The thin face, sometimes referred to as gaunt, can exist in both the young and old. It is seen more frequently as one ages with loss of fat in the cheeks and side of the face. But it can also occur as a normal makeup os some people’s facial architecture even when one is relatively young. (Abraham Lincoln is the most famous example from an historical perspective, actor Scott Glenn and others are more recent examples) Known medically as facial lipoatrophy, it can also occur from certain diseases and medications. (such as HIV) Fat replacement by injection is both a logical and a minimally invasive method for its treatment.
Fat grafting is becoming increasingly popular and is ideal for the gaunt face. Fat is harvested with a small liposuction cannula from a suitable donor site. The amount of fat needed does not usually make for a significant contour change in the donor site. So patient’s shouldn’t expect that they will be getting an equivalent liposuction result elsewhere. I usually use abdominal fat harvested from inside the belly button. There is no scientific evidence yet that supports one donor site over another in terms of being better fat that will last longer after transfer.
The fat is prepared by removing loose liquids and impurities by washing and then spinning it in a centrifuge. It is then placed into syringes and injected into the desired facial areas through either the corner of the mouth, a crease in front of the ear, or within the crease of the nasolabial fold. The fat is injected in multiple small tunnels in a criss-crossing pattern if possible. The injected fat is then massaged around until it is smooth with no obvious irregularities.
Injecting fat into the face is a bit of an art form. In the gaunt face, the area below the cheek bones and into the side of the face are the most common. But other areas can be done as well including below the eyes and around the base of the nose. The amount of injected fat is relatively small with less than 10cc in each side of the face. It can be surprising how even small volumes of fat can make a significant volumetric difference.
This procedure can comfortably be done under local anesthesia, with oral or IV sedation if desired. Whether it is done in the office or an OR suite depends on which provides the best sterility and has the required equipment for fat harvesting and preparation.
The unknown variable in this procedure for every patient is how much fat will survive. One should not expect that 100% fat survival will occur. But the lateral face and cheek area are currently thought to be the most favorable with studies reporting up to 70% retention. My experience is closer to 50% so some overfilling is always done. What one sees at three months after treatment can be expected to be retained long-term.
In older patients that may have some loose skin in the jowl or neck, it can be combined with a limited or tuck-up facelift for even better results. While the fat does add volume and can help fill some lax skin, improvement below the facial hollows must come from skin tightening. I have seen some reports which tout that the overlying skin improves after fat grafting, suggesting that the new fat somehow rejuvenates aging skin. Some claim that its is the effect of the transplanted stem cells. I doubt that there are such effects but the underlying volume fill does stretch out the overlying skin and can give the impression of smoother skin.