image of silk fabric and dry skin

L. M. Donofrio, MD

Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA


The fat compartments of the face undergo changes and are responsible for age-related alterations in facial shape. The overlying skin responds to changes in fat in much the same way as a garment clings or sags to the body underneath. By rearranging the underlying fat via suction and fat replacement techniques, a younger-shaped face can be achieved without conventional excisional surgery.

Key Words:
fat rebalancing, aging

Aesthetics of the Aging Face: Gravity vs. Fat

Age-related morphologic changes in the face are due largely to fat redistribution. From infancy through adulthood, it is fat that characterizes the face’s shape. A baby has an identifiable distribution of fat in its chubby cheeks, jowls and neck rolls. Interestingly, this distribution occurs again in the older adult, but we ascribe it to loose skin and blame gravity.

Gravitational aging is the target for much of conventional cosmetic surgery. The premise of gravitational descent has founded surgical corrections like face, brow, and neck lifts, blepharoplasty, and laser resurfacing. But to consider gravity the exclusive culprit of facial aging and sagging is simplistic. There are no animal models for gravitational aging. There is tremendous individual variability in the degree of sagging, and age-related fibrosis (can anyone touch their toes like they used to?) may counteract increased laxity.

Indeed, sagging of the aging face may occur mostly as a result of changes in the fat compartments that are coincident with chronological aging. Localized overabundance of fat may weigh down the tissue. Pendulous abdomens may hang due to excessive fat on the lowermost portion. Conversely, an area devoid of fat resembles a deflated balloon by inducing the downward displacement of facial skin. Inelastic recoil due to photodamage compounds this effect. If altered fat distribution underlies the differences between the young and old face, then a new model for the youthful countenance arises.

Facial Topography in the Young and Old

A young face has a smooth, ample distribution of fat. It resembles a continuous, “gently rolling plain” because the fat is evenly distributed. There is a forward projection with facial arcs highlighting specific areas and causing minimal shadow. In contrast, the aging face has “hills and valleys” producing deep shadows and irregular highlights. In thin individuals these “hills” of fat may be minor, but in most middle-aged adults the hills occur in a strip down the central face from midcheek to jowl, along the nasolabial and labiomental folds. Fat pocketing can also be seen suborbitally on the lateral zygoma, submentally and along the neck platysmal bands. Since body fat rises with age, so does facial fat. “Valleys,” in contrast, occur periorbitally and periorally, in the malar, buccal and temporal areas, and on the far lateral cheek. Fat loss manifests around the mandible, and throughout the forehead and scalp.

The Goal of Fat Rebalancing

One major goal of rejuvenation procedures is to rebalance fat and restore harmony to the face. This can be accomplished by microliposuction of the fatty “hills” and fat transfer to the sunken “valleys”. Restoration of homogeneity to the facial structure reduces the sharp shadows associated with aging.

Initial Consultation

At the initial visit, the patient’s face is compared to a photograph from 10-15 years ago. The dermatologic surgeon develops a “blueprint” of the areas to be augmented with fat and the areas to be suctioned. Dynamic changes in the underlying structure of the entire face are thus planned.

Principles of Facial Fat Rebalancing: A Step-by-Step Approach

  1. Tumescent anesthesia (1l Lactated ringers solution, 50ml of 1% xylocaine, 1mg epinephrine, 12meq sodium bicarbonate) is locally infiltrated.
  2. Fat is harvested from a donor site from which fat removal can induce cosmetic benefit. Buttock, outer thigh or abdomen fat has the greatest lipogenic activity.
  3. Fat is harvested with minimal trauma.
  4. Extraction is with an open tipped cannula attached to a 10cc syringe. The plunger is withdrawn 1cc at a time, generating small negative pressures. Suction machines are avoided.
  5. The fat is sterilely centrifuged for 30 seconds at 3400 RPM.
  6. The spun fat is transferred to 1cc syringes leaving the triglyceride layer.
  7. Recipient sites receive facial blocks when possible to avoid distortion, then infiltration with 0.5% lidocaine with epinephrine.
  8. Target areas are tumesced for hemostasis and anesthesia.
  9. Entry sites on the face are made with an 18g Nocor®. Blunt-tipped 18g (or larger) cannulas are used.
  10. Fat is transferred in less than 0.1cc aliquots, under low injection pressures.
  11. Fat is deposited in thin strands during the withdrawal phase.
  12. Fat is transferred starting submuscular when possible and weaving fat in a crosshatched 3-D design through the muscle to the subdermis. Periorbitally, fat is conservatively placed deep to the muscle.
  13. Fat is only deposited in “virgin” tissue via fresh tunnels.
  14. Fat is placed in and around folds to “suspend” skin. All facial areas are addressed.
  15. Extra fat is stored in a freezer at -20∞ and labeled in triplicate with name, date and SS#.
  16. “Touch-ups” are performed every 4-8 weeks.
  17. Frozen fat is rapidly thawed by placing syringes in an examination glove next to the patient’s skin.
  18. Fat from hypertrophic areas is suctioned by hand-held 10cc syringes and blunt-tipped 18-cannulas. Suction is staged for gradual skin contraction. Suction machines are avoided on the face.
  19. Patients need 4-8 transfers +/- facial suction over a year for total correction.

Technique Dependence: Potential Pitfalls

Fat transfer is notoriously technique dependent. Common pitfalls are:

  1. Underestimating the fat needed. Since most transfers place only 35cc of fat over the entire face, many transfers are required for remodeling.
  2. Placing too much fat in one session. The fat may not survive, and the risk of lumps and cysts, especially around the eye, is increased.
  3. Assuming incorrectly that the immediate posttreatment volume change is from fat. When blunt instruments are used, edema results. Patients usually like this swelling, because it allows them to “preview” the final results. However, this edema (lasting in a mild form for up to 2 months) will abate.
  4. Filling the folds only. Folds in the face derive from “upstream” tissue shifts. For instance, the nasolabial folds are due to loss of central cheek mass. Cheek filling helps push up these folds.
  5. Pouring off triglycerides before freezing, and slow “countertop” thawing of fat. Like glycerol, triglycerides have cryoprotective effects and should be left in before freezing1. Rapid thawing is associated with ice crystal formation and cell death2.

Utility of Frozen Fat

Using a patient’s own frozen fat obviates the need to resuction them. Frozen fat “takes” better than fresh fat.3,4,5 This may be from dehydration-induced stability of the adipocytes, or perhaps freezing “stresses” the cells into stability. In a rabbit model, previously suctioned frozen fat survived as well as fresh fat.6 Histologically, fat previously frozen for up to two years appears as morphologically intact as fresh fat.7 Additional evidence is the long-term volume change that the author has witnessed with frozen fat.

Long-term Outcomes

Gradual improvement occurs over a year, and the brief “down-time” accommodates active lifestyles. Patients “de-age” over time since the blueprint is fashioned on their younger selves. Each transfer/suction may make them look 2-5 years younger. Excellent fat retention results from small-volume, repeat injections and woven placement of fat grafts. Dynamic shifting of tissues is accomplished by global filling. Fat grafts remain anchored in fat and muscle.

There is controversy in the literature about the persistence of transplanted fat. Sadick8 found that in 5 of 6 patients, gluteal fat placed in the nasolabial folds could not be identified as such 4 months later. But Kaminer and Omura9 noted that secondary fibrosis rather than persistence of the fat per se may be responsible for the cosmetic benefits observed by many practitioners. They also reiterate that fat transplantation is a deceptively simple procedure with many parameters that can be altered and numerous operator-specific variations. In expert hands, fat rebalancing appears efficacious and is associated with high patient satisfaction.

Potential Complications

Possible complications include infection, graft absorption, bruising, swelling and under-correction. Over-correction should not be seen, since the process is designed to be gradual and incremental.

Fat Rebalancing vs. Facelifting

Fat rebalancing can be done earlier than a facelift. Rather than inappropriately altering the patient’s appearance, fat makes the patient look like he or she used to look. Skeletonization or unnatural pulling is avoided. The fat procedure suits the 55 year-old who wants to look 40, or the 40 year-old who wants to look 30. In contrast to facelifts “tailoring” the skin around the aging framework, fat rebalancing replaces the lost framework so the skin can reassume its previous position. The patient can subsequently decide to modify the “blueprint.”

Maintenance and Repeat Treatment

Since patients will continue to age after the rebalancing treatments, they should consider maintenance visits 1-2 times a year. However, if they choose to stop treatments, they will age from that point on, the transplanted fat behaving like their own facial fat. Patients should maintain a consistent body weight for optimal postoperative results.


  1. Jezek D, Schulze W, Kalani-Bognar S, Vukelic Z, Milavec-Puretic V, Krhen I. Effects of various cryopreservation media and freezing-thawing on the morphology of rat testicular biopsies. Andrologia 33(6):368-78 (2001 Nov).
  2. Lawrence N. Fat Transfer: Laboratory Analysis. Presented at: The American Academy of Dermatology Annual Meeting, Feb 2002, New Orleans, USA.
  3. Jackson RF. Frozen fat – does it work? Am J Cosmet Surg 14:339-43 (1997).
  4. Fulton JE, Parastouk N. Fat grafting. Dermatol Clin 19(3):523-30, ix (2001 Jul).
  5. Donofrio LM. Structural autologous lLipoaugmentation: a Pan-facial technique. Dermatol Surg 26(12):1129-34 (2000 Dec).
  6. Shoshani O, Ullmann Y, Shupak A, et al. The role of frozen storage in preserving adipose tissue obtained by suction-assisted lipectomy for repeated fat injection procedures. Dermatol Surg 27(7):645-7 (2001 Jul).
  7. Donofrio LM. The histologic morphology of frozen fat. Presented at: The American Society of Dermatologic Surgery Annual Meeting, Oct 2001, Dallas TX, USA.
  8. Sadick NS, Hudgins LC. Fatty acid analysis of transplanted adipose tissue. Arch Dermatol 137(6):723-7 (2001 Jun).
  9. Kaminer MS, Omura NE. Autologous fat transplantation. Arch Dermatol 137(6):812-4 (2001 Jun).