The art of fat injection in the face

Fat injection —or fat transplant as it is called by plastic surgeons—has recently become a very hot topic of discussion.  In order to understand why it is garnering so much interest, it is crucial for patients and plastic surgeons to be informed not only about the procedure itself, but about why medical methodology and surgical artistry are paramount to the success of the treatment.

WHAT IS FAT INJECTION ?

Fat transplant is the addition of a filler that can be used anywhere in the body to correct the appearance of skin depressions following the loss of tissue caused by aging or trauma.  Most commonly it is used in the face, buttocks, and breasts.  The ideal material to restore fat loss—caused by the depletion of fatty tissue—is fat itself, harvested from other areas of the body.

WHAT HAPPENS WITH AGING ?

The majority of patients seek fat transplant as a result of aging. Over time, fat loss occurs in both deep compartments, which are close to the bony structures of the face, as well as in superficial compartments that are nearer to the skin.  Both contribute to the loss of a youthful appearance, and plastic surgeons ideally should augment each area during a fat transplant procedure.  But let’s consider skin laxity—or lack of tightness—as well.  Laxity is a condition that increases with age due to the effects of gravity, but it is also impacted by diet, genetics, stress, and sun exposure, among other factors.   Most patients approach plastic surgeons for a facelift to correct skin laxity, however, this procedure often does not take into account the loss of fat volume under the skin.  Therefore, optimal results cannot be achieved solely by this type of surgery. Restoring volume by fat injection is often more effective—and a far less involved procedure—than correcting tissue laxity through surgery.  As an added bonus, when restoring volume loss with fat injection, skin laxity is often improved, eliminating the need for a facelift entirely if skin laxity is moderate. However, fat transplant can be combined with a facelift procedure if severe laxity of the skin is present.

WHAT MAKES FAT INJECTION SUCCESSFUL?

In order for fat transplant to yield desirable results, it is imperative to consider the plastic surgeon’s artistry.  While the technique of fat placement in the face involves volume and location, there are other areas of concern that come into play.  Having performed close to 6,000 of these procedures—with a high satisfaction rate—has helped me to develop a highly skilled method of not only knowing the ideal fat ratio, but also a deft understanding of how to achieve optimal rejuvenation. This is where knowledge, experience, and considering the patient’s needs and aesthetic come into play.  As fat transplant is an office procedure performed under local anesthesia, my surgical methodology is to restore volume in the deep compartments as well as the superficial ones during the same session. The surgeon must also carefully consider both the location and the volume of fat to be injected.  It is easier to add more fat at a later time than it is to remove excess fat.  When seeking this type of plastic surgery, most patients do not want to alter their appearance as much as they want to refresh their look.  Therefore, a conservative approach is the key to success. As the treatment is done under local anesthesia, it is usually tolerated quite well and the patient is able to return to work the next day, greatly reducing healing time and offering a speedier resumption of daily activities.  Because of the lack of invasiveness of the procedure, there is also minimal discomfort and swelling.

IS IT COST- EFFECTIVE ?

Many patients are concerned about the cost of the treatment; it is important to realize that non-surgical options have significant drawbacks. Currently there are many fillers on the market that are available and ready to use in a sterile syringe. However, in contrast to fat injections, these options are all temporary and require repeated injections for one to two years.  In addition, the repetitive nature of the procedure becomes a great financial burden on the consumer.  And, using one’s own fat tissue is also highly preferable to injecting the body with potentially questionable fillers. (The exception is wrinkle treatment for which artificial fillers are still the method of choice.) By contrast, fat transplant done properly lasts for a period of years. Another advantage of fat transplant is that the appearance of ecchymosis (black and blue markings) at the injection site is rare.  This condition can often develop through syringe injections due to the use of blunt-tipped cannulas.

WHAT IMPORTANT ARTISTIC DECISIONS NEED TO BE CONSIDERED?

With aging, the nine areas that need to be addressed as far as augmentation include: the temple area, the nasal jugular, the malar, the sub malar (under the cheekbones), the nasolabial area, the marionette lines, the medial cheeks (lateral to the nose), the pre-jowl area, and the lips.  The treatment is individual and is tailored to each patient.

HOW DOES SURGICAL APPROACH DIFFER BETWEEN MEN AND WOMEN?

There are significant differences to consider between men and women.  In men, the surgeon needs to be conservative, avoiding augmenting the cheeks and concentrating on the nasal jugular, nasolabial grooves and improvement of the jawline and chin if necessary.  In women, cheek augmentation is very useful for restoring a youthful look while at the same time enhancing overall appearance.

WHAT ABOUT CHEEK AUGMENTATION?

In men and women, surgeons must be conservative when considering cheek augmentation if the chin is deficient.  The exception to this, of course, is if the patient is undergoing chin augmentation at the same time as the other procedures. In addition, the surgeon must decide if there is a need to augment the submalar, the malar area, or both.  Extending the augmentation laterally on the side should be minimized in individuals with wider facial structures since it may create an even broader look that may not be desired.  On the other hand, narrow-faced individuals often choose to augment the cheeks laterally together with the submalar area to create more balance and harmony in the face.

HOW DOES FACIAL HARMONY PLAY A ROLE?

There is a need for careful analysis of the facial structure in addition to demonstrating potential improvements to the patient in front of a mirror.  For example, when analyzing the need for cheek augmentation, a surgeon must look at the oblique view of both sides of the face and take into consideration the length, height, and width of the face as well as the degree of nasal and chin prominence.

WHAT ABOUT LIP AUGMENTATION?

Upper lip augmentation should also be conservative. If the upper jaw (maxilla) is prominent, or the lips are wide, then it is important that upper lip augmentation is minimal.  At the same time, the “M” shape of the upper lip needs to be preserved.  Augmentation of the lower lips is advisable if the chin is prominent.

SHOULD PATIENTS CHOOSE A MINI FACELIFT OR FAT INJECTION ?

In the pre-jowl area, a common place of concern to women aged 40 and up, a decision should be made as to whether or not to fill this area or to proceed with a mini facelift procedure.  If the jowl is prominent enough to create a square look of the face then the preferred approach would be a facelift in order to restore the more triangular youthful look.

It is not surprising that many patients opt for non-surgical rejuvenation by choosing a fat transplant.  Many times volume restoration by fat is so impressive that it can render the surgical approach unnecessary.  It is cost-effective, offers quick recovery time, and can be an enhancement for younger patients and a procedure for more mature patients looking to restore their youth.

 

Dr. Yoel Shahar, MD is a plastic surgery specialist in New York, NY and has been practicing for 28 years. He graduated from Hadassah Medical School, The Hebrew University Of Jerusalem in 1973 and specializes in plastic surgery.

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