Fat grafting and volume with facelift

What it is

Fat grafting moves the patient's own fat to the face. The surgeon collects fat by liposuction, prepares it and injects it into the areas that have hollowed (PMID 37159906). A 2024 review calls it the preferred filler for facial hollowing because it is plentiful, easy to obtain and fully compatible with the body (PMID 37159906).

The lift and the fat do different jobs. The facelift moves sagging tissue back up; the fat replaces what has been lost. Fat loss in specific compartments is a major part of how the face ages (PMID 37159906). Losing the deep fat of the inner cheek makes the cheek look as if it has dropped and deepens the fold from nose to mouth (PMID 18520902). The bones recede too, at the upper jaw, the rim of the eye socket and the jaw in front of the jowl (PMID 22580543).

Where it came from

Sydney Coleman described structural fat grafting, which he called lipostructure, in 1997 and 1998 (PMID 9142473, PMID 19328166). In 2001 Trepsat named Coleman's lipostructure as the major change in his own facelift: he almost always grafted fat in the same operation, placing it before he lifted the skin (PMID 11604644).

Anatomy then showed where fat was missing. Rohrich tied the dropped look of the aging cheek to loss of the deep medial cheek fat (PMID 18520902), and his lift-and-fill facelift placed fat into chosen cheek compartments and the nasolabial fold during the lift (PMID 24569422). Swanson then measured the result: MRI showed the cheek fat still present months after surgery (PMID 21228737), and standardized photographs showed how much of it stayed (PMID 33173678).

Use has grown. In American Board of Plastic Surgery case data, surgeons added fat to facelifts more often in recent years, and more patients arrived worried about lost volume (PMID 38302713). Tonnard introduced nanofat in 2013, fat broken down fine enough to inject into the skin (PMID 23783059). Poly-L-lactic acid, an injectable approved by the FDA for cosmetic use in 2009, is now used to replace fat that does not survive (PMID 24719078, PMID 35662905).

Who it suits

• Hollow cheeks, temples or under-eye area. Fat fills the deep compartments that have deflated, while the lift moves the surface fat back up with the SMAS (PMID 31688754).
• A deep fold from nose to mouth. After lift-and-fill facelifts, the nasolabial fold improved by at least one grade in about 4 in 5 patients (PMID 24569422).
• A hollow in front of the jowl. Fat placed in this hollow, with little skin released, corrected jowls better than cutting the mandibular ligament, and with fewer side effects (PMID 39001648).
• Lean patients and those who plan to lose weight. A high lean body mass and weight loss after surgery were common reasons patients needed more volume later (PMID 35662905).

Practice varies by surgeon. Surgeons who use deep-plane lifts report relying less on fat for the midface (PMID 38354840), and fat grafting was not widely adopted among facial plastic surgeons surveyed in 2026 (PMID 41251721).

How it is done

Where the fat goes

• Common sites during a facelift are the nasolabial folds, tear troughs, temples, cheeks, marionette grooves, lips and earlobes (PMID 31907534).
• In the lift-and-fill method, fat goes to the deep cheek, the high outer cheek and the nasolabial fold (PMID 24569422).
• Fat restores deep cheek volume with every SMAS technique, and each technique uses it to cover what that lift leaves undone (PMID 36729730).

When and how much

• Trepsat places the fat in the same operation, before lifting the skin, with small touch-ups at the end (PMID 11604644).
• In an MRI study, surgeons placed about 9 cc of fat in each cheek (PMID 21228737).
• More fat gave more cheek projection (PMID 33173678). Marten's guide sets out why, where, how and how much fat to place in each area of the face (PMID 30171292).

Fat, nanofat and filler

• Fat is sorted by parcel size into macrofat, microfat and nanofat. Macrofat and microfat add volume and improve skin; nanofat improves skin texture and color (PMID 37159906).
• Nanofat has no living fat cells but keeps the stem cells, and it passes through needles as fine as 27 gauge (PMID 23783059). Studies report better scars and skin, at a low level of evidence (PMID 37400953, PMID 40250993).
• Some surgeons combine fat with platelet-rich plasma to treat the skin and the SMAS layer (PMID 37816491).
• Poly-L-lactic acid is an injectable that prompts the body to build volume. It is used after a facelift to replace fat that was lost and to treat areas that were not grafted (PMID 35662905).

Results and how long they last

• About a third of the fat injected into the cheeks during a facelift stays (PMID 33173678).
• That fat added about 3 mm of cheek projection on average (PMID 33173678). The lift alone added less than 1 mm (PMID 33173678).
• The gain held at a year, with no later drop (PMID 33173678). On MRI the added tissue was fat, and it was still there at 6 months (PMID 21228737).
• Patients who had fat with a high-SMAS lift rated their results higher on some satisfaction scales (PMID 28002252). A systematic review found that fat with a facelift improves facial volume and appearance (PMID 31907534).
• Survival varies from patient to patient, which O'Daniel calls an accepted reality of fat grafting (PMID 35662905). Aging and weight loss keep taking volume after surgery (PMID 35662905).

Risks and how surgeons lower them

• Volume lost after surgery. Some fat does not survive. Surgeons replace it with poly-L-lactic acid injections, and in one surgeon's series no nodules, papules or granulomas formed (PMID 35662905).
• Fat in an artery (embolism). Facial fat grafting is considered generally safe, but fat that enters an artery can block blood flow to the eye or brain; every reported patient whose eye artery was blocked lost vision permanently, and some patients died (PMID 37563433).
• Where embolism happens. Reported cases most often followed injections between the eyebrows or across several areas, then the temples and forehead (PMID 37563433). No evidence-based treatment exists, and the authors call for a database of cases to improve safety (PMID 37563433).
• Side effects at the jowl. Grafting the hollow in front of the jowl with less skin dissection had fewer side effects than cutting the ligament (PMID 39001648).
• Overall safety. A systematic review rates facelift with fat grafting as safe (PMID 31907534). In a MACS lift practice that adds fat to nearly every lift, no major complications occurred (PMID 40906287).

Recovery

• The cheek gain is visible at the first month and holds through 6 months on MRI (PMID 21228737).
• On photographs the gain held at 1, 3 and 6 months, and at a year in the patients followed that long (PMID 33173678).
• Volume that fades can be topped up with poly-L-lactic acid in the months after surgery; some patients receive it before surgery too (PMID 35662905).

With a facelift

• Fat is grafted in the same operation as the lift (PMID 11604644, PMID 33173678).
• A lift moves tissue but does not replace lost volume, so fat is used with every SMAS technique to restore the deep cheek (PMID 36729730, PMID 31688754).
• The MACS lift has grown to include fat grafting to the center of the face in nearly every case, often with nanofat needling for the skin (PMID 40906287).
• Surgeons who use deep-plane lifts report less need for fat in the midface (PMID 38354840).
• In O'Daniel's practice, poly-L-lactic acid injections after a facelift with fat grafting are used to maintain volume (PMID 35662905).

Questions to ask a surgeon

• Which parts of my face have lost volume, and which have sagged? (PMID 31688754)
• Will you add fat during my facelift, and where will it go? (PMID 24569422)
• How much of the fat do you expect to stay, and what happens if some is lost? (PMID 33173678)
• If I lose weight after surgery, how will you restore the volume? (PMID 35662905)
• Will you inject fat between my eyebrows, at my temples or on my forehead, and how do you keep fat out of the arteries there? (PMID 37563433)
• Will you treat the hollow in front of my jowl with fat or by releasing the ligament? (PMID 39001648)
• Do you use nanofat for skin quality, and what results do you expect from it? (PMID 40250993)

Open questions

• Why fat survival varies so much between patients (PMID 35662905, PMID 33173678).
• Whether every facelift needs fat: use is rising among plastic surgeons (PMID 38302713), limited among surveyed facial plastic surgeons (PMID 41251721), and lower in some deep-plane practices (PMID 38354840).
• Whether nanofat improves skin in controlled trials; the 2025 consensus found the clinical evidence weak (PMID 40250993).
• How to treat fat embolism; no evidence-based treatment exists (PMID 37563433).

Terms

• Autologous fat grafting / lipofilling: collecting the patient's own fat and injecting it elsewhere (PMID 31907534).
• Lipostructure: Coleman's structural fat grafting method (PMID 9142473).
• Macrofat / microfat / nanofat: fat graft types sorted by parcel size (PMID 37159906).
• Retention: the share of injected fat still present at follow-up (PMID 33173678).
• Malar projection: how far the cheek stands out, seen from an angle (PMID 33173678).
• Pseudoptosis: a cheek that looks dropped because it has lost volume (PMID 18520902).
• Prejowl sulcus: the hollow in front of the jowl (PMID 39001648).
• PLLA: poly-L-lactic acid, an injectable that stimulates the body to build volume (PMID 35662905).
• Lift-and-fill: a SMAS facelift combined with fat grafting to chosen fat compartments (PMID 24569422).
• Arterial embolism: fat carried in an artery that blocks blood flow (PMID 37563433).

Papers