Why volume
- Fat loss in specific compartments contributes to structural aging of the face (PMID 37159906).
- Deep medial cheek fat loss produces pseudoptosis and a deeper nasolabial fold (PMID 18520902).
- Compartment anatomy explains regional cheek deflation; deep compartments are augmented, superficial fat repositioned with the SMAS (PMID 31688754).
- Skeletal resorption with age: maxilla, orbital rim, prejowl mandible (PMID 22580543).
Fat grafting with facelift: history and adoption
- Coleman: structural fat grafting / lipostructure (PMID 9142473, PMID 19328166).
- Trepsat 2001, "volumetric face lifting": lipostructure performed in the same session as the facelift, usually before undermining (PMID 11604644).
- Rohrich 2014, lift-and-fill: fat grafted to deep malar, high/lateral malar and nasolabial compartments in 100 facelifts; malar projection +13.47% (PMID 24569422).
- ABPS tracer data: concomitant fat grafting rose from 15% (2006-2014) to 24% (2015-2021) of facelifts; patients concerned about deflation rose from 25% to 37% (PMID 38302713).
- MACS originators, 2018-2024: lipofilling in 96.3% of 380 MACS lifts (PMID 40906287).
- AAFPRS survey 2026: fat grafting not widely adopted among responding facial plastic surgeons (PMID 41251721).
Outcomes
- Systematic review, 15 studies: adding fat grafting to facelift improved facial volume and aesthetic assessments; safe (PMID 31907534).
- 100 sub-SMAS facelifts with (61) or without (39) malar fat: fat added a mean 3 mm of malar projection vs under 1 mm; calculated retention 34%; sustained to 1 year in 44 (PMID 33173678).
- MRI in 5 patients: malar thickness increase from fat present at 6 months (PMID 21228737).
- FACE-Q, 200 high-SMAS facelifts: patients with lipofilling more satisfied in 3 subscales (PMID 28002252).
- Evidence and case review: fat grafting used with every SMAS technique to restore deep malar volume (PMID 36729730).
- Prejowl sulcus: fat grafting with little release corrected jowls more than mandibular ligament release (PMID 39001648).
- Fat grafting how-to by region and volume (Marten) (PMID 30171292).
Macrofat, microfat, nanofat
- Fat grafts divide by parcel size into macrofat, microfat and nanofat; macro and micro restore volume, nanofat improves skin texture and pigmentation (PMID 37159906).
- Tonnard 2013: nanofat (emulsified and filtered microfat) contains no viable adipocytes but retains adipose-derived stem cells; injected through needles up to 27 gauge in 67 cases (PMID 23783059).
- Systematic review 2024, 12 studies: nanofat improved scars in 6 studies (253 patients) and skin quality in 4; low level of evidence (PMID 37400953).
- Expert consensus 2025: nanofat defined as washed lipoaspirate emulsified 20-30 passes through a 1.2-1.6 mm connector and filtered at 300-500 micrometers; clinical evidence not robust (PMID 40250993).
- Nanofat microneedling used in 64.7% of 380 MACS lifts (PMID 40906287).
- Platelet hybridized adipose therapy (PHAT) for SMAS and dermal rejuvenation (PMID 37816491).
Poly-L-lactic acid (PLLA) after facelift
- O'Daniel and Kachare 2022, 241 patients with facelift plus fat grafting and PLLA (190 after surgery, 51 before): indications were early fat graft loss, postoperative weight loss, aging, high lean body mass and untreated sites; no nodules, papules or granulomas (PMID 35662905).
- PLLA consensus recommendations (O'Daniel coauthor): FDA approval 2004 for HIV lipoatrophy and 2009 for cosmetic use (PMID 24719078).
Safety
- Arterial embolism after facial fat grafting, 61 reported patients: permanent vision loss in all 26 with ophthalmic artery occlusion; 6 deaths; glabella and multiple regions most common sites (PMID 37563433).
Glossary
- Autologous fat grafting / lipofilling: harvesting and reinjecting the patient's own fat (PMID 31907534).
- Lipostructure: Coleman's structural fat grafting method (PMID 9142473).
- Macrofat / microfat / nanofat: fat graft types by parcel size (PMID 37159906).
- Retention: share of injected fat volume still present at follow-up (PMID 33173678).
- PLLA: poly-L-lactic acid, an injectable biostimulator (PMID 35662905).
- Lift-and-fill: SMAS lift combined with compartment fat grafting (PMID 24569422).
Papers
| PMID | First author | Year | Journal | Title | Finding |
|---|---|---|---|---|---|
| 31907534 | Molina-Burbano F | 2021 | Aesthet Surg J | Fat Grafting to Improve Results of Facelift: Systematic Review of Safety and Effectiveness of Current Treatment Paradigms. | Systematic review: facelift plus fat grafting safe and effective |
| 31688754 | Stuzin JM | 2019 | Plast Reconstr Surg | The Facial Fat Compartments Revisited: Clinical Relevance to Subcutaneous Dissection and Facial Deflation in Face Lifting. | Fat compartments and deflation in face lifting |
| 33173678 | Swanson E | 2020 | Plast Reconstr Surg Glob Open | Photographic Comparison of Malar Projection in 100 Facelift Patients Treated with and without Fat Injection. | Malar fat with facelift: +3 mm, 34% retention |
| 35662905 | O'Daniel TG | 2022 | Aesthet Surg J Open Forum | The Utilization of Poly-l-Lactic Acid as a Safe and Reliable Method for Volume Maintenance After Facelift Surgery With Fat Grafting. | PLLA after facelift and fat grafting, 241 patients |
| 37159906 | Strong AL | 2024 | Plast Reconstr Surg | Technical Precision with Autologous Fat Grafting for Facial Rejuvenation: A Review of the Evolving Science. | Macro, micro and nanofat review |
| 18520902 | Rohrich RJ | 2008 | Plast Reconstr Surg | The youthful cheek and the deep medial fat compartment. | Deep medial cheek fat and pseudoptosis (landmark) |
| 22580543 | Mendelson B | 2012 | Aesthetic Plast Surg | Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. | Facial skeleton resorption with age (landmark) |
| 9142473 | Coleman SR | 1997 | Clin Plast Surg | Facial recontouring with lipostructure. | Coleman lipostructure (landmark) |
| 19328166 | Coleman SR | 1998 | Aesthet Surg J | Structural fat grafting. | Coleman structural fat grafting (landmark) |
| 11604644 | Trepsat F | 2001 | Plast Reconstr Surg | Volumetric face lifting. | Volumetric face lifting (landmark) |
| 24569422 | Rohrich RJ | 2014 | Plast Reconstr Surg | Lift-and-fill face lift: integrating the fat compartments. | Lift-and-fill facelift, 100 patients |
| 38302713 | Stein MJ | 2024 | Aesthetic Plast Surg | Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery. | ABPS: fat grafting with facelift 15% to 24% |
| 40906287 | Sommar P | 2026 | Aesthetic Plast Surg | Use of Ancillary Procedures in Combination with the MACS-Lift for Facial Rejuvenation: A Retrospective Cohort Study. | MACS lifts: lipofilling 96.3%, nanofat 64.7% |
| 41251721 | Pak KY | 2026 | J Craniofac Surg | Evaluating Facelift Outcomes and Technique Trends in the United States. | AAFPRS survey: fat grafting not widely adopted |
| 21228737 | Swanson E | 2011 | Plast Reconstr Surg | Malar augmentation assessed by magnetic resonance imaging in patients after face lift and fat injection. | MRI confirms malar fat at 6 months (landmark) |
| 28002252 | Kappos EA | 2017 | Plast Reconstr Surg | Validating Facial Aesthetic Surgery Results with the FACE-Q. | FACE-Q: lipofilling raises satisfaction (landmark) |
| 36729730 | Avashia YJ | 2023 | Plast Reconstr Surg | An Evidence-Based and Case-Based Comparison of Modern Face Lift Techniques. | Fat grafting used with all SMAS techniques |
| 39001648 | Talei B | 2024 | Aesthet Surg J | Mandibular Ligament and the Prejowl Sulcus Explained. | Prejowl: fat grafting vs ligament release |
| 30171292 | Marten T | 2018 | Aesthetic Plast Surg | Facial Fat Grafting: Why, Where, How, and How Much. | Facial fat grafting why, where, how, how much (landmark) |
| 23783059 | Tonnard P | 2013 | Plast Reconstr Surg | Nanofat grafting: basic research and clinical applications. | Nanofat introduced (landmark) |
| 37400953 | Tran VVT | 2024 | Plast Reconstr Surg | Effects of Nanofat in Plastic and Reconstructive Surgery: A Systematic Review. | Nanofat systematic review |
| 40250993 | Arcani R | 2025 | Facial Plast Surg Aesthet Med | Nanofat Use in Regenerative Medicine: A Systematic Literature Review and Consensus Recommendations from Expert Opinions. | Nanofat consensus definition |
| 37816491 | Talei B | 2025 | Facial Plast Surg | PHAT Lips and PHAT Face: Platelet Hybridized Adipose Therapy for Superficial Musculoaponeurotic System and Dermal Rejuvenation. | PHAT technique |
| 24719078 | Vleggaar D | 2014 | J Drugs Dermatol | Consensus recommendations on the use of injectable poly-L-lactic acid for facial and nonfacial volumization. | PLLA consensus recommendations (landmark) |
| 37563433 | Moellhoff N | 2023 | Aesthetic Plast Surg | Arterial Embolism After Facial Fat Grafting: A Systematic Literature Review. | Arterial embolism after facial fat grafting, 61 cases |
| 38354840 | Talei B | 2024 | Facial Plast Surg | The Detailed Anatomy of the Deep Plane of the Face and Neck with Current Nomenclature. | Deep plane with less reliance on fat grafting |
Open questions / controversies
- Retention is variable: 34% measured in one 100-patient series (PMID 33173678); O'Daniel calls the variability of fat survival an accepted reality (PMID 35662905).
- Adoption differs by specialty: rising among ABPS surgeons (PMID 38302713), not widely adopted among surveyed AAFPRS surgeons (PMID 41251721); deep-plane advocates report less dependence on fat (PMID 38354840).
- Nanofat lacks robust clinical evidence and a standard preparation until the 2025 consensus (PMID 40250993).
- Embolism risk has no evidence-based treatment algorithm (PMID 37563433).