IDEAL FACE®

Fat Injection

Ideal Lips

Facial Fat Injection Sites. The minimum number of incisions is used. Note that the lips are treated using a single incision for each lip, tucked on the inside of the left corner of the mouth.

INTRODUCTION

Fat injection is a very popular treatment on its own or in combination with other facial procedures. Today we recognize that part of the aging process involves loss of fatty tissue from the face. Restoring this lost volume is a key part of facial rejuvenation. In my practice, most patients having facelifts also have fat injection.

Advantages of Fat Injection

The advantages of fat injection compared with “off-the-shelf” fillers such as hyaluronic acid (HA) fillers (Juvéderm) include:

It is your own tissue.
There is usually an abundant supply so that large volumes can be injected.
It provides living cells, some of which will survive the transfer and provide lasting results.
Stem cells (adipose-derived stem cells) are injected with the fat.

Some investigators believe that stem cells can improve the quality of the overlying skin.

Is Fat Injection a New Procedure?

No, fat injection is not new, but definitely refined! When I was in residency in the 1980s, fat injection had a bad reputation. Some surgeons cautioned, “It looks good at first but then it gets absorbed.” In retrospect, this observation is not surprising. In the past, fat was suctioned and injected using high suction and injection pressures through small caliber needles that would break up the fragile fat cells. Fat injection received an upgrade with the development of liposuction. Plastic surgeons learned better how to manipulate fat and use less traumatic instruments. Influenced by the work of Dr. Sydney Coleman of New York City in the 1990s, plastic surgeons learned better techniques so as not to break up the fat cells when harvesting and injecting fat. This “kinder, gentler” fat transfer allowed fat cells to survive the transfer to their new location. Long-term results became possible.

Surprisingly, even today, many surgeons do not regularly perform fat injection. They may say that fat injection is just not predictable, or they have encountered problems with unevenness.

With proper technique and experience, predictability improves and problems become fewer. Fat injection should be part of every plastic surgeon’s armamentarium because there is no better filler. It is one of the best tools I have learned since residency and I use it in almost every patient over the age of 50 undergoing facial rejuvenation. I also perform fat injection regularly in the hands and buttocks, and occasionally in the breasts and other parts of the body where filler is needed.

Fat Injection in the Lips

It is not unusual for women to be nervous about fat injection, particularly in the lips. They are worried about looking ridiculous afterward (there are a number of celebrities’ names that are mentioned as examples). However, women (and men) readily appreciate that their lip volume and fullness is less than it was when they were 20 years old. They have lost firmness, and the lips have become more flaccid. I reassure them that the amount of fat injected can be conservative, simply a restoration of lost volume. Any woman who wears lipstick appreciates the aesthetics of lips. Increased lip volume is impossible to duplicate with lipstick or other commercial products that are applied to the surface. Lipstick that goes over the natural border of the lip looks unnatural, even clownish.

Is Fat Injection Compatible With Other Fillers?

Yes. A patient who has had fat injection in the past can have injections of commercial fillers (such as Restylane and Juvéderm) afterward and vice versa. A patient may decide to have an injection of hyaluronic acid in the office, to see if she likes it, and return for fat injection later. Alternatively, a patient treated with fat injection may have a touch-up in the office with hyaluronic acid (HA) at a later date to increase fullness or to compensate for any fat that has dissolved. Of course, a touch-up fat injection is also possible.

PATIENT PHOTOS

J.J., Age 26
Procedure: Fat Injection of lips (3 cc per lip)

Before, 1 month after

T.S., Age 37
Procedure: Fat Injection of lips (3 cc per lip) and nasolabial creases (2 cc per side)

Before, 2 months after

J.M., Age 37
Procedure: Fat Injection of lips and submental lipectomy.

Before, 3 months after (with makeup)

L.H., Age 38
First Procedure: Lower blepharoplasties, fat injection of lips and nasolabial creases, periorbital and perioral erbium laser resurfacing. Second procedure; 4 years later: Upper blepharoplasties. Third procedure; 7 years later: Submental lipectomy

Before, 1 month after, 8 years after

M.K., Age 39
Procedure: Facial fat injection (55 cc), repair of witch’s chin, Botox injection of forehead and crow’s feet.

Before, 6 weeks after

V.L., Age 45
Procedure: Facial fat injection (46.5 cc) and CO₂ laser resurfacing

Before, 3 months after

V.C., Age 48
Procedure: Fat injection of lips and nasolabial (smile) creases (14 cc)

Before, 3 days after, 11 days after

Fat injection may be done awake under local anesthesia or asleep under intravenous sedation. If a small area is being treated, such as the lips and smile creases, this may be done awake. However, if other areas of the face are being treated, or if other procedures are being done simultaneously, it is more comfortable for the patient to be asleep.

Donor Site Selection

The abdomen usually serves as the fat donor site, but other areas can be used too. On very thin women, the outer thighs are a good alternative donor site. Sometimes patients ask if the fat under the chin can be used as a source. It does seem like an obvious choice, but there is usually insufficient fat in this location.

Technique

Local anesthetic is injected and fat is withdrawn (aspirated) using a mini-liposuction cannula. Presently, I use a fat collection system called “LipiVage” that separates out the fat component as it is suctioned. The “pure fat” component is prepared by the nurse in small syringes and then injected using a tiny cannulae. These thin metal tubes are a little bigger than needles, so that the fat globules can be injected with less chance of breaking up the fat cells. Also, the tip is rounded to avoid trauma to the tissues or possible injection into a blood vessel.

Typical areas for fat injection

• Lips

• Smile creases (“nasolabial creases”)

• Creases at the corners of the mouth, called “marionette lines” or “labiomandibular creases.”

• Other areas—cheeks, tear troughs, jawline, chin crease, eyebrows, temples, and the frown lines between the eyebrows.

Incisions

Fat injection is done using tiny incisions. Incisions are needed because the injection instrument is not a needle but a narrow blunt-ended hollow cannula. This is different from injection of other fillers, which are injected through a needle. If fat were injected through a needle, the fat cells would likely break up from the extra trauma of being forced through such a narrow passage. The fat cells would not survive the transfer and would be absorbed. In fact, this was a problem with early techniques, before liposuction made surgeons more comfortable using blunt-ended cannulae. The little incisions are closed with a single suture; the scars are almost invisible.

How Are the Fat Cells Injected?

I prefer to minimize the number of passes under the skin because I believe this causes less tissue trauma, and therefore less swelling. The goal is to deliver more transplanted fat cells using fewer injections, causing less trauma, less swelling and an easier recovery. Also, the fat cells are more likely to “take” with less injury to the recipient tissues providing blood supply to the transplanted fat cells. Using this approach, there are fewer alternative paths for the fat cells to take so they are less likely to migrate.

Bruising and Swelling

As might be expected, there is swelling of the treated areas and probably some degree of bruising. There is also bruising at the donor site where the fat was harvested, usually the tummy. Sometimes patients are surprised at how much bruising there is on the tummy.

Absorption

I typically inject a little more than the replacement volume, knowing that some of the fat will be absorbed. There is variability in fat take from one site to another and between patients. However MRI studies on our patients showed excellent retention of fat injected in the cheeks (Swanson E. Malar augmentation assessed by magnetic resonance imaging in patients after facelift and fat injection. Plast Reconstr Surg. 2011;127:2057–2065).

Injecting too much fat in the lips can be counterproductive, because there will be more absorption as fewer fat cells gain a blood supply from the surrounding tissue. For example, injecting 3.5 cc of fat in the upper lip may provide an ultimately fuller lip than injecting 5 cc or more because of reduced absorption when greater volumes are injected. There is a limit to the increment in fullness from one fat injection. This is one reason that patients do not need to be overly concerned about having too much lip fullness after one fat injection treatment.

Asymmetry

There may be more swelling on one side than the other shortly after injection. This asymmetry tends to correct itself as the swelling subsides. Although I measure the amount of fat injected, persistent asymmetry is possible.

Nodules

In most cases, nodules gradually settle down. If a few months have been allowed and there is a persistent visible nodule, this may be excised using a small incision. If the nodule is one you can feel but not see, it probably represents scar tissue that will eventually soften and it is best to just be patient and let it improve with time. The tear trough areas are notorious for such nodules and these unforgiving areas demand expertise on the part of the surgeon to fill in the troughs without causing conspicuous irregularities.

Infection

Fortunately, infections are rare on the face.

Fat Embolus

This is a scary complication indeed. Presumably, a fat globule enters one of the little arteries supplying an area of skin of the face, potentially causing skin loss or even blindness. Of course, this is very rare. Recommended techniques to reduce this risk include the use of blunt injection instruments (as opposed to sharp needles) and low-pressure subcutaneous injection. Preoperative injection with lidocaine and epinephrine probably helps by shrinking the blood vessels. Pre-injection also lessens the potential for bruising.

Fat Hypertrophy

If there is significant weight gain after surgery, the transplanted fat cells may also enlarge, causing excessive fullness in the treated areas. Fortunately, this is seldom a problem in practice.

Getting Back to Normal

• Swelling and bruising are normal. At first, the lips look very swollen, but the swelling subsides quickly. There is a big difference within the first 24 hours. Do not be concerned that your lips will look too big. When the swelling goes down, they will be fine.

• There are small sutures at the site of fat injection. These are typically removed between 2 and 5 days after surgery.

• You can start bathing the day after surgery. It’s OK for the sutures to get wet. Apply a small amount of Neosporin ointment to the wounds.

• You may feel the little sutures at the left corner of the mouth. There are no sutures on the right side because the instrument is long enough to allow injection all the way across the lip from the left side.

• Asymmetry is usually caused by swelling and tends to even out as the swelling goes down.

• The injected areas feel hard. When tissue spaces under the skin fill with fluid, they feel surprisingly firm. This is normal and this firmness gradually softens.

Q: Where do you get the fat from?

A: The donor site is usually the abdomen. In very thin patients, I tend to use the outer thighs. There is almost always extra fat in these areas in women.

Q: How long does the injected fat last?

A: Plastic surgeons do not have a good answer for that question. We know that the injected fat can develop a new blood supply and survive in its new “home.” The percentage of take is variable. At least some of the fat is absorbed, typically within the first month after surgery. Accordingly, plastic surgeons tend to over-inject slightly, anticipating that some of the injected fat will not take.

Q: Will I bruise?

A: Yes, you will likely have some degree of bruising.

Q: Do you inject the fat with a needle, like Juvéderm?

A: No, fat is injected using a small injection cannula. A needle would likely cause excessive trauma to the fat cells.

Q: Can the fat move around?

A: No. When the fat is injected in little tunnels under the skin, it is unlikely to move around because the little fat globules are held in natural tissue compartments. For this reason, the surgeon is careful to place the fat just where it is needed. Although some operators make numerous passes with the cannula, I try to limit them so that the fat does not have other paths to follow. Limiting passes also helps reduce swelling because there is less tissue trauma.

Q: When will I be comfortable in public?

A: Recovery time depends on the amount of swelling and bruising, how much fat is injected, and your comfort level looking a little swollen. Most patients are quite self-conscious about their appearance during the week after the fat injection.

Q: I’m nervous about having my lips enlarged. How can I be sure they are not too big afterward?

A: No one wants to be ridiculed. A good rapport with the surgeon is the key. Before surgery, many patients worry that their lips will be too big. After the fat injection, patients are worried that the fullness will go away! Lip augmentation does not have to be “all or none.” The surgeon may inject a small volume of fat in the patient who wants to be conservative and more in the patient who desires more volume.

Q: Do you do fat injection in men’s lips?

A: Yes. Men do not need to have thin, old-looking lips any more than women do. Frequently when I perform other facial cosmetic procedures in men, I inject a small amount of fat in the lips simultaneously.