Izzo L, et al. Superficial enhanced fluid fat injection (SEFFI) to correct volume defects and skin aging of the face and periocular region. Aesthet Surg J. 2015;35:504–515.
51. Schendel SA. Enriched autologous facial fat grafts in aesthetic surgery: 3D volumetric results. Aesthet Surg J. 2015;35:913–919.
52. Ibrahiem SMS, Farouk A, Salem IL. Facial rejuvenation: serial fat graft transfer. Alexandria J Med. 2016;52:371–376.
54. Ismail T, Bürgin J, Todorov A, et al. Low osmolality and shear stress during liposuction impair cell viability in autologous fat grafting. J Plast Reconstr Aesthet Surg. 2017;70:596–605.
55. Streit L, Jaros J, Sedlakova V, et al. A comprehensive in vitro
comparison of preparation techniques for fat grafting. Plast Reconstr Surg. 2017;139:670e–682e.
56. Hivernaud V, Lefourn B, Robard M, et al. Autologous fat grafting: a comparative study of four current commercial protocols. J Plast Reconstr Aesthet Surg. 2017;70:248–256.
57. Fatah F, Lee M, Martin L, et al. Lipomodelling Guidelines for Breast Surgery; 2012.
58. Rennekampff HS, Dusseldorf GB, Rezek D. Leitlinie “Autologe Fetttransplantation”; 2015.
59. Shim YH, Zhang RH. Literature review to optimize the autologous fat transplantation procedure and recent technologies to improve graft viability and overall outcome: a systematic and retrospective analytic approach. Aesthetic Plast Surg. 2017;41:815–831.
60. Grunebaum LD, Bogdan Allemann I, Dayan S, et al. The risk of alar necrosis associated with dermal filler injection. Dermatol Surg. 2009;35 Suppl 2:1635–1640.
61. Lazzeri D, Agostini T, Figus M, et al. Blindness following cosmetic injections of the face. Plast Reconstr Surg. 2012;129:995–1012.
62. Peter S, Mennel S. Retinal branch artery occlusion following injection of hyaluronic acid (Restylane). Clin Exp Ophthalmol. 2006;34:363–364.
63. Kang YS, Kim JW, Choi WS. A case of sudden unilateral visual loss following injection of filler into the glabella. Korean J Dermatol. 2007;45:381–383.
64. Goldberg DJ. Breakthroughs in US dermal fillers for facial soft-tissue augmentation. J Cosmet Laser Ther. 2009;11:240–247.
65. Imadojemu S, Sarwer DB, Percec I, et al. Influence of surgical and minimally invasive facial cosmetic procedures on psychosocial outcomes: a systematic review. JAMA Dermatol. 2013;149:1325–1333.
66. Hibler BP, Schwitzer J, Rossi AM. Assessing improvement of facial appearance and quality of life after minimally-invasive cosmetic dermatology procedures using the FACE-Q scales. J Drugs Dermatol. 2016;15:62–67.
67. Kornstein AN, Nikfarjam JS. Fat grafting to the forehead/glabella/radix complex and pyriform aperture: aesthetic and anti-aging implications. Plast Reconstr Surg Glob Open 2015;3:e500.
68. Mailey B, Saba S, Baker J, et al. A comparison of cell-enriched fat transfer to conventional fat grafting after aesthetic procedures using a patient satisfaction survey. Ann Plast Surg. 2013;70:410–415.
Supplemental Digital Content
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.