The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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ecognizing the components of the aging deformity of the face and appreciat-
ing the underlying anatomic abnormalities are essential to selecting the ap-
propriate treatment and planning surgical procedures. Careful analysis will reveal
that most patient problems fall into three broad categories:
1. Aging and breakdown of the skin surface
2. Facial sagging, skin redundancy, and loss of youthful facial contour
3. Hollowing, wasting, atrophy, and/or age-related lipodystrophy of the face
Selecting the appropriate treatment will depend on the types of problems present,
the patient’s priorities, and the time, trouble, and expense she or he is willing to ex-
pend to obtain the improvement desired.
Patients primarily concerned with surface aging of their faces may not require for-
mal open surgery; they may be able to achieve the improvement they desire through
salon care and dermatologic surface treatments of the skin. These treatments include
skin peels, skin resurfacing, intense pulsed light (IPL), chemodenervation (botulinum
injections), injection therapy (with tissue fillers such as Restylane, Juvéderm, and
Radiesse), and various forms of cutaneous laser and other treatments designed to
remove or reduce age spots, spider veins, wrinkles, and other age-related skin sur-
face imperfections.
Patients primarily concerned with facial sagging, skin excess, and loss of facial con-
tour will achieve marginal, if any, improvement if only surface treatments are em-
ployed. They will require formal surgical lifts in which sagging tissue is repositioned
and redundant tissue excised if these problems are to be properly corrected and an
attractive and natural-appearing improvement is to be obtained. The misapplication
of surface treatments of the skin to a sagging face with excess tissue will produce lit-
tle more than a smooth, saggy face with no improvement in contour. This sort of
“smooth-saggy” look, typically seen in an older patient who has undergone laser
resurfacing, is unnatural looking, because patients with a loss of facial contour gen-
erally have concomitant skin surface aging. It is arguably more attractive and natu-
ral appearing to have a well-contoured face with a few wrinkles and surface imper-
fections than a smooth but saggy one.
In patients with significant facial atrophy, age-related hollowing, and loss of facial
fat, improvement from both surface treatments of facial skin and surgical lifts will
generally be suboptimal. Smoothing the skin will not hide a drawn appearance caused
by loss of facial volume, and it is difficult to create aesthetically pleasing, natural,
and attractive contours by lifting and repositioning tissues that have abnormally
thinned and involuted with age. Using fat injections to restore lost facial volume is
a powerful technique that is now acknowledged by most plastic surgeons and other
physicians who treat the aging face to be the most important advance in aesthetic
surgery in several decades or more. Properly performed, the addition of fat to areas
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Chapter 47  Combined Face Lift and Facial Fat Grafting
of the face that have atrophied from age or disease can produce a significant and
sustained improvement in appearance that is unobtainable by other means.
Why Perform a Face Lift and Fat Injections?
Why not perform just a face lift? The answer to these questions lies in the multifac-
torial origin of facial aging, and the fact that fat is predictably lost from the face,
which develops hollows as a person ages, in addition to sagging, drooping, and other
gravitational effects. An isolated face-lift procedure, even when aggressively and com-
prehensively performed, only addresses tissue ptosis and redundancy and often pro-
duces a lifted but telltale hollow and an underrejuvenated look, sometimes referred
to as a “cougar” appearance. Fat injections, however, allow the loss of facial fat to
be treated concurrent with the face lift, and these appearances to be avoided.
All things being otherwise equal, a concurrent face lift and fat injections will pro-
duce a better result than either technique performed alone, and when a face lift is
performed in conjunction with fat injections, both loss of contour and facial atro-
phy can be corrected, and optimal improvement can be attained. This 75-year-old
patient, seen preoperatively on the left, had tissue ptosis and redundancy, and sig-
nificant facial atrophy. On the right, she is shown 1 year and 17 months after a high
SMAS face lift, a neck lift, a closed forehead lift, upper and lower bleph aroplasties,
and panfacial fat injections. Combined lifting and filling of her face has produced a
better outcome than either technique could have alone. The patient has had
hyaluronic acid filler placed in her lips.

Volumetric Rejuvenation
Fat injections have other advantages for the face lift surgeon: they provide volumet-
ric rejuvenation, a new means by which to improve facial appearance and a new di-
mension for plastic surgeons to work in. Unlike injectable fillers, fat is autologous
and produces a sustained and long-lasting improvement. In addition, fat injections
may actually induce an improvement in facial tissue quality through an as yet not
clearly defined “stem cell effect,” and when performed with a face lift may consti-
tute, for the first time, rejuvenation in the true sense of the word.
Nomenclature
The nomenclature for autologous fat transplantation can be confusing, since sur-
geons and others who inject fat into the face have used various terms to describe the
procedure. In addition, in an effort to market the procedure, many proprietary mar-
keting names and catch phrases have been created, and these can be especially con-
fusing to patients. In essence, the commonly used terms fat transfer, fat grafting, au-
tologous fat grafting, autologous fat transplantation, fat injections, lipofilling, and
lipoinjection all refer to the same basic procedure. We typically use the terms fat in-
jections or fat transfer in our discussions with patients, because these are straight-
forward descriptive terms that do not include medical jargon and are most easily un-
derstood and remembered.
Additional confusion has been created by the term stem cell face lift, a procedure in
which fat is variously injected into the face with the purported but as yet unproven
benefit of tissue rejuvenation mediated through a “stem cell effect.” In most cases fat
only is injected, but in some cases limited traditional face lifts are performed con-
currently. At present it is a stretch of the available scientific data to make such a claim,
and it is medically more correct to refer to the two procedures simply as combined
but separate and distinct surgeries.
Drawbacks of Fat Injections
Performing fat injections in conjunction with a face lift has certain disadvantages
that must be acknowledged, including the learning curve associated with any new
procedure, the increase in operating room time, increased postoperative edema, a
longer period of recovery, and the uncertainty of graft take. Certain patient mis-
conceptions must also be overcome, including misguided notions held by many that
injected fat can migrate or fall, or that fat injections will make the face “look fat.”
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Chapter 47  Combined Face Lift and Facial Fat Grafting
Personal Evolution in Fat Grafting in the Face
I performed my first fat grafting procedures almost two decades ago; these were usu-
ally limited in scope, targeting specific areas such as the lips and nasolabial creases,
as is the case for most beginning injectors. Over time, I began to address bigger prob-
lems that were otherwise difficult to treat, including overexcision of buccal fat by
other surgeons, HIV-associated facial wasting, and the hollow upper orbit.
Buccal fat excision is often erroneously recommended as a way of creating a “high
cheekbone” and a more angular facial appearance. In reality, it often produces an ill,
haggard, gaunt appearance and an unfeminine look in women, especially when per-
formed aggressively. This patient had buccal hollowing following buccal fat excision
by an unknown surgeon. The patient is shown 11 months after fat injections to the
buccal area. Fat was also placed in the infraorbital, midface, cheek, preoral, and jaw-
line areas.
Still later, I expanded my use of fat injections to the treatment of thin-faced patients
with significant atrophy but minimal sagging and redundancy who mistakenly be-
lieved a face lift alone would help them, and secondary and tertiary face-lift patients
who had cervicofacial fat that had been erroneously removed by other surgeons dur-
ing the primary procedures. For these secondary and tertiary face-lift patients, the
fat injections quickly became more important than the face lift itself, and this re-
mains true to this day.

This thin-faced man with marked facial atrophy but minimal tissue sagging and re-
dundancy had had no prior surgery when he presented requesting a face lift. He is
shown 16 months after fat injections to the infraorbital, midface, cheek, and jawline
areas. No implants were placed, and a face lift was not performed. Improvement is
evident in all areas, and the patient appears healthier, more fit, athletic, and mascu-
line. A face lift alone could not have produced this kind of improvement and arguably
might have accentuated his facial hollowness.
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This woman had a previous face lift and related procedures performed by an un-
known surgeon. She is shown 13 months after a combined secondary face lift and
panfacial fat injections. She has also undergone foreheadplasty, eyelid surgery, pto-
sis correction, a neck lift, and perioral dermabrasion. Although the face lift allowed
scars to be moved to more concealed locations and corrected her earlobe malposi-
tion, the replenishment of lost facial volume with fat injections was more important
to the overall outcome of the procedure. Significant improvement of facial atrophy
can be seen in the temples, upper and lower orbits, cheeks, midface, lips and peri oral
area, over the buccal recess, and along the jawline.

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Chapter 47  Combined Face Lift and Facial Fat Grafting
In time, however, I came to recognize that I was not obtaining full correction in many
of my own primary face-lift patients, no matter how careful and technically profi-
cient I was at lifting their ptotic tissue and removing excess skin. In most cases, re-
gardless of how skillfully the procedures were performed, the patient still lacked the
healthy, fit, and sensual appearance that younger faces with more facial fat had.
Other facts confirmed for me the concept that the volume addition to the aging face
had artistic merit, including patients’ and surgeons’ preoccupation with the swollen
face. I observed that patients overwhelmingly liked the appearance of their faces the
first few weeks and months after traditional face-lift procedures, because the swelling
present at that time gave them an almost surreally youthful appearance. Plastic sur-
geons also seem to like the swollen face for the very same reason, as is evident in the
early face-lift results typically shown in advertisements, on the Internet, and even at
scientific meetings and symposia. Although showing early results in these ways is de-
ceptive and without scientific merit, it nevertheless affirms the importance of vol-
ume to an attractive and youthful appearance.
As groundbreaking as the idea of volume addition to the face was, at some point
I came to realize that fat injections may offer something far more profound than just
added volume, but I was slow to recognize this. My first realization that something
above and beyond simple volume addition might result from fat injections was at an
instructional course I was giving on face-lift surgery at a plastic surgery conference.
After showing a large series of well-matched high-resolution before-and-after pho-
tographs of face-lift patients, a member of the audience raised his hand and inquired,
“What type of laser and what energy settings are you using to resurface your pa-
tients?” I answered that other than limited perioral dermabrasion in some cases,
none had had resurfacing of any kind. Confused by my response, he followed up by
asking, “Then why do they all look so smooth?” Missing the significance of his ques-
tion at that moment and the importance of his observation, my answer was simply
that “they had had face lifts.” I could not make any connection to the fat injections
they had also received as part of their face-lift procedure. But he was seeing some-
thing in my patients that I had overlooked, or erroneously assumed to be solely the
result of traditional surgery, that he was not seeing in his own face-lift patients. This
difference is now known to very likely be the result of the much talked about but as
yet not clearly scientifically defined “stem cell effect” obtained with fat injections.
Simply put, fat contains “adult stem cells” that are thought to elaborate “growth
factors” and other yet to be defined cellular “mediators” that appear to have a ben-
eficial and regenerating effect on tissues adjacent to where the fat is injected, and it
is likely that injecting fat into the face as part of a face-lift procedure has a rejuve-
nating and regenerative effect of this sort on the facial skin. Numerous anecdotal ac-
counts and a growing number of scientific reports now support this idea, and fat

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is currently being used to successfully treat atrophic scars, radiation necrosis, and
other problem wounds that were previously deemed untreatable. It is my opinion,
and that of other surgeons, that the combination of fat injections and dermabrasion
is arguably the most effective treatment we currently have for peri oral wrinkles, but
this may be the result not only of restoring lost volume and the traditional im-
provement gained from dermabrasion, but also may reflect a direct regenerative stem
cell effect. Only further research can conclusively answer the question as to whether
fat injections can actually improve skin quality and facilitate healing through an
adult adipocyte-mediated stem cell effect, but this is now a widely held belief by many
clinicians.
Over time, I began to look beyond the lines and grooves on the face that had previ-
ously held my attention and that typically gain the notice of the traditionally trained
eye, and I came to see the loss of facial fat as an undeniable and important panfa-
cial occurrence requiring comprehensive replenishment. I have also since come to
recognize the face as an incredibly nuanced sculptural form, and fat injections as an
astonishingly powerful tool to improve the outcome of my face-lift procedures.
My initial attempts to discuss the importance of fat injections in rejuvenating the ag-
ing face with patients was met with confusion and skepticism by many of them. The
initial reaction by most patients was that they were “already too fat,” and that fat
injections would just make them “look fatter.” They could not see atrophy and loss
of facial fat as part of the aging deformity of their face. As a result, my initial use of
fat in my face-lift patients was to tell them that we would do their face lift first, move
sagging tissues to a more youthful position, remove excess skin, then reevaluate them
6 months after the procedure and perform fat injections at that time, if indicated. In
some instances patients would submit to a second-stage fat injection procedure, but
for quite a while it was an uphill battle. Over time, however, the concept of adding
volume to the face and the beneficial effects of doing so became known to prospec-
tive patients through the educational efforts of a handful of early adopters of the fat
injection technique, through the resulting increased exposure of the procedure in the
lay press, and through patients’ growing experience with nonautologous injected
fillers. As patients came to understand the procedure and its benefits, they began to
reject my suggestion that fat injections be performed as a second stage. Many pa-
tients began to arrive in my clinic knowing that fat injections were needed and did
not feel they could take the time off from their personal and professional lives to un-
dergo a second-stage procedure. These patients asked if I could do both their face
lift and fat injections at the same time. I responded that I felt I could, and I was

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Chapter 47  Combined Face Lift and Facial Fat Grafting
stunned by the results when we did so. Today I feel as if I have “one hand tied be-
hind my back” when I must perform a face lift without fat injections, and fat injec-
tions are now performed as part of most of my face-lift procedures.
Why Not Just Inject Fat?
Age-related loss of facial fat rarely exists as an isolated event in a healthy patient,
and thus patients who are troubled by it are rarely logically or appropriately treated
by fat injections alone. Isolated fat injections are also arguably of questionable ben-
efit to a patient with significant facial sagging and skin redundancy. Although ag-
gressive filling of the sagging face with fat can improve contours and produce a
smoother skin surface, it generally results in an unusually large, overfilled, “filler
face” that looks both unnatural and unfeminine. Such an overfilled face is hard to
correct in an attractive manner at a later date, and it is both more logical and prac-
tical to perform fat injections in conjunction with formal surgical lifts if needed,
or sometime after ptotic tissue has been repositioned and redundant tissue has been
removed.
Where Should the Fat Be Injected?
Areas in need of treatment will vary among patients, and planning fat injections re-
quires looking at the face in a different way—more as a sculptor—and less as a tailor
as we have done in the past. Any area that can be successfully treated with nonau-
tologous injectable fillers is potentially treatable with fat injections, including, but
not limited to, the temples, brow, radix, upper orbit (upper eyelid), lower orbit (lower
eyelid), cheeks, midface, lips and the perioral area, the nasolabial folds, genio -
mandibular grooves, jawline, and chin—and experience with fillers is a useful point
of reference for planning fat additions to the face. Perhaps the best way to decide
where fat is needed is for the surgeon to study his or her face-lift outcomes carefully
and identify areas where the procedure has fallen short. In most cases the biggest
shortcoming for an experienced surgeon will be evident as a failure to replenish lost
volume, and the areas in need of treatment will be obvious. In time, and after en-
gaging thoughtfully in such study, one will gain a deeper appreciation of facial at-
rophy and an increasing desire to correct it.

This 45-year-old patient is shown before and 2 years and 4 months after a high SMAS
face lift, neck lift, lower blepharoplasty, and fat injections. She had had no prior sur-
gery. The shaded areas (center) show where fat was placed: 3 cc was placed in each
upper orbit, 4 cc in each temple, 1 cc in each tear trough, 3 cc in each infraorbital
area, 4 cc in each cheek, 2 cc in each nasolabial crease, 1 cc in each stomal angle,
2 cc in each geniomandibular groove, 3 cc in each lip, and 2 cc in the glabella, for a
total of 50 cc of injected fat.
Sequencing Fat Injections With Other Procedures
When fat grafting is best performed during face-lift surgery has not yet been an-
swered scientifically, but as a practical matter, it is most expedient to inject fat at the
beginning of the procedure before the face lift itself has been started. The reasons for
this include the fact that it is easier to harvest the fat at the beginning of the proce-
dure, before the face has been prepared or draped, and when the patient is typically
in a deeper plane of anesthesia. In the beginning of the procedure, the tissue planes
of the face have also not been opened, the face is not swollen, and preoperatively
made pen marks and facial landmarks are easier to identify. Finally, surgical princi-
ples suggest that it is also probably best to inject the fat before the start of the face-
lift procedure to limit the time the harvested fat is out of the body.
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Chapter 47  Combined Face Lift and Facial Fat Grafting
Fat Injection Technique
The technique for facial fat grafting has been described in detail by Coleman, and
we adhere to Coleman’s principles when performing fat injections (see Chapter 13).
Logistics of Concurrent Face Lift and Fat Injections
Fat injections are viewed by many surgeons as a simple procedure that can be per-
formed in a few minutes’ time. However, this is rarely the case, and such an attitude
will lead to frustration, disruption of the workflow, and poor outcomes. Fat must
be harvested in a specific, atraumatic, and time-consuming manner if viable tissue
is to be obtained that will survive and “take” at the facial recipient site. It must then
be processed and injected in a technically demanding and time-consuming process
that cannot be rushed. Fat grafting is also an artistically demanding activity that re-
quires a considerable amount of the surgeon’s intellectual, creative, and physical en-
ergy. When anything other than small amounts are being injected, the entire proce-
dure can encompass an hour or more, something that can significantly tax an already
overburdened surgical team engaged in a demanding operation entailing multiple
procedures. Therefore time must be planned appropriately.
Equipment
Special blunt-tipped cannulas are required for injection, in addition to other spe-
cialized equipment for harvesting and processing the fat. Poor outcomes are typi-
cally obtained if sharp hypodermic needles are used to harvest or inject fat, or if fat
is injected using a technique similar to that used to inject nonautologous facial fillers.
Sharp-needle injection can also result in fat embolization and serious related problems
and thus is not recommended.

Choosing a Donor Site
Currently there is no scientific unanimity as to where the “best” fat for grafting should
be obtained. Donor sites are typically chosen and marked with the patient in a way
that the fat harvest procedure will improve her or his silhouette, although the ideal
locations are arguably the areas of diet- and exercise-resistant fat deposits where the
fat is biologically programmed to be stubbornly persistent throughout the patient’s
life. For women this is typically the hips, outer thighs, or abdomen, and for men the
love handle and spare tire areas.
Although the lower abdomen might appear on casual consideration to be the easi-
est and best place from which to harvest fat, my experience has shown otherwise,
and I prefer to take fat from the hip and lateral thigh when possible, if the patient
agrees. There are several reasons for this. First, although using the abdomen as a
donor site means that the patient does not need to be turned and that only one site
is prepared and draped, abdominal fat is usually harder to extract, and the fat ob-
tained seems to be more fragile and have a higher “oil” content. In addition, when
anything more than a small amount is needed, the abdominal area is far less forgiv-
ing than the hip or the outer thigh because of the thinner, less elastic skin that is typ-
ically present, and postoperative irregularities and contour problems are far more
likely to occur. For that reason, consideration should be given to placing the patient
in a liposuction garment or abdominal binder if anything more than a small amount
of fat is harvested from the abdomen. Harvesting fat from the hips and outer thighs
requires that the patient be turned and that two areas be prepared and draped, but
the fat in these areas is much easier to extract and the tissue obtained is usually more
durable and nearly free of blood and oil. The hips and thighs also have thicker, more
elastic skin, and I find that postoperative problems and contour irregularities almost
never occur in these regions. Overall, patients are typically more pleased with the
improvement in their figures when fat is harvested from their hips and outer thighs
than when it is removed from their abdomen.
In thin patients, small harvests from multiple areas may be required, including the
inner thighs, inner knees, upper buttocks, and anterior axilla, and this will add ad-
ditional time to the procedure. It is recommended that the donor sites and site mark-
ings be photographed preoperatively to document what harvest sites were agreed on
and to avoid any dispute over the patient’s preoperative condition after surgery.
Marking the Face
Fat injections cannot be placed arbitrarily; a careful plan must be marked preoper-
atively with the patient seated in an upright position. Marking will consume a sig-
nificant amount time and is best carried out in a private area that is free from dis-
tractions. Creating an initial plan on a life-sized laser print of a photograph of the
patient’s face is helpful in organizing one’s thoughts and facilitates the discussion
with the patient as to which areas will be treated. In most cases marks are made in
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Chapter 47  Combined Face Lift and Facial Fat Grafting
conjunction with the patient while she or he holds a hand mirror so the plan can be
discussed and clarified during this stage. The goal is to create a topographical map
of the deficient and atrophic areas of the face to guide the surgeon during the pro-
cedure—essentially a reverse plan of that used when liposuction is performed.
Because an aging face is undergoing a process of lipodystrophy—that is, fat is be-
coming deficient in some areas and excessive in others—marks are also made where
fat needs to be removed, when indicated. These areas can be marked in a different
color or designated by some other means.
Once the markings are complete, additional photographs are taken of the patient’s
marked face and printed for use during the procedure. Some surgeons go so far as
to have patients sign and date a laser print copy of the marked plan to avert any
postoperative questions about what the patient’s preoperative requests were and
what was agreed on and consented to.
Anesthesia
Most modern face lifts are time consuming and technically demanding, and the ad-
dition of fat injections will test the patience and composure of most surgeons. It is
highly recommended that the services of an anesthesiologist or experienced CRNA
be enlisted when combined procedures are performed. This is particularly important
when the procedure is to be performed on a patient who is apprehensive or has a
history of anesthetic difficulties, hypertension, or other significant medical problems.
The majority of face lifts I now perform are done with the patient under deep seda-
tion, administered by an anesthesiologist using a laryngeal mask airway. This allows
the patient to be heavily sedated without compromise of the airway, but the patient
need not receive muscle relaxants and can be allowed to breathe spontaneously. It is
also easier to harvest fat from a heavily sedated patient, especially when fat must be
harvested from multiple sites, and comprehensive treatment of the face with fat is
facilitated under these conditions. However, any skillfully administered anesthetic is
adequate for performing the procedure.
Harvesting Fat
Fat is harvested the day it is needed; it is not frozen or stored. There are several rea-
sons for this. First, it would be a questionable practice to store harvested fat in ca-
sually labeled syringes in a small, unmonitored refrigerator/freezer of the type in-
tended for home or office use. These devices typically do not provide around-the-clock
monitoring of internal temperatures or have backup power, and most surgeons do
not have the means to properly log in tissue to be stored and guarantee that cross-
contamination, inadvertent thawing and refreezing, or mislabeling has not occurred.
In addition, storage of fat in this manner could be construed as “tissue banking,” a
practice that only licensed tissue banks are legally allowed to do in certain states.

More to the point, the preponderance of scientific information currently indicates
that to be viable, fat must be flash-frozen to very low temperatures, much in the way
that a human egg cell would; it will not be viable if slow-frozen in a typical food
freezer and later thawed. Research and development in fat banking is underway, and
in the future it is likely that surgeons will be able to store viable patient fat at a re-
gional blood bank or a center created specifically for this purpose.
Fat should be harvested in a thoughtful and artistic manner that improves the pa-
tient’s figure; thus it must generally be removed bilaterally and symmetrically unless
body contours dictate otherwise. Patients must be advised that fat harvest does not
constitute a formal liposuction procedure, however, and that the small instruments
used to harvest fat are not capable of making large improvements in body contour.
It is prudent to examine the patient at the first consultation, because thin patients
with limited fat stores or patients who have undergone prior liposuction often pre sent
significant challenges, and considerable extra time and effort will be required to har-
vest fat from them. Anesthesia and operating times and the surgeon’s fee must be cal-
culated accordingly.
Fat is harvested after anesthesia is initiated, but before preparation of the face. In all
but the unusual case, complete preparation of the torso is not necessary. Typically, a
limited preparation of the marked area is made, and a sterile field is established about
the prepared area with adhesive-edged blue paper drape towels (sticky blue towels).
The surgeon and the surgical assistant need not gown for this part of the procedure,
because sterile gloves are adequate for maintaining sterile technique.
If fat is to be harvested from the hip or lateral thigh, the patient is turned to a semi-
lateral decubitus position; preparation, draping, and fat harvesting are performed,
then the patient is turned to the opposite side, where the harvest procedure is re-
peated. If the patient is positioned carefully, this technique can be used to harvest
fat from multiple additional sites, including the upper buttocks, inner thigh, and
knees. Obtaining fat from multiple sites is particularly important in thin patients
with minimal fat stores.
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Chapter 47  Combined Face Lift and Facial Fat Grafting
Areas from which fat is to be harvested are conservatively infiltrated with 0.1% li-
docaine with 1:1,000,000 epinephrine solution using a specially designed multiholed
local anesthetic infiltration cannula, and an adequate time is allowed for a proper
anesthetic and hemostatic effect. It is not necessary or desirable to infiltrate in a
tumescent fashion, since overwetting the donor site will result in an overdilute har-
vest and more time being spent in the harvesting process. Local anesthetic should be
injected, even if deep sedation or a general anesthetic is used.
Fat is then harvested with special harvesting cannulas attached to 10 cc Luer-Lok sy-
ringes; the cannulas are used to atraumatically extract fat from donor sites using gen-
tle hand-applied suction to avoid vacuum barotrauma to the tissue. If fat is harvested
with too much applied suction, poor graft survival and compromised outcomes are
likely. In general, a 30% to 50% overharvest is made to be sure that an adequate
supply of processed fat will be available for use on the face. Fat harvested with these
cannulas easily passes through injection cannulas as small as 0.7 mm. Shown from the
top down: a 10 cc Luer-Lok syringe, a 1.6 mm by 15 cm local anesthetic infiltration
cannula, a 2.4 mm by 15 cm Tulip “triport” harvesting cannula, and a 2.4 mm by
15 cm Coleman harvesting cannula. A closeup of instrument tips, shown from the
top down, includes a 10 cc Luer-Lok syringe, an infiltration cannula, a Tulip har-
vesting cannula, and a Coleman harvesting cannula.
Once the fat harvest is complete, the stab incision used to obtain the fat is closed
with a simple interrupted suture of 6-0 nylon. The harvest site is then washed free
of prep solution, and the sutured site is dressed with a Tegaderm dressing.

Processing Harvested Fat
Harvested fat is generally not uniform in character and concentration as extracted
from the donor sites: each syringe will contain a variable amount of fat, blood, lo-
cal anesthetic, and ruptured fat cells (oil), and some type of processing is necessary
to consistently obtain uniform, viable material for injection. Although fat can be sep-
arated simply and inexpensively from the oil and water fractions using a tea strainer
type of sieve, the majority of the stem cells, growth factors, and “cellular messen-
gers” are likely lost when this is done. Centrifugation, on the other hand is believed
to allow separation of the oil and water fractions from the fat cells with minimal
loss of these other potentially important components. In fact, currently efforts are
underway to develop low-cost devices for use in clinical settings to process fat in a
way that concentrates stem cells, or even allows them to be separated. As these de-
vices become available, the outcomes of fat injection procedures could be signifi-
cantly enhanced, and many new and beneficial uses of autologous fat will likely be-
come possible.
Controversy exists as to whether the forces applied to the fat during centrifugation are
harmful and decrease eventual graft take. Available evidence seems to indicate that
the spin speeds and resultant applied forces in most countertop laboratory centrifuges
typically sold and used for processing fat are at or below the cut-off value, but sur-
geons concerned with this can use commercially available rheostats to reduce the
voltage and lower spin speeds, if desired. It is likely that once unanimity is reached re-
garding “safe” spin speeds and threshold G forces, centrifuges will be produced that
operate below the appropriate cut-off levels.
Before centrifugation is begun, a sterile, disposable plastic Luer-Lok cap is placed
on the end of the syringe to keep harvested fat inside it, and the syringe plunger is
removed from the syringe barrel. Capped syringe barrels containing unprocessed fat
are then loaded into the centrifuge rotor in a balanced fashion and spun for 1 to
3 minutes. Most small, portable centrifuges are inexpensive and have rotors that can
be sterilized so that the syringes the fat are in remain sterile and can be handled by the
scrubbed surgical team. Others centrifuges have sterilizable tubes that fit into the ro-
tor for this purpose.
1636
Part VIII  Face Lift and Neck Lift

1637
Chapter 47  Combined Face Lift and Facial Fat Grafting
A small, portable, countertop centrifuge is shown, as well as a closeup view of the
centrifuge rotor being loaded with unprocessed fat in 10 cc syringes. The syringe tip
has been sealed with a disposable plastic cap. The removable and sterilizable metal
sleeves shown fit into the rotor to keep syringe barrels sterile and allow them to be
handled on the sterile field after spinning.
Oil from ruptured fat cells
Fat
Water, lidocaine, blood
Harvested fat is shown after centrifugation. Three layers can be seen in the centrifuged
material: an upper oil layer consisting of ruptured fat cells, a middle layer of intact fat
cells, and a bottom layer of blood and local anesthetic.
The often blood-tinged water/local anesthetic component is separated by simply re-
moving the syringe tip cap and allowing it to run out, and the cap is then replaced.
The oil fraction is poured off out of the top of the syringe, and neurosurgical cot-
tonoid sponges are placed inside the syringe barrel to wick up the small amount of
residual oil.

1638
Part VIII  Face Lift and Neck Lift
A test tube rack to hold the syringes greatly facilitates fat processing activities. On
the left, the syringes contain unprocessed fat; in the center, syringes contain cen-
trifuged fat. The rack also conveniently holds 1 cc syringes, syringe components, and
other equipment used in the fat grafting procedure.
Injecting Fat
After centrifugation and the oil and water fractions have been discarded, the fat tis-
sue obtained is transferred into 1 cc Luer-Lok syringes using a transfer coupling, be-
cause proper injection in the very small aliquots needed in the face cannot be made
with 3 cc, 10 cc, or larger syringes. A 10 cc Luer-Lok syringe, 1 cc Luer-Lok syringe,
Luer-to-Luer transfer coupling, and transfer coupling in use are shown.
Nerve blocks are then performed with 0.25% bupivacaine with epinephrine
1:200,000 local anesthetic solution and adequate time is allowed for proper anes-
thetic and hemostatic effect. It is typically not necessary to directly infiltrate areas to

1639
Chapter 47  Combined Face Lift and Facial Fat Grafting
be treated with local anesthetic if nerve blocks are performed correctly and sedation
is administered.
If patients state that they have had recent hyaluronic acid filler injections (such as
Juvéderm or Restylane) in the areas that they want treated with fat injections, it is
likely that the presence of the filler will compromise graft survival and the ultimate
outcome of the procedure. In these patients, direct infiltration of areas containing
filler can be made with hyaluronidase. In most cases, an immediate and almost
instantaneous dissolution of the filler will be noted, and fat injections can then be
performed.
Once nerve blocks have been administered, 1.2 mm, 0.9 mm, and 0.7 mm cannulas
are used to infiltrate fat into the face through small stab incisions in the facial skin
in multiple passes, in multiple planes, from at least two separate injection sites while
feathering into adjacent areas depending on the area being treated. Injecting from at
least two separate injection sites allows “crisscrossing” of cannula passes during
graft placement, and helps avert a “row of corn” effect that might result if injection
was made from only one site.
As the cannula is advanced, the surgeon feels for tissue resistance, and if resistance
is felt, a small injection is made as the cannula is withdrawn. Approximately 0.5 cc
or less is injected per pass. This corresponds to 20 passes or more for each 1 cc sy-
ringe of processed fat. If the injector does not feel tissue resistance as the injection
cannula is advanced, this indicates that a pass has already been made in that area,
and injection should not be made as the cannula is withdrawn.
The goal is to inject the fat in a way that optimizes its chance of developing a blood
supply and surviving. The injector should have a mental model of scattering tiny
particles of fat into the recipient site in multiple crisscrossing fine trails in multiple
planes in such a way that each particle ideally sits in its own compartment and has
maximal contact with perfused tissue. If fat is injected in the way in which a flu shot
would be given or nonautologous fillers are typically administered, fat cells will be
bunched together, and only those on the periphery of the injected area will have tis-
sue contact and will be likely to survive. Most of the more centrally situated fat par-
ticles will only have contact with each other and will be less likely to survive.
At first the advancement and withdrawal of the injection cannula will necessarily be
made slowly, but as familiarity with the technique is acquired, the movements can
be made faster. Ultimately, all other things being equal, faster movements are desir-
able in that if the injection cannula is constantly in motion, intravascular injection
is less likely, and an accidental large injection into one area is avoided.

How the syringe is held is also important in controlling the volume injected with
each pass, and avoiding overinjection of any area. If the syringe is held in the man-
ner one would typically use to give an injection with the thumb on the end of the
syringe plunger, it is easy to inject too much fat if tissue resistance suddenly changes.
More control can generally be maintained, and overinjection more easily avoided, if
the syringe is held with the end of the plunger in the palm of the hand. Although a bit
of practice is required at first, when held this way a slight closing of the hand results
in only a small amount of fat being expressed from the cannula.
Although cannula obstruction will be very uncommon if fat is harvested and pro -
cessed as described, if a cannula becomes blocked, additional injection pressure
should not be applied, because this is the most common cause of a sudden and un-
intentional overinjection. It is better to simply withdraw the blocked cannula, pass
it to the surgical assistant, and continue with a different one. The assistant can then
clear the obstruction while the surgeon continues to work.
Injections will necessarily be made in different planes, depending on the areas being
treated. In many areas where multiple tissue layers are present to inject and over-
lying skin is thick, injections can be made comprehensively at the treated site from the
periosteum to the subdermal layer. These areas typically include the geniomandib-
ular groove, piriform aperture, midface, cheek, and chin. These are the easiest areas
for the beginning injector to treat. In other areas, injections must be placed with
greater precision, skill, and care because of the anatomic characteristics of the treated
sites and to avoid irregularities. These areas include the temples, upper and lower
orbit, tear trough, lips, jawline, and the dorsum of the hand. In the beginning it is
wise to “stay deep” and place the majority of the graft in a predominantly preperi-
osteal plane. Once the injector is familiar with the technique, areas in the second cat-
egory can then cautiously be treated.
1640
Part VIII  Face Lift and Neck Lift

1641
Chapter 47  Combined Face Lift and Facial Fat Grafting
Temple Area
Fat Injection Instrument Set
Diameter
Length
Number
Instrument
(mm)
(cm)
Harvesting
2
Multihole local anesthetic infiltrator
1.6
15
2
Harvesting cannula
2.4
15
10 cc Luer-Lok syringes
Luer-Lok disposable plastic syringe caps
Fat Processing
2
Luer-Lok anaerobic transfer coupling
1
Syringe rack
1
Centrifuge
Injection: Face
2
Injection cannula
0.7
4
2
Injection cannula
0.9
5
2
Injection cannula
1.2
6
1
V-dissector 1
1.4
6
1 cc Luer-Lok syringes
Injection: Breast and Body
2
Injection cannula
1.2
8
2
Injection cannula
1.4
8
3 cc Luer-Lok syringes
Temporal hollowing is a consistent marker of the fourth decade of life that is read-
ily improved with fat injections. This 45-year-old patient is shown before surgery
and 2 years and 4 months after a high SMAS face lift and fat injection to the tem-
ples. Fat has also been injected in the upper and lower orbital areas.

Injections in the temples must be made in a predominantly subcutaneous plane, usu-
ally from small stab incisions just within the temporal hairline. Injection of the tem-
ples is performed with a 1.2 mm cannula, and typically 3 to 5 cc of fat is placed on
each side, but occasionally more will be indicated.
In most cases a blunt 1.2 mm injection cannula is preferred to sharper and smaller
types. This helps to avoid perforation of the tortuous veins often seen in the tempo-
ral area. These larger, blunter cannulas usually bounce off these veins and allow fat
to be placed over and around them to conceal them, and this compression and con-
cealment of veins is a significant part of the effect gained when treating the temples
and the dorsum of the hand. If a temporal vein is accidentally penetrated during in-
jection despite these precautions and swelling from the leakage of venous blood is
noted, pressure is applied on the temporal area for a few moments with a surgical
sponge. Typically, after applying uniform and continuous pressure for a few minutes,
bleeding stops and treatment of the area can be completed.
Upper Orbit/Upper Eyelid Area
Whether a hollow upper orbit is the result of illness, aging, or an overzealous surgi-
cal procedure, it can be filled to produce a remarkable rejuvenation of the upper eye-
lid, eliminating an unnaturally hollow and elderly appearance sometimes referred to
by patients as “nursing home eyes.”
1642
Part VIII  Face Lift and Neck Lift

1643
Chapter 47  Combined Face Lift and Facial Fat Grafting
This patient had an unnaturally hollow and elderly ocular appearance after a bleph -
aroplasty performed by an unknown surgeon. The patient is shown after fat injec-
tions to the upper orbit demonstrating a healthier, more youthful appearance.
What layers fat should be placed in in the upper orbit (upper eyelid) is a subject of
some debate, however, and subcutaneous, suborbicularis oculi, and even subseptal
(intraorbital) locations have all been safely and effectively used by various surgeons. For
the beginning injector, it is safest to avoid the subseptal area because of the small but
not insignificant risk of intraorbital and retrobulbar bleeding and other problems. It
is also wise to avoid a purely subcutaneous injection in this area at first because of
the extremely thin skin present, and to limit initial injections to a preperiosteal/
suborbicularis oculi location. As the injector gains experience, injections can be ex-
tended to a subcutaneous plane to obtain a combined filling of the submuscular and
subcutaneous areas.
A common misconception in treating the hollow upper orbit is that the fat is needed
and should be injected in the preseptal portion of the eyelid itself. Not only would
this be difficult and dangerous, it is unnecessary. Volume replacement is more prop-
erly and practically restored by placing fat in a preorbital position along the inferior
margin of the supraorbital rim, and conceptually the process is best thought of as
lowering the supraorbital rim and filling the upper orbital area to push skin that has
retracted up into the orbit down onto the preseptal eyelid to create a full and creased
upper eyelid. Once one accepts that improvement is obtained by injection of the or-
bit, and not the eyelid itself, it becomes apparent that larger volumes than might oth-
erwise be expected are required, and in general 2 to 3 cc of fat must be placed in
each upper orbit to achieve the improvement typically required. Smaller injection
cannulas now available have made injecting the upper orbit easier and more pre-
dictable than in the past; they can be advanced more smoothly and accurately through
tissues and allow deposition of very small aliquots of fat per pass. Currently a 0.7
or 0.9 mm cannula is preferred, but even smaller cannulas may become available and
may provide even better results.

1644
Part VIII  Face Lift and Neck Lift
It should always be remembered that when injecting the upper orbit one is working
in very close proximity to the eye, and although the injection cannulas are blunt
tipped, they are small and easily capable of perforating the ocular globe. Thus two
important technical considerations should be observed. First, injection sites should be
placed in such a way that the injection cannula will be passed parallel to the globe
and the supraorbital rim, not perpendicular to it.
Incision sites and a plan for injecting fat into the upper orbital (upper eyelid) area are
shown. Injection of the upper orbital area is performed with a 0.7 or 0.9 mm can-
nula and fat is placed in a suborbicularis oculi/preperiosteal plane. Typically, 2 to
3 cc of fat is placed in each upper orbit. Directing the cannula toward the globe when
injecting the upper orbit is dangerous and should be avoided.
Second, the surgeon should always have his or her index finger of the nondominant
(noninjecting) hand held firmly on the inferior margin of the supraorbital rim as can-
nulas are passed into tissues and injection is made, and this finger should always be
kept between the tip of the cannula and the globe. The idea is to position the finger
so that the cannula would hit against it instead of penetrating the globe if the can-
nula is inadvertently misdirected. Having one’s finger in this position also gives im-
portant feedback as to where the tip of the cannula is and helps the injector place
fat as accurately as possible.

1645
Chapter 47  Combined Face Lift and Facial Fat Grafting
Lower Orbit/Lower Eyelid Area
Injecting the infraorbital (lower eyelid) area is in some ways analogous to injecting the
upper orbit: there are similar misconceptions about where fat should be placed, sim-
ilar technical considerations about which tissue layers fat should be injected into, and
similar concerns regarding injury to the ocular globe. In addition, as with injecting
the upper orbit, the artistic payoff is high if the procedure is carried out correctly.
This patient’s lower eyelids had an unnaturally hollow and elderly infraorbital ap-
pearance. The lower eyelids appeared long, and there was a distinct line of demar-
cation between the lower eyelid and the cheek. The patient is shown after a face lift
and fat injections to the infraorbital area. There is a smooth transition from the lower
eyelid to the cheek, and the patient now has a healthier, more youthful and attrac-
tive appearance. The upper orbit, radix, cheek, and nasolabial fold have also been
treated with fat injections, and the patient has undergone ptosis correction.
Injecting the infraorbital area corrects the age-related hollowness that lends the face
an ill or haggard appearance and “shortens” the apparent length of the lower eye-
lid. Fat injections produce a youthful, attractive and highly desirable smooth transi-
tion from the lower eyelid to the cheek that is generally unobtainable by traditional
lower eyelid surgery, fat transpositions, “septal resets,” midface lifts, free fat grafts,
and other means. As in the upper orbit, fat need not and should not be injected in
the pretarsal lower eyelid. Fat should be injected deep in a submuscular/preperiosteal
plane until experience is obtained. The technical goal of the procedure should be
thought of as raising and building up the infraorbital rim rather that filling the lid
itself. And, as in the upper orbit, the volumes required to obtain corrections in the
lower orbit are typically more than one might initially expect: 3 to 4 cc is usually nec-
essary to produce the desired effect. Experience has shown, however, that unlike the
upper orbit, fat is best and most easily injected perpendicular to the infraorbital rim,
and while I cannot speak from personal experience, it is my observation that sur-
geons injecting fat parallel to the infraorbital rim have more problems with irregu-
larities, “lumps” and “bumps,” and untoward results.

1646
Part VIII  Face Lift and Neck Lift
Injection of the infraorbital area is generally performed with a 0.7 or 0.9 mm injec-
tion cannula from injection sites in the midcheek or perioral area. Incision sites and
plan for injecting fat into infraorbital (lower eyelid) area are shown. Fat is placed in
a suborbicularis oculi/preperiosteal plane. Until experience is obtained, more su-
perficial injections should be avoided. Typically, 3 to 4 cc of fat is placed on each
side.
As with the upper orbit, when injecting the lower orbit the surgeon should place the
index finger of the nondominant (noninjecting) hand firmly on the inferior margin
of the infraorbital rim to protect the ocular globe as cannulas are passed into tissues
and injections are made.
As the injection cannula is advanced perpendicular to the orbit and toward the fin-
gertip through infraorbital tissues, the orbitomalar ligament can be felt along the in-
fraorbital rim and the cannula tip is allowed to penetrate it slightly. This important
landmark helps guide the injector as to exactly where most of the fat needs to be
placed for an optimal result. Typically, after placement of 3 cc of fat in this manner,
no resistance will be felt along the course of the ligament, and it is assumed that the
multiple passes used to place the graft have effectively released it, further improving
the overall outcome. Another guideline for the placement of fat in the infraorbital
area is for the surgeon to imagine filling the area in which one might place an infra-
orbital implant, since the goal of treatment is essentially the same.
It is wise to avoid any subcutaneous injection in the infraorbital area until consid-
erable experience has been obtained because of the extremely thin skin in the region,

1647
Chapter 47  Combined Face Lift and Facial Fat Grafting
and to limit initial injections to a preperiosteal/suborbicularis oculi plane, as rec-
ommended previously. As experience is gained, injection can then be extended to a
subcutaneous plane to obtain a combined filling of the submuscular and subcuta-
neous areas. This will produce improved outcomes and can help correct dark circles
in the infraorbital area by improving the transmission of light through thin infraor-
bital skin and masking the darker-colored muscle underneath.
Tear Trough
Where the infraorbital area ends and the tear trough and cheek areas begin is hard to
define. In reality, the infraorbital, cheek, and tear trough areas must be treated con-
currently and the treated areas will overlap to a certain extent. In addition, it must
always be remembered that the ultimate goal of the procedure is to create a youth-
ful and attractive contour, not simply to fill a specific area.
Treatment of the tear trough is most easily and best performed using the same inci-
sions used to treat the infraorbital area. Incision sites and plan for injecting fat into
the nasojugal (tear trough) areas are shown. Injection of the naso jugal area is typi-
cally performed with a 0.7 mm or 0.9 mm injection cannula and fat is placed in a
preperiosteal/suborbicularis oculi plane. Until the injector gains experience, more-
superficial injections should be avoided. Fat can be safely placed subcutaneously de-
spite the very thin skin in this area, and improved outcomes are obtained. Typically,
0.5 to 1.5 cc of fat is placed in the tear trough area on each side, depending on how
far inferiorly and laterally the tear trough extends onto the cheek.

1648
Part VIII  Face Lift and Neck Lift
Another guideline for the placement of fat in the tear trough area is for the surgeon
to imagine filling the area in which one might place a tear trough implant, since the
goal of treatment is essentially the same. This patient is shown before and after fat
injection to her hollow nasojugal groove (tear trough). Preoperatively it can be seen
that she had an unnaturally hollow and elderly appearance. Postoperatively the de-
fect has been filled and a healthier, more youthful appearance is evident.
Cheek
Treatment of the cheek is usually performed using access incisions on the cheek and
the perioral areas. Injection of the cheeks is performed with a 0.9 mm or 1.2 mm in-
jection cannula, and fat is placed in all tissue layers between the periosteum and skin.
Typically, 3 to 7 cc of fat is placed in each cheek, depending on the degree of atro-
phy present, but occasionally more will be indicated.

1649
Chapter 47  Combined Face Lift and Facial Fat Grafting
Often an asymmetrical placement of fat will be required on the right and left sides,
because malar asymmetry is seen in many patients. Another guideline for the place-
ment of fat in the cheek area is for the surgeon to imagine filling the area in which
one would place a cheek implant.
As the cheek atrophies, the lower eyelid “fat bags” become more exposed and promi-
nent. Removing lower eyelid fat would create a hollow, elderly appearance. This pa-
tient presented with an atrophic cheek, and the lower lid fat was exposed. Seen af-
ter fat injections to the cheeks, the patient’s protruding lower eyelid fat has been
disguised by building up the cheek; this has produced a more youthful, fit, and at-
tractive appearance than removing lower lid fat would have. The upper orbit has
been replenished with fat grafts as well.
Nasolabial Injection
One of the first areas most patients inquire about when considering fat injections,
and most surgeons are eager to treat, is the nasolabial folds. Nonetheless, one must
be aware of certain misconceptions and several limitations of the fat injection tech-
nique in regard to the treatment of this area. The first is that treatment of the na-
solabial folds with fat is generally not as effective as treatment with nonautologous
fillers. Fat is softer and is typically placed deeper than nonautologous fillers, and fat
is better used to treat a volume deficiency in a region of the face as opposed to a more
discrete line, wrinkle, or fold that is subject to the repeated stress of facial muscle
contraction and facial movement. Patients undergoing fat injections solely for treat-
ment of their nasolabial folds will generally be disappointed with the outcome. How-
ever, this is not the case when a concurrent face lift is performed, with cheek and
midface tissues repositioned and redundant cheek skin excised. In such instances, fat
injection is an excellent adjunct in the treatment of the nasolabial fold (see the pa-
tient on p. 1650). It is also not intuitively obvious, but increasingly it is more widely
appreciated by those injecting nonautologous fillers into the face that filling the up-
per cheek produces a profoundly beneficial effect on the nasolabial fold, and that
treatment of the fold is more effective when filling of both these areas is combined. If
the cheek is filled, less fat is needed to improve the nasolabial fold.

This patient had midface ptosis and heavy nasolabial folds; a high SMAS face lift
was performed, with fat injections to the nasolabial creases. The combined lifting
and filling provided a better correction than either procedure would have if performed
alone.
Experience has shown that nasolabial folds result, at lease in part, from age-related
loss of maxillary projection, and the goal in injecting fat in the nasolabial areas should
be thought of as more of an augmentation and restoration of maxillary/midface pro-
jection than as simple filling of the soft tissue crease. Thus the surgeon’s efforts should
be concentrated on the peripiriform areas, and injections should be placed predom-
inantly along the rim of the piriform aperture in the upper nasolabial area.
1650
Part VIII  Face Lift and Neck Lift
Injection of the piriform and nasolabial crease
is performed with a 0.9 mm or 1.2 mm injec-
tion cannula and fat is placed in all tissue lay-
ers between the periosteum and skin using ac-
cess incisions in the perioral area. Typically,
2 to 3 cc of fat is placed in the piriform/
nasolabial area, depending on the degree of
the problem present, but occasionally more
will be indicated.
Another guideline for the placement of fat in
the piriform area is for the surgeon to imag-
ine filling the area in which one would place
a perinasal or piriform implant.
Overfilling the nasolabial area is a common eventual response when a surgeon feels
frustrated upon treating the nasolabial crease with fat in the same manner in which
nonautologous fillers would be injected. Higher and higher volumes may be tried in

1651
Chapter 47  Combined Face Lift and Facial Fat Grafting
a typically futile effort to efface the fold, but the crease will not be improved; instead,
an abnormally heavy and unaesthetic fullness of the midface will be produced. In
addition, overfilling the nasolabial area can produce changes in the position of the
patient’s mouth, the shape of the smile, and a change in the overall “look.” For these
reasons it is important to advise patients accordingly, for the surgeon to set reason-
able goals, and to limit the amount of fat placed in the nasolabial area to a reason-
able amount.
Lips
Treating the lips with fat grafts has distinct advantages and disadvantages that will
both attract and repel surgeons and patients alike. Fat is autologous and is arguably
like the tissue that was present at a younger age, and if the procedure is successful
and graft take is good, patients will be spared the inconvenience and discomfort of
having to undergo repeated painful and expensive treatments. Fat also produces a
soft, natural-appearing improvement, and usually a slight undercorrection that I find
to be most appropriate and even desirable for the typical face-lift patient who needs
some enhanced volume in the mouth. In fact, overcorrection of the lips with fat in-
jections, in my experience, is nearly impossible, unless patients undergo multiple
treatments.
Fat injections produce soft, natural-appearing lips. Nonautologous fillers invite over-
correction and tend to produce a more stylized-appearing lip. The perioral area of
this face-lift patient is shown before fat injections and after a face lift that included fat
injections to the lips. The lips are fuller, but soft and natural appearing.
Fat injections to the lips have a distinct disadvantage in that they usually produce a
“monstrous” amount of swelling that is slow to resolve; also, the take of the graft
varies from patient to patient, and thus the eventual outcome is variable. Patients
seeking a quick recovery, a specific lip size or shape, or nuanced changes are not
good candidates for a fat injection procedure. In particular, patients must be warned
that when using fat, it is generally not possible to create the highly stylized “stung
by a bee” or “cover girl” lip appearance seen in fashion magazines. Such an appear-
ance can only be obtained using nonautologous fillers, and patients seeking such ap-
pearances should be advised accordingly.

1652
Part VIII  Face Lift and Neck Lift
Patients seeking nuanced changes in their lip appearance are also not good candi-
dates for fat injections. These include patients seeking corrections of small asymme-
tries, patients seeking accentuation of the vermilion-cutaneous junction, or who re-
quest specific parts of their lip be “lifted,” “rolled out” and the like. Although fat
can be placed to achieve these appearances to some degree, it rarely is dramatic
enough to satisfy most patients requesting these sorts of improvements, and patients
making these kinds of requests are currently best treated with nonautologous fillers.
When the lips are to be treated, the preparation of the face should include the up-
per and lower gingivobuccal sulci, the buccal surface of the anterior teeth, and the
tongue if it rests in the surgical field anterior to the incisors. A 0.7 or 0.9 mm can-
nula is usually used to infiltrate fat into the lips, but a slightly larger 1.2 mm can-
nula may be easier for the beginning injector, since it is harder to accidentally per-
forate the mucosa or vermilion with the larger instrument. Injection is made from
access incisions in the perioral region, and fat is generally infiltrated through all lay-
ers of the lip.
Fat is usually placed in submucosal and intramuscular planes. Typically, a total of
1.5 to 2 cc is placed in each side of each lip, for a total of 3 to 4 cc per lip. Smaller
amounts generally produce suboptimal outcomes after the initial swelling has abated.
Larger amounts increase swelling but generally do not result in an improved out-
come.

1653
Chapter 47  Combined Face Lift and Facial Fat Grafting
The first few passes of the cannula are used to place fat subcutaneously or submu-
co sally directly under the vermilion-cutaneous junction. Fat is then infiltrated into
the lip muscles, and then beneath the dry lip vermilion. If maximum lip protrusion
is desired, fat is placed submucosally beneath the wet mucosa of the inner aspect of
the lip.
A common error when injecting fat (or nonautologous filler) into the lips is to indis -
criminately fill the lips in such a manner that a large but shapeless and unnatural-
appearing “sausage lip” is produced. To some extent the fat injection technique is not
prone to this, because lips treated with fat naturally tend to assume the shape of the
patient’s existing lip envelope once the swelling abates and healing is complete. An
attractive lip is generally one that is not just big, however, but one that has an aes-
thetically pleasing shape, and fat can and should be injected in a way that creates
these appearances. An attractive lower lip typically has two tubercles; that is, two
areas of fullness laterally, with a slight central depression between them. An attrac-
tive upper lip, on the other hand, has three aesthetic tubercles, a central one and one
on each side laterally, with slight depressions between them. The time taken to inject
fat to create a natural and aesthetic appearance in these tubercles is well spent. In
addition, depressions between lip tubercles can be enhanced on completion of injec -
tions by placing a finger and thumb on the inside and outside of the lip and gently
bidigitally compressing areas between tubercles to optimize fat position and lip shape.
The second common mistake when injecting the lips with either fat or nonautolo-
gous fillers is to make the upper and lower lips the same size. This is an unnatural
situation and produces a “clown mouth” or “Halloween wax lips” appearance. In
an aesthetic, natural-appearing mouth the lower lip is distinctly larger and fuller
than the upper lip, and this should be the goal when augmenting the lips.
Perioral Area
Yet another important use of perioral fat injections is for the treatment of a patient
with perioral wrinkles and “pucker lines.” Traditional resurfacing by peel, laser, or
dermabrasion typically provides an incomplete solution for these patients in that
these procedures only address the skin itself, and do nothing to replenish the age-
associated loss of perioral subcutaneous fat. Patients have smoother-appearing skin
in repose after these treatments, but when they speak or move their mouth, deep and
objectionable lines appear and perioral deflation and subcutaneous atrophy becomes
evident. This appearance spoils an otherwise excellent face-lift result and stands as
telltale evidence that the patient is really older than she or he otherwise appears.
With fat injections this can be avoided, and the fat previously situated between skin
and orbicularis oris can be replaced. A second likely but as yet unproven benefit of
peri oral fat injections rests in the stem cell effect the procedure probably provides.

1654
Part VIII  Face Lift and Neck Lift
Experience with combined dermabrasion or laser resurfacing and perioral fat injec-
tions suggests that healing and the overall outcome are better when resurfacing pro-
cedures are combined with fat injections, beyond the improvement gained by simple
added volume.
This woman had a wrinkled, atrophic perioral area that gave her an unhealthy, el -
derly appearance. She is shown 2 years and 7 months after a high SMAS face lift that
included combined perioral fat injections and perioral dermabrasion. Both atrophy
and wrinkling have been improved, and the mouth has a more youthful, vibrant,
healthy appearance. The combined treatment produced a better appearance than ei-
ther procedure would have if performed alone.
When injecting the perioral area, care must be taken to not simply overfill the white
roll of the upper lip to reduce wrinkles, because the patient’s upper lip can be length-
ened, dental show can be reduced, and an abnormal, convex, simian contour in pro-
file can result. A better strategy is to concentrate injections on and near the white
roll, where the wrinkles are typically the deepest and most objectionable. Less fat is
then placed more superiorly. Results are further enhanced by injecting additional fat
at the columellar-labial angle, which helps to restore a youthful transition from the
nose to the lip and helps to create a concave upper lip shape. Injection in the peri -
oral area is necessarily made with small (0.7 to 0.9 mm) injection cannulas in a sub-
cutaneous/premuscular plane. Placing the fat deeper and intramuscularly is not help-
ful in creating the type of improvement needed in this area.
Geniomandibular Groove
Injection of the prejowl/geniomandibular groove area with fat has a high aesthetic
payoff and is a good area for the beginning injector to gain experience with the tech-
nique. Although not immediately intuitively obvious, filling the geniomandibular
groove creates a strong, uninterrupted aesthetic line from chin to the posterior
mandible, and is a highly desirable improvement on both the male and female face.
The effect is similar to the placement of a Mittleman prejowl implant but is autolo-
gous and arguably simpler to perform.

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Chapter 47  Combined Face Lift and Facial Fat Grafting
This patient had a deep geniomandibular groove. Her chin appeared narrow and
pointed, and there was poor continuity between the chin and jawline. She under-
went a face lift with injection of fat to fill the geniomandibular groove (prejowl sul-
cus) area. A chin implant was not placed. Postoperatively the chin appears broader
and more aesthetically integrated with the jawline. Fat was also used to strengthen
the posterior jawline and lower the mandibular angle, and to fill the lips, nasolabial
crease, cheeks, and infraorbital areas.
Injection of the geniomandibular groove is typically performed with a 1.2 or 0.9 mm
injection cannula from injection sites on the mandibular border and the perioral area
and fat is placed in all tissue layers between the periosteum and skin. Typically, 1 to
3 cc of fat is placed in the geniomandibular groove, depending on the size of the de-
pression present, but occasionally more will be indicated. Another guideline for the
placement of fat in the geniomandibular groove area is for the surgeon to imagine
filling the area in which one would place a prejowl implant.

Chin
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Part VIII  Face Lift and Neck Lift
Injecting the chin with fat can enhance a patient’s profile and approach the kind of
improvements obtained when small chin implants are placed. This patient had an
underprojected chin that was also atrophic and feeble looking from the shrinkage
that occurs with age. She is shown after a secondary face lift, with fat injections to
the chin and geniomandibular groove (prejowl sulcus). A chin implant was not placed.
Fat was also injected in the upper and lower orbits, cheeks, lips, and jawline. The fat
injections have broadened and strengthened the contours of her chin and jawline,
and the submental crease has been filled. Typically, the chin must be treated in con-
junction with correction of the geniomandibular groove, and the two areas will over-
lap each other in most cases. Treatment of the chin along with the geniomandibular
groove and jawline areas strengthens the entire lower facial contour.

1657
Chapter 47  Combined Face Lift and Facial Fat Grafting
Injection of the chin is typically performed with a 1.2 or 0.9 mm injection cannula
from the same injection sites on the mandibular border and the perioral area used
to inject the geniomandibular groove. Occasionally a third incision is used in the
midline of the lower lip. Fat is placed in all tissue layers between the periosteum and
skin. Typically, 1 to 3 cc of fat is placed in each side of the chin, depending on its
size and shape and the degree of atrophy, but occasionally the need for more fat will
be indicated. Another guideline for the placement of fat in the chin area is for the
surgeon to imagine filling the area in which one would place a “extended anatomic”
chin implant.
Despite the suggestions of some to the contrary, fat injections to the chin are best
used for small augmentations only. If large changes in chin projection are attempted
with fat injections, a globular and less sculptural appearance usually results. Patients
in need of larger increases in chin projection are arguably better treated with a chin
implant.

Jawline
1658
Part VIII  Face Lift and Neck Lift
Injection of the jawline border area with fat can enhance a patient’s facial shape and
produce the kind of improvements obtained when mandibular border and Taylor-
style mandibular angle implants are placed. This patient is shown before surgery
with a small mandible, narrow intergonial distance, and lower facial disproportion.
The patient is shown after high SMAS face lift and fat injections to the posterior jaw-
line. No implants have been placed. Strengthening the jawline and posterior mandibu-
lar border results in a more fit and proportionate appearance, and helps avert the
tight and deficient mandibular contour typically seen in an elderly face after a face
lift is performed. Fat has also been injected in the chin, geniomandibular grooves,
buccal recess, and lip areas. (See also the patient on p. 1626, whose jawline was broad-
ened without implant placement, using only fat injections.)
Injection of the jawline is typically performed
with a 1.2 mm injection cannula from the
same injection sites on the perioral area and
mandibular border used to treat the genio -
mandibular groove, and fat is placed predom-
inantly in a preperiosteal position. Typically, 3
to 6 cc of fat is placed in each side, depending
on the deficiency present, but occasionally 7 to
10 cc or more on each side will be indicated.

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Chapter 47  Combined Face Lift and Facial Fat Grafting
This patient had a small mandible and a long face. A previous face lift performed by
another surgeon had tightened the mandibular line and accentuated her facial length.
The patient is shown after fat injections to the jawline, chin, cheeks, midface, buc-
cal recess, and lip areas. No implants were placed. The long appearance has been im-
proved, and a more balanced and proportionate look has been obtained.
Final Touches
Injections are continued until the desired volume of fat has been added to target ar-
eas. Typically, a twofold to threefold overcorrection must be made compared with
the volumes one would use if nonautologous fillers are used. As such, the process is
time consuming and technically and artistically demanding, and its difficulty should
not be underestimated. That said, it is likely it will also become an enjoyable one
that will yield great benefits to patients.
Although not intuitively obvious, strengthening the jawline and posterior mandibu-
lar border makes one appear more youthful, fit, and attractive and is an artistically pow-
erful adjunct to a face lift. This helps to avert the scrawny, deficient, and fragile mandib -
ular contour typically seen in an aging and elderly face, which is usually made worse
when a face lift only is performed (see the patient examples on pp. 1669 and 1670).
Fat injections to the jawline are particularly useful in a secondary face-lift patient
and in a patient with a long face seeking facial rejuvenation or improvement. Typi-
cally, the secondary face-lift patient has experienced significant loss of jawline vol-
ume as a result of loss of or inappropriate surgical removal of facial fat, and this is of-
ten compounded by overzealous tightening of the overlying tissues. These appearances
are readily improved with fat injections to the jawline, and these form a major part
of most of my treatment plans for my secondary and tertiary face-lift patients. A pa-
tient with a long face usually will benefit in a similar way, because face-lift proce-
dures tend to narrow the lower face and accentuate facial length. Fat injections al-
low the face to be broadened, and the overall proportions are improved.

After fat has been infiltrated, treated areas are palpated to ensure that the fat has
been distributed smoothly and evenly in the target tissue, and any lumps or irregu-
larities are gently pressed out. The lip and cheek areas can be bidigitally palpated af-
ter injection is complete to ensure that fat has been placed in an even distribution,
and if the orbits have been treated, the ocular globe should be gently depressed and
any irregularities sought in the infraorbital area.
Microliposuction
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Part VIII  Face Lift and Neck Lift
The face undergoes a process of lipodystrophy over time; the aging deformity con-
sists not only of atrophy, but also of excess fat accumulation in some areas. When
indicated, fat can be extracted from areas where excess is present by applying suc-
tion to an infiltration cannula attached to a 3 cc Luer-Lok syringe. This microlipo-
suction technique provides a simple, precise way for removing small quantities of
fat. The amount of fat extracted can be determined by emptying the contents of the
syringe on a gauze sponge and allowing the blood and fluid to separate from the fat
that has been removed. On the right is the fat extracted from the patient’s jowl area;
on the left is fat extracted from the nasolabial fold.
Documenting What Was Done
A member of the operating room team should keep a detailed record of areas treated
and the amounts of fat injected in each; a Fat Injection Treatment Record is useful
for this purpose. Typically, a mark is entered on the record by the circulator for each
1 cc syringe injected.

1661
Chapter 47  Combined Face Lift and Facial Fat Grafting
FAT INJECTION TREATMENT RECORD
Place patient sticker here
FACE
RIGHT
LEFT
Geniomandibular groove/perimental
Piriform/nasolabial crease
Cheek
Midface
Preauricular
Tear trough
Chin
Upper lip
Lower lip
Jawline
Stomal angles
Buccal recess
Perioral
Columella/nasolabial angle
Temple
Infraorbital
Brow/supraorbital
Glabella
Radix
Nasal base
Other (list):
Total Fat Injected: Face
HANDS
Ray:
1
2
3
4
Fingers:
(thumb) 1
2
3
4
5
Thenar
Hypothenar
Dorsal wrist
Total Fat Injected: Hands
FAT HARVEST SITE (check all that apply)
FAT HARVEST DATA
 Outer thighs  Hips  Abdomen
Total fat harvested (cc)
 Knees  Inner thigh
Total fat after centrifuging (cc)
 Other (list):
Centrifuge time:  3 minutes  _____ minutes
Nurse signature
Date

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Part VIII  Face Lift and Neck Lift
If no circulating nurse is present, a copy of this record can also be sterilized and a
temporary tally of the fat injected kept by a scrubbed member of the operating room
team using a sterile surgical marker. The information recorded can later be tran-
scribed to the patient’s official Fat Injection Treatment Record after the procedure
has been completed.
Learning the Procedure
The first step in learning the fat injection technique and adding it to one’s face-lift
procedure is appreciating atrophy as a significant part of the aging process and learn-
ing to recognize it. This is more easily said than done and will take some time to mas-
ter. Then one needs to obtain the needed equipment to properly perform the proce-
dure and learn the basics of the fat injection technique. Once problems have been
identified, needed equipment to perform the procedure obtained, and basics of the
technique mastered, one must analyze patient problems carefully and budget the ap-
propriate amount of time needed to carry out the procedure in a technically and ar-
tistically appropriate fashion. It is wise to make small additions of fat at first to “safe”
areas, such as the geniomandibular groove and the cheeks, to gain familiarity with
the technique. Less forgiving areas, such as the upper and lower eyelids (orbits), tear
troughs, and temples, should be avoided until injection in the safe areas is mastered.
Starting out conservatively in this manner will mean that problems, should they oc-
cur, will be minor and easily managed. Finally, patients should be followed up care-
fully, outcomes critically evaluated, and the injector should look for ways to improve
technique and perform the next case with increased skill.

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Chapter 47  Combined Face Lift and Facial Fat Grafting
Completion of Concurrently Planned Procedures
On completion of the fat injections, other planned procedures are performed to the
face, neck, forehead, and upper and lower orbits. Next, perioral dermabrasion and
any other adjunctive procedures are done, as indicated. Because the majority of fat is
needed and will be injected in the anterior face and other areas that do not overlap
the areas dissected in these other procedures, performing them after fat is injected
does not interfere with their execution or compromise outcomes.
Dressings
After all planned procedures have been completed and all incisions have been closed,
the patient’s hair is shampooed and rinsed. No dressing is required or applied. Pa-
tients are typically discharged with a hat, scarf, and sunglasses.
Postoperative Care
Most patients undergoing combined face lifts and fat grafting are discharged to an
aftercare specialist the first night after surgery with specific written instructions con-
cerning their care. Patients are asked to rest quietly and apply iced compresses to
their eyes and other treated areas for 15 to 20 minutes of every hour while they are
awake for the first 3 days after surgery, or to use a commercially available thermo-
statically regulated water-cooled mask. For most patients, edema peaks at about
3 days.
Learning the Fat Injection Procedure
 Recognize atrophy as part of the aging deformity.
 Learn the basics of the fat injection technique and obtain the needed equipment to
properly perform the procedure.
 Make the needed commitment of time to properly perform the procedure.
 Do not underestimate the technical and artistic difficulty of the procedure.
 Make small additions at first to gain familiarity with the technique.
 Critically analyze outcomes.
 Constantly seek ways to improve your technique.

All patients are provided oral analgesics, sleeping pills, antiemetic suppositories, and
are instructed to sleep flat on their backs without a pillow. A small cylindrical neck
roll is permitted if the patient requests it. This posture ensures an open cervicomen-
tal angle and averts neck flexion, dangerous folding of the neck skin flap, and the
obstruction of regional lymphatics that inevitably occurs if the patient is allowed to
“elevate the head on pillows,” as is commonly recommended. In addition, swelling
will drain to the back of the head instead of the anterior neck and submental region
in this position, where it is not harmful, is less noticeable, and is more rapidly trans-
mitted away from the head and neck area to the torso when the patient sits upright.
Patients are allowed to take their usual diet as tolerated after surgery but are en-
couraged to avoid salty and difficult-to-chew foods for several weeks. Patients are
asked to abstain from drinking alcohol for 2 weeks after surgery and until they are
no longer taking pain pills (acetaminophen included) or sleeping medication. Show-
ering and shampooing are not harmful and are permitted even when drains are in
place.
Recovery and Healing
When patients can return to work and their social activities will depend on how ag-
gressively their procedure was performed (how much fat was injected), their toler-
ance for surgery, their capacity for healing, the type of work they do, the activities
they enjoy, and how they feel overall about their appearance. Patients are asked to
set aside 2 to 3 weeks, to recover from surgery, and additional time off is recom-
mended before an important business presentation, family gathering, vacation, or
like events.
If the patient is doing well and is not experiencing problems, she or he is allowed to
return to light office work and casual social activity 9 to 10 days after surgery. It is of-
ten wise for the patient to begin with a limited workday and to adjust the schedule
thereafter. If a patient’s job entails more strenuous activity or physical labor, a longer
period of convalescence will likely be required. Patients are advised not to drive for
the first 10 days after surgery and until they are feeling well, their vision is clear, and
they are no longer taking pain medications.
Patients should avoid all strenuous activity during the first 2 weeks after surgery, in-
cluding heavy lifting, stooping, straining, and bending forward; they should be in-
formed that aerobic activities and exercise can result in internal bleeding and
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Part VIII  Face Lift and Neck Lift

1665
Chapter 47  Combined Face Lift and Facial Fat Grafting
hematoma formation. Two weeks after surgery, patients are allowed to begin light
exercise and gradually work up to their presurgical level of activity. Four to 6 weeks
after surgery, they are allowed to engage in more vigorous activities, including most
sports, as tolerated.
Patients are informed that it will often take 2 to 3 months to have a natural appear-
ance in a photograph or to be seen at an important function. They are also advised
to expect some firmness in the face and submental areas for 6 to 9 months.
Patients will often mistakenly interpret the resolution of swelling and the return of
some facial wrinkles as poor graft survival and will often comment once healing is
complete that “the fat went away.” Such comments arise out of the joy most patients
experience when they see their faces quite full and smooth initially after the proce-
dure and the fact that volume addition to the face often produces subtle three-
dimensional changes. Most patients simply forget the extent to which the treated
areas lacked volume before the procedure. The treating physician may sometimes ini-
tially experience similar disappointment for related reasons; it takes time to train
one’s eye to recognize the improvements that have been made. The key to assessing
outcomes is to take well-matched photographs in multiple views and to learn to rec-
ognize the rejuvenating effects of the injections. Reviewing preoperative photographs
with the patient after surgery is an excellent way to assure them that a beneficial im-
provement has been obtained and that the procedure was productive and worth-
while.
Retreatment
Most of the change in facial contour seen on the patient’s face 4 to 6 months after
the procedure is likely to consist of living fat and comprises a persistent improve-
ment. At that point, patients can be told that “what you see is what you get,” be-
cause swelling and induration will have almost completely resolved by that time.
Four to 6 months after surgery is also the time at which most surgeons performing fat
injections think that facial edema, induration, and inflammation have resolved suf-
ficiently that retreatment can be considered if indicated and the patient requests it.
Because there is a limit to the amount of fat that can be infiltrated into a thin,
atrophic face, the need for secondary fat grafting should not be viewed as a failure
of the primary procedure; it is simply an inherent limitation of the technique. If the
patient achieved improvement with the primary treatment, a secondary procedure
will typically be equally or more beneficial, and often can be far less comprehensive
than the first.

Complications
No major complications attributable to fat injections have been seen while performing
the procedure concurrent with face lifts, including infection and embolization. How-
ever, these problems have been reported and are known to occur when fat injections
are performed. To date and to my knowledge, there had been no reports of em-
bolization with blunt-needle injections, but this could change as infiltration cannu-
las become smaller and more surgeons perform the procedure. Embolization and re-
lated complications, including blindness, have been reported with sharp-needle
injection; these and other complications of fat injections have been discussed in de-
tail by Coleman.
Complications of simultaneous face lift and fat injections attributable to the fat in-
jection procedure fall largely under the heading of “aesthetic problems” and include
lumps, oil cysts, asymmetries, undercorrection, overcorrection, and donor site ir-
regularities. These are more accurately considered inherent risks of the procedure,
however, in that even if the procedure is technically performed properly and with
care, variations in “take” that can occur with any graft that are beyond the surgeon’s
control can cause them. This is particularly true in the case of a fat graft, because fat
has shown itself to be a comparatively fragile tissue.
Most complications will be small and easily managed if fat injections are performed
properly and conservative additions are made. Oil cysts can usually be simply aspi-
rated or unroofed. Lumps have been exceedingly rare in my practice but are now be-
ing increasingly seen in patients treated by other physicians. These can usually be
treated by microliposuction, direct excision, or overgrafting with more fat. Asym-
metries and undercorrections are generally treatable by additional fat injections and
donor site irregularities with touchup liposuction and/or fat grafts. Overcorrection
is uncommon in single-stage treatments and is typically seen in patients undergoing
multiple fat injection procedures. Overcorrection can usually be improved by judi-
cious extraction of fat from overcorrected areas.
It is best to avoid complications altogether; the surgeons with the fewest are likely
to be the ones who take the time to learn to perform the procedure properly, obtain
the needed equipment necessary to do so, and introduce it into their practice grad-
ually and in a conservative manner.
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1667
Chapter 47  Combined Face Lift and Facial Fat Grafting
Results
This 45-year-old woman had overall facial laxity and panfacial atrophy; she had no
previous plastic surgery. She is shown 2 years and 4 months after a high SMAS face
lift, neck lift, closed forehead lift, lower blepharoplasty, and fat transfer to the tem-
ples, cheeks, lips, nasolabial folds, geniomandibular grooves, stomal angles, and up-
per and lower eyelid areas (see p. 1630 for an indication of where fat was placed in
this patient). A total of 50 cc of fat was placed. Note the soft, natural facial contours
and the absence of a tight, pulled, or face-lifted appearance. Facial atrophy has also
been corrected, and the patient has a healthier, more youthful, and feminine ap-
pearance. The combined face lift and fat injection procedures have produced a re-
sult that could arguably not be obtained by either procedure alone.

This 68-year-old man had sagging cheeks, deep cheek folds, and jowls. Loss of fa-
cial volume was also evident in his cheeks and infraorbital, perioral, and genio -
mandibular groove areas. The patient is shown 1 year and 9 months after a high
SMAS face lift, neck lift, closed forehead lift, upper and lower blepharoplasty, par-
tial facial fat injections, and earlobe reduction. A total of 28 cc of fat was placed.
A more youthful facial shape has been restored without a tight or pulled appearance.
His facial atrophy has also been corrected, and he has a healthier, masculine ap-
pearance. The combined face lift and fat injection procedures have produced a re-
sult that could arguably not be obtained by either procedure alone.
1668
Part VIII  Face Lift and Neck Lift

1669
Chapter 47  Combined Face Lift and Facial Fat Grafting
This 53-year-old woman had facial sagging, and although her face appears full at
first glance, a careful examination shows that regional atrophy was present in her
temples, cheeks, infraorbital, perioral, geniomandibular groove, chin, and jawline
areas. The patient had prior upper and lower blepharoplasties performed by another
surgeon. She is shown 1 year and 5 months after a high SMAS face lift, neck lift, tem-
ple lift, canthopexy, and fat transfer to the temples, cheeks, infraorbital, nasolabial,
perioral, geniomandibular groove, chin, and jawline areas. A total of 66 cc of fat was
placed concurrent with the face lift and related procedures. Soft, natural facial con-
tours have been restored, without a tight, pulled, or face-lifted appearance. Her fa-
cial shape has been significantly improved, and she now has a more youthful ap-
pearance. Although fat has been added to her face, she has a trimmer, more fit, and
feminine appearance. Her lips are fuller but natural looking. An unwanted mole has
been removed from the left upper lip.

This 75-year-old woman had had multiple prior face lifts and related procedures, in-
cluding previous laser resurfacing performed by other plastic surgeons. She had sig-
nificant cheek laxity despite these surgeries, and a fragile, elderly appearance as a
result of uncorrected panfacial atrophy. Another face lift would predictably have pro-
duced a gaunt, haggard, or even ill appearance. The patient is shown 1 year and
7 months after a high SMAS face lift, neck lift, forehead lift, upper and lower bleph -
aroplasties, canthopexy, and fat transfer to the temples, cheeks, midface, upper and
lower eyelids, lips, nasolabial folds, stomal angles, geniomandibular grooves, chin,
and jawline. A total of 90 cc of fat was placed concurrent with the face lift and re-
lated procedures. No skin resurfacing, facial implants, or other ancillary procedures
were performed. In these situations, fat injections are arguably more important to
the overall outcome than the face lift itself. Her facial contour has been significantly
enhanced and her facial volume restored. The patient has a healthy, fit, more youth-
ful, and feminine appearance—one that could not be obtained by either procedure
performed alone.
1670
Part VIII  Face Lift and Neck Lift