Autologous fat transfer (AFT) is a practical option for those patients desiring a more dramatic global change in facial appearance. Recent anatomic research suggests that facial fat is delineated in discreet fat compartments that change morphologically over time.7 Therefore, using fat as a filler is done with the intent of restoring the youthful architecture to these fat compartments. This provides broader rejuvenation to the aging face affected by volume loss. Fat is a versatile filler, effective in the periorbital area as well as the lips. Because it is autologous, it is the filler of choice for patients with collagen vascular disease or proven allergic reactions to collagens or hyaluronic acids. AFT is a more involved surgical procedure than the injection of the other fillers previously discussed. Exclusion criteria for treatment include concomitant anticoagulant treatment and poor health.
Preparation and Anesthesia
For 2 weeks before the initial AFT procedure, the patient must stop taking all nonsteroidal anti-inflammatory drugs, vitamin E, ω-3 fatty acid supplements, and ginkgo, ginger, or ginseng supplements. The patient is instructed to begin therapy with an appropriate antistaphylococcal antibiotic starting the day before procedure. On the day of the procedure, the donor fat site and the face are both washed with an antibacterial soap. The physician then delineates the area to be suctioned with a marking pen. Every attempt should be made to choose a donor site that benefits a patient aesthetically. The outer thighs and hips in women and the flanks in men are usually good sites for fat harvesting.
In preparation for fat transfer, a pattern is drawn on the face delineating the areas in which fat is to be placed and highlighting any scars or baseline asymmetry. The patient is then placed on a sterile, draped operating table and the areas requiring fat suctioning are infiltrated with dilute local anesthesia until turgid (tumescent technique; Table 254-2; see Chapter 253).
Table 254-2 Tumescent Anesthesia Solution
It takes at least 20 minutes for the epinephrine in the tumescent fluid to achieve hemostasis. The face is then anesthetized diffusely with dilute 0.5% lidocaine with epinephrine 1:200,000, and segmental nerve blocks are established where appropriate. For safety, the total lidocaine dose in the tumescent fluid should not exceed 35 mg/kg of body weight.
Suctioning of the fat used for transplantation should be done by hand with an open-tipped harvesting cannula attached to a 10-mL syringe. After a hole is made with a 1.5-mm punch or No. 11 blade, the cannula is inserted into the deep fat and moved back and forth while the plunger on the syringe is retracted. Fat collection usually occurs quite rapidly and, due to the vasoconstrictive properties of the tumescent fluid, is nearly bloodless. After fat extraction, the syringes may be placed into a centrifuge and spun at 3,400 rpm for 20 seconds or left to stand for 20 minutes to allow separation of the hydrophilic tumescent fluid from the lipophilic fat. The infranate of tumescent fluid should then be decanted before the fatty layer is transferred to 1-mL syringes in preparation for injection into the face. Any supranate of ruptured fat cells (triglycerides and free fatty acids) should be discarded.
All AFT to the face is performed with the patient fully supine using an 18-gauge or smaller blunt cannula for infiltration. Incision sites can be made with an 18-gauge needle, a NoKor needle (Becton, Dickinson and Co., USA), or the tip of a No. 11 blade scalpel. Fat is infiltrated in a retrograde manner; that is, fat is injected only as the cannula is withdrawn. Injection is in small aliquots of 0.1 mL or less using a threading or depot method. Placement of fat always starts closest to bone when possible and then proceeds up through muscle and into subcutaneous fat. Fat is deposited in a crosshatched three-dimensional lattice and thus imparts structure as well as augmentation to the tissues. All areas of the face should be addressed to achieve filling laterally as well as anteriorly. The goal is to advance tissues forward and thereby elevate them away from the bone, fill in areas of shadow, and restore youthful contours.
Immediately after the procedure and on and off for the next 2 days, ice should be applied to the face. The area suctioned is dressed with absorbent pads, and a snug garment is applied. Incision sites on the body and face are left unsutured. The patient is instructed not to submerge the body in water until all incisions are healed (approximately 1 week). Antibiotics must be continued for 6 days after the initial procedure. Intramuscular triamcinolone may be given to reduce postoperative edema.
Postoperative edema and ecchymoses are common and last for approximately 2 weeks. Undercorrection with a gradual decrease in augmentation is common and usually represents a decline in edema rather than absorption of the fat. For this reason, fat transfer should never be recommended as a one-time procedure but rather as a series of treatments with cumulative augmentation and long-term results. Small, persistent lumps can occur that represent either fat cysts or accumulation of fat. They can be treated, usually to resolution, with intralesional injection of triamcinolone (2–4 mg/mL). If a larger fat lump is present, the best option is to feather it into the surrounding tissues with an infiltration cannula. Irregularities can also occur at the harvest site, but operator experience and judicious removal of fat makes this a highly unlikely event. Rarely, infections such as atypical mycobacteria can be seen and should be in the differential diagnosis for any nodules occurring up to 1 year following AFT.
Many authors using a standardized, multilevel microinjection technique have published photodocumentation of long-term follow-up demonstrating persistence of autologous fat (Fig. 254-4).8 However, the controlled, double-blinded, multicenter studies available for evaluation of other fillers have not been done.
Fifty-five-year-old woman before (A) and 20 months after (B) full-face fat transfer treatment series.