The quality and quantity of fat removed from the face is often insufficient for lipotransfer to other regions of the face. There is a higher concentration of connective tissue in the cervico-facial region that makes a great proportion of the contents removed during liposuction worthless for transplantation. Therefore, body liposuction is advocated to remove adequate fat tissue for transfer to the deficient facial zones. The abdomen tends to be a reliable source of generous adipose tissue, particularly in the more corpulent patient. The medial, anterior, and posterior hips are another source from which adipose may be procured, especially in the thinner individual. The point of entry should be within a natural skin crease or other acceptable concealed site, e.g., within the umbilicus and at the groin or buttock crease.
A small plastic protector that the senior cosmetic surgeon has designed should be mounted at the liposuctioning cannula entry site and secured to the skin in order to minimize unnecessary cutaneous trauma. All of these precautions are warranted in the Asian skin, which is prone to hyperpigmentation and hypertrophic scarring. The same technique is advocated for body liposuction as for facial liposuction. If only a minor amount of adipose is required, e.g., to fill in the hollowed upper-lid region, then a syringe with a handheld suction can be used to remove smaller quantities. At the end of the procedure, the area that has undergone liposuction should have a compressive dressing applied for a 1-week duration, and the patient should maintain limited activity for a 10-day period. Once all the fat has been harvested into a sterile suction canister, the fat must be processed for transplantation. Cotton gauze is placed over the mouth of an empty pitcher and the fat placed atop the gauze. Iced normal saline solution is poured over the fat in order to strain the excess blood and poor-quality fat through the gauze into the pitcher. A spoon can be used to swirl the mixture to expedite passage of the saline through the gauze. The gauze is then wrapped around the fat and squeezed by hand to remove the excess saline. The entire process is repeated several times until the fat achieves a pasty, solid consistency and assumes a yellow-to-orange color.
The fat can be placed into 1-, 2.5-, or 5-ml syringes depending on the intended area for lipotransfer. The 1-ml syringe outfitted with an 18-gauge needle is ideal for upper-lid, temporal, frontal, and nasolabialfold augmentation; whereas the 2.5- or 5-ml syringe outfitted with a 2-mm cannula is preferred for larger volume transfers into the cheek and possibly the frontal and temporal regions. The 2.5- or 5-ml syringe should not be equipped with an 18-gauge needle, as the increased pressure from a larger syringe into a smaller needle may traumatize the adipocytes excessively. The patient should receive proper intravenous sedation before fat transplantation, as no local anesthesia should be infiltrated into the recipient sites. Local anesthesia hinders accurate assessment of the amount of fat that should be transferred and should be avoided. Unlike for liposuction, the cannula or needle need not be rotated as the fat is injected. Furthermore, the fat should only be injected during withdrawal of the needle or cannula so that a uniform distribution may be achieved.
For the upper lid, the 18-gauge needle attached to a 1-ml syringe is inserted inferior to the lateral extent of the eyebrow and passed medially into the subcutaneous plane (above the orbicularis oculi), with injection during withdrawal. The needle should pass in a radial fashion to promote even fat allocation. Typically, a total of 2–3ml of fat is required per side. In a postblepharoplasty, the cosmetic surgeon should tent the skin upwards to avoid inadvertent postseptal injection. For the nasolabial fold, the 1-ml syringe and 18-gauge needle can be passed along the nasolabial fold entering first from the inferior end of the fold then the superior end following a deep-to-superficial order of injection. Radial injection is not indicated in this situation, as all the fat should be deposited immediately along the fold or slightly medially. A 2-mm cannula attached to a 2.5- or 5-ml syringe should be used to inject the fat into the malar and/or submalar regions from a stab incision at the lobule–cheek interface. The same technique for liposuction should be used for lipotransfer, with the exceptions that no tumescent injection is used, the flap need not be undermined first, the cannula need not be rotated, and the injection should be made only during withdrawal.
Otherwise, the radial, deep-to-superficial cannula movement should be emulated. The forehead can also be infiltrated to achieve a more uniform appearance using a 1-ml syringe with an 18-gauge needle. Finally, the temporal region can be restored with fat infiltration in a manner similar to lipotransfer to the cheek, starting, however, from the hairline just above the helical crus. The cosmetic surgeon is cautioned to stay in the subcutaneous plane at all times to avoid possible, but unlikely, facial nerve injury. An important step after fat transplantation that should not be overlooked is molding the transplanted fat between fingers to ensure a more uniform distribution. The fat can be pinched between two fingers and gently massaged until the contour feels smooth and even.
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