Patient 9. A, Three-dimensional colorimetric analysis demonstrating areas of volume change (blue) at the 18-month follow-up visit. Volume retention was 68% on the left side and 55% on the right side. Increasing depth of blue color represents increased volume. B, Three-dimensional midface area measured (blue) at the 18-month follow-up visit.
Patient 19. A, Three-dimensional colorimetric analysis 2 months after surgery. B, Three-dimensional colorimetric analysis 18 months after surgery. The increased amount of volume is demonstrated by increased blue color change in the midface.
Patient 16. Three-dimensional colorimetric analysis at 3 (A) and 17 (B) months after surgery.
Patient 16. Corresponding 2-dimensional photographs taken before surgery (A) and 3 (B) and 17 (C) months after surgery.
Meier JD, Glasgold RA, Glasgold MJ. Autologous Fat GraftingLong-term Evidence of Its Efficacy in Midfacial Rejuvenation. Arch Facial Plast Surg. 2009;11(1):24-28. doi:10.1001/archfacial.2008.518
To provide quantitative objective data demonstrating the longevity and amount of volume augmentation in the midface obtained with autologous fat grafting.
A prospective analysis of all patients who underwent autologous fat transfer to the midface region at our private practice and were followed up for at least 1 year. Three-dimensional imaging was performed with a Canfield Scientific Vectra camera and software, with quantitative volume measurements evaluating the amount of postoperative volume change.
Thirty-three patients (66 hemiface-midface regions) were included in the study. The mean follow-up time was 16 months. The mean amount of autologous fat injected into each midface region was 10.1 mL. Overall, the mean absolute volume augmentation measured at their last postoperative visit was 3.3 mL (31.8% take). There was variability between patients in the volume amount and percentage that remained. Touch-up procedures were performed in 8 patients.
To our knowledge, this study is the first clinical quantification of autologous fat transfer and/or grafting in the literature that provides definitive evidence on the amount as well as the resultant longevity in the midface. Autologous fat transfer to the midface has definite long-term volume augmentation results. On average, approximately 32% of the injected volume remains at 16 months. However, some variability exists in the percentage of volume that remains that may require a touch-up procedure.
The efficacy of autologous fat transfer or grafting has been debated since its popularization in the 1990s owing to the lack of clinical objective data in the literature regarding longevity, predictability, and survivability of the fat grafts. There are conflicting results from studies, each recommending various techniques to improve the durability and survivability of transplanted fat.1 Despite the lack of quantitative data, this procedure has become an increasingly popular technique for facial rejuvenation. The incorporation of fat transfer has been driven by a greater appreciation of the role of volume loss in facial aging and the importance of restoring volume to achieve a natural rejuvenated appearance.
There has been great disparity in the reported results of fat grafting in terms of survivability and long-term outcomes. Studies evaluating survivability of transplanted fat have reported volume retention of between 20% and 90%. However, most of these data are based on subjective analysis of photographs or anecdotal assessment by the physician's experience.2- 5 Coleman6 reported long-term results of up to 11 years and disputed the article by Ersek2 on disappointing results at 3 years, with only 10% survival of grafts and no benefit with acne scarring.
In the few objective studies attempted, magnetic resonance imaging or ultrasonography was used to measure fat survivability and longevity. Magnetic resonance imaging quantified volume retention (termed survival) with a result of 51% survival at 3 months and a 45% survival at 6, 9, and 12 months.7 Ultrasonography has also been used to demonstrate results up to 1 year after fat transfer.8,9
The aim of the present study was to quantifiably assess and provide definitive clinical evidence of long-term volume augmentation using autologous fat grafting in the midface region.
After obtaining institutional review board approval, an analysis of all patients who underwent autologous fat transfer to the midface region at our private practice during a 12-month period was completed. Written informed consent was obtained, and patients were followed prospectively for at least 1 year. Patients who did not complete preoperative or postoperative 3-dimensional (3-D) imaging were excluded.
Standard atraumatic harvesting and injecting techniques with blunt cannulas were used and are described in detail in the authors' textbook.10 The fat was harvested primarily from either the abdomen or thigh. All facial recipient sites were meticulously recorded as to the specific area and volume injected.
Autologous fat grafting was usually combined with other facial procedures such as rhytidectomy and blepharoplasty. All rhytidectomy procedures were performed in a deep plane (sub–superficial musculoaponeurotic system dissection), and all lower-lid blepharoplasty procedures were performed using a transconjunctival approach. In all patients who had a concurrent transconjunctival lower-lid blepharoplasty, blepharoplasty was performed before fat grafting. Care was taken to inject fat into a plane that was not surgically interrupted during combined procedures.
Three-dimensional imaging was completed using a Canfield Scientific Vectra camera and software (Canfield Scientific Inc, Fairfield, New Jersey). Care was taken to ensure similar nonsmiling facial tone in both preoperative and postoperative photographs. Three-dimensional color schematic representation of volume changes between and preoperative and postoperative photographs was first obtained (Figure 1A). The midface region that was defined and measured included the inferior orbital rim, the nasojugal groove, the anterior cheek, and the lateral cheek. The midface region as defined was selected and highlighted as the area of volume measurement (Figure 1B) between the nasolabial fold and the inferior orbital rim. Quantitative volume measurements were then made using the 3-D imaging software that compares the volume difference between preoperative and postoperative images in this midface region. All volume measurements were recorded in milliliters.
Data were analyzed for demographics, volume injected into the midface region, volume augmentation at follow-up, ancillary procedures, and percentage of volume retained. Statistical analysis was performed by the Department of Statistics, Rutgers University, Piscataway, New Jersey, using SAS software (SAS Institute Inc, Cary, North Carolina).
Thirty-three patients (66 hemiface-midface regions) were included in the study. The female to male ratio was 32:1. The mean age was 54 years (range, 39-70 years). Mean follow-up time was 16 months, with a range of 12 to 21 months.
The mean amount injected into each midface region was 10.1 mL (range, 3.0-22.5 mL). All but 3 patients had equal amounts injected into each side in the midface. At follow-up, the amount of augmentation was recorded in milliliters and compared as a percentage to the total amount injected into the midface region. There was some variability between patients in the absolute amount and percentage of volume retention (Table 1). Overall, the mean absolute volume augmentation that was present at the last follow-up examination was 3.3 mL (range, 0.06-12.9 mL). The mean percentage of volume that was present at the last follow-up examination was 31.8%, which was statistically significant (P < .05).
The most common concurrent procedures were upper-lid blepharoplasty followed by lower-lid blepharoplasty, then deep-plane rhytidectomy (Table 2). Lower-lid blepharoplasty and rhytidectomy were analyzed for an effect on the amount of volume augmentation due to the proximity of the procedures. Neither lower-lid blepharoplasty nor rhytidectomy had a significant effect on the amount of volume augmentation or resorption (P values of .87 and .99, respectively).
Touch-up or secondary procedures were performed in 8 patients. These patients had a lower overall percentage of volume retention (29.6%) of the total amount injected. However, this was not significantly different (P = .71).
Three different age groups (39-49 years [7 patients], 50-59 years [17 patients], and 60-70 years [17 patients]) were analyzed to evaluate differences in percentage of volume retention. No significant difference in the amount of fat resorption or percentage of volume retention was present (P values ranged from .23 to .89).
To our knowledge, this study is the first clinical quantification of autologous fat transfer and/or grafting in the literature. We provide definitive clinical evidence (ie, objective and quantitative long-term data) of midface volume augmentation that occurs with fat transfer. Our study demonstrates that an average of 32% of the initial volume injected remains at approximately 1.5 years of follow-up. This finding can be very useful in guiding the surgeon in planning the initial injection amounts as well as in establishing appropriate patient expectations preoperatively. The results of this study compare favorably, in terms of volume retention at 1 year, to prior objective studies using magnetic resonance imaging.7
Nonimaging modalities have also been used to demonstrate adipocyte survival following autologous grafting. Biological markers of fatty acid composition have shown fat persistence at 1 year after transfer.11 In addition, animal studies have also documented long-term survival of fat grafts up to 5 years, with histologic analysis demonstrating persistent fat survival in biopsy specimens.12 To our knowledge, no studies to date have delineated whether the volume augmentation is due to tissue fibrosis, adipose survivability and hypertrophy, or stem cell proliferation. Further research is needed to quantify which, if not all, processes contribute to the retained volume.
The midface region tends to be the primary area of age-related volume loss. Clinically, these changes present as tear trough deformities, malar hollowing, formation of a double convexity, and loss of cheek definition. Autologous fat grafting provides a means for addressing all of these signs of aging with a single procedure. In our practice we routinely perform fat transfer with most blepharoplasties and rhytidectomies to address the significant volume loss that occurs with aging and achieve a balanced facial rejuvenation. A statistical analysis of our data showed that neither patient age nor concurrent surgical procedures (blepharoplasty or rhytidectomy) had a significant effect on the amount of volume that remained in long-term follow up.
Despite standardization of technique, there was variability in the degree of volume retention between patients in this study. This variability in augmentation is consistent with what has been reported previously in the literature.2- 5 Regardless, most patients were overwhelmingly satisfied, and only 8 patients (24%) required a touch-up fat grafting procedure. The indication for touch-up procedures in all 8 patients who underwent a secondary surgery was to correct for inadequate volume augmentation from the initial procedure. No patients required touch-up procedures for correction of noticeable asymmetries. The volume of fat injected in secondary procedures was usually considerably less than that used at the original procedure. Touch-up procedures were usually performed with local anesthesia and had less associated downtime. A waiting period of 6 months is generally recommended to allow for initial swelling and resorption to subside.
Volume retention also varied between sides in some individual patients. The variability found in the absolute amount and percentage of volume augmentation between sides in an individual patient may not be clinically appreciated. However, the majority of patients had symmetry in midface volume augmentation to within 1 mL. Intrapatient variability may be explained by differences in blood supply or positioning postoperatively (laying on 1 side at night).
Coleman6 has stressed the need for standardized and meticulous photography to evaluate postoperative fat grafting results. The importance of photographic evaluation of results cannot be overemphasized because it guides us on the efficacy of fat grafting (ie, what volume to use) and effectively demonstrates the postoperative results to patients. Despite efforts to control consistency of photographic technique, documenting fat grafting results for these purposes with 2-D photography is very difficult. Two-dimensional photography is limited in its ability to document volume changes because these changes in facial shape and contour are often reflected as changes in shadowing. Even with standardized lighting techniques, determination of volume changes with 2-D photography is inherently variable. Using 3-D photography and software, we can predictably and reliably follow the volume change that occurs with time. We strongly advocate the use of 3-D photography for surgeons who are using fat transfer in their practice. We have found that a decrease in volume occurs over the first 2 to 3 months, after which an actual increase of volume occurs over the next year to a stabilized volume (Figures 2, 3, and 4). This corresponds with our anecdotal clinical finding that patient results are often improved at 1 year compared with earlier postoperative results. No significant apparent weight changes were noted during the follow-up period; therefore, this increase in volume was likely due to transplanted adipocyte survival and hypertrophy, collagen deposition, and/or stem cell proliferation.
Some of the anecdotal disappointment previously reported with fat transfer is likely related to an expectation of greater volume gain (or retention) than can be achieved in a single procedure. We counsel all patients regarding the possible need for a touch-up procedure at 6 to 12 months to obtain a satisfactory amount of volume augmentation. As in every procedure, it is ever important to set appropriate patient expectations.
One important finding of this study is that the volumes required to make a visible change in midfacial rejuvenation are considerably less than we originally anticipated. The mean measured persistent volume change at last follow-up was 3 mL, which corresponded to a visibly good result. This information is not only useful in terms of procedure planning but also in realizing that other off-the-shelf injectables may play a viable role in midfacial volume augmentation as well.
This study focused on a single technique of injection based on a structured format that is easily reproduced.10 It does not address or compare intramuscular injection or other processing and harvesting techniques. Clinically, we have found that autologous fat grafting provides effective long-term results; we have patients who are 5 and 10 years out from their procedure who visibly have persistent augmentation.
We routinely use 3-D photography when assessing dermal fillers such as hyaluronic acid gel (Restylane [Q-Med AB, Uppsala, Sweden] and Juvéderm [Allergan Inc, Irvine, California]) as well as autologous fat grafting results.13 As more studies using the novel method of 3-D photography in the analysis of volume augmentation are completed, they can provide further evidence and objective data in various facial plastic and reconstructive surgery applications. Further studies with autologous fat grafting are warranted in other areas of the face, which anecdotally have less volume retention, such as the nasolabial folds and lips. We also look forward to providing longer objective data with 5- and 10-year results in the midface region.
In conclusion, autologous fat transfer to the midface has definite long-term volume augmentation results. On average, approximately 32% of the injected volume remains at 16 months. However, some variability exists in the percentage of volume that remains that may require a touch-up procedure.
Accepted for Publication: August 28, 2008.
Correspondence: Jason D. Meier, MD, 11701-32 San Jose Blvd, Ste 211, Jacksonville, FL 32223 (firstname.lastname@example.org).
Author Contributions:Study concept and design: Meier, R. A. Glasgold, and M. J. Glasgold. Acquisition of data: Meier, R. A. Glasgold, and M. J. Glasgold. Analysis and interpretation of data: Meier, R. A. Glasgold, and M. J. Glasgold. Drafting of the manuscript: Meier. Critical revision of the manuscript for important intellectual content: Meier, R. A. Glasgold, and M. J. Glasgold. Statistical analysis: Meier. Obtained funding: R. A. Glasgold and M. J. Glasgold. Administrative, technical, and material support: R. A. Glasgold and M. J. Glasgold. Study supervision: R. A. Glasgold and M. J. Glasgold.
Financial Disclosure: None reported.
Funding/Support: Canfield Scientific Inc, Fairfield, New Jersey, provided the 3-D camera and software for research purposes.
Previous Presentation: This study was presented at the American Academy of Facial Plastic and Reconstructive Surgery Annual Fall Meeting; September 18, 2008; Chicago, Illinois.