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Powers, perils of facial fat grafting technique

Article-Powers, perils of facial fat grafting technique

Dr. Perry
San Diego — It may be a tool that is best used in the hands of the obsessive-compulsive surgeon, yet all who take advantage of facial fat grafting should be aware of the aesthetic perils that this powerful procedure can produce.

The importance of minute, gradual insertion involved with fat grafting is impressed upon most surgeons. Also, while complications are becoming less common, some persist. Edema, fat nodules and unexpected patient reaction can mar this procedure, although with extra effort, these can be avoided.

"With facial fat grafting you have the ability to contour areas that you can't with an implant, yet you have to be careful of not becoming a victim of your success," says Curtis Perry, M.D., director, Artistic Surgical Center,East Greenwich, R.I. "You can achieve dramatic aesthetic changes with fat — you should be careful of not only the technical errors, but also the facial changes that can cause psychological ramifications for the patient."

This patient had facial sculpting by fat grafting to the superior cheeks and lips combined with liposuction of the jowl and submental areas.
Technique redux Speaking here at the American Academy of Cosmetic Surgeons (AACS) meeting, Dr. Perry placed importance first on the technique of grafting fat in the facial area. Little nuances such as placing very minute pearls of fat into multilayers of subcutaneous tissues allow for a "fanning out" of the fat and a lattice of deposition, he says.

Besides persistent edema, the other most problematic result from facial fat grafting is the formation of fat nodules in the lower eyelid — a result most commonly caused by incorrect technique.

"I basically eradicated this problem by using subdermal grafting with a 90 degree angle approach to the dermis," says Dr. Perry, who is also assistant clinical professor, Tufts University School of Medicine. "I call this the 'cobblestone technique' because the pearls of fat are placed immediately beneath the skin in an attempt to mimic the small, tightly packed globules of fat that are naturally adherent to the dermis and are often referred to by anatomists as a cobblestone appearance. Previous to using this technique, 20 percent of 75 patients who received grafts in the lower eyelid experienced fat nodules. In the next 75 patients who were treated with the subdermal 'cobblestone' grafting approach, none developed nodules."

Two-stage procedure While the renowned fat grafting expert, Sydney Coleman, M.D., is known to complete his procedures in one session, Dr. Perry leans toward a two-stage procedure to ensure slow and precise placement. An 18-gauge cannula with a sideport also allows for more accuracy, especially around the eyelid and lip area.

"Fat grafting is definitely most successful when used by the fastidious and precise surgeon. While a facelift is more two dimensional, with this you have to think three dimensionally — you have to think how you are going to bring the face out in layers to create changes in volume," Dr. Perry says.

Powerful proportions As facial fat grafting replaces implants, patients should be aware of the major changes the procedure can produce, especially in patients who are older.

"A patient of mine in her fifties, who had undergone several different procedures including a browlift and facelift, also wanted fuller lips and specifically asked for fuller lips than when she was younger. Objectively, she was asking for this body image change, yet she wasn't psychologically prepared for the end result; she wasn't happy and we had to do a secondary procedure to reduce the fat," Dr. Perry says.

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