Fat Grafting to Thicken Skin Under Lower Eyelids and Above Lips?

Fat transfer is an excellent option to treat volume loss whether congenital or aging related.  Volume loss in this region, leave the eyes looking tired and less vibrant.  Everyone has thin skin in that region, but the question is do you have hollows and dark circles as a result of the reduced fat volume?  In either case, make sure whoever you choose to do this procedure is experienced with fat transfer below the eyes.  This is a challenging region to perform fat transfer, however if done well, it can look remarkably natural and rejuvenated. 

A very common aging change in the lower eyelids is the development of 'bags', which are in most cases due to an outward bulging of the fat pads behind the lower lids. These 'bags' of fat can be improved by conservative removal through an invisible incision on the inside of the lower lid (trans-conjunctival approach) in patients that do not require skin excision, or through the under-eyelash (sub-ciliary approach) in patients that are having some excess lower lid skin removed.

As with skin removal, I believe that the reduction (NOT total removal) of lower lid fat pads should be conservative. Excessive removal of lower lid fat pads results in a hollowed-out appearance that makes blepharoplasty patients look tired or even ill. I see quite a number of eyelid surgery patients who require structural fat grafting of the lower lids to improve that very problem following an over-aggressive lower blepharoplasty in the past.

In some case lower lid 'bags' can be improved by repairing or reinforcing the soft tissues that normally hold them back. Additionally, excessive lower lid fat can sometimes be mobilized and transposed inferiorly to fill in periorbital hollows or depressions such as the 'tear trough' at the medial junction of the lower lid and cheek.

Some eyelid 'bags' involve redundant muscle tissue which must be removed and/or repositioned, usually in patients who are in their sixties or older. This is performed through an under-eyelid (sub-ciliary) incision which is extended laterally into the 'crow's feet' area.

Structural Fat Grafting of the Lower Lid

As mentioned above, it is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin.

In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.

In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient. Because of the tremendous variability in all of these factors, there is tremendous variability in fat grafting results.  To perform fat grafting successfully and reproducibly a surgeon must employ careful preoperative planning, appropriate instrumentation and meticulous surgical technique.  It is not something you can 'rush through' or spend just a few minutes on during a larger surgical procedure.  The unfortunate reality is that not everyone who performs fat grafting is willing to put in the level of education, training, investment in instrumentation and operative effort required to produce aesthetically ideal results.

One must also have an aesthetic vision for ideal and youthful-appearing facial fullness.   Just like traditional facelift surgery can be overdone or performed incorrectly to produce an unnaturally tight, pulled, 'windswept' look, fat grafting can be overdone to produce an excessively full and even bizarre postoperative appearance.  Too much fat grafted into any area (or any fat placed where it doesn't belong) looks unnatural.  It's analogous to breast augmentation results: if the surgeons selects an appropriate implant volume and positions the implants correctly, the patient gets a beautiful, natural-appearing breast enhancement.  If the surgeons stuffs a pair of 500cc implants behind the breasts of an average-sized patient, then that patient ends up with a cartoonish 'boob job'.  I think many of the unfavorable results in fat grafting are from the overzealous placement of excessive amounts of fat, which may have been the inevitable response to the recent paradigm shift in aesthetic facial surgery: away from the 'wind tunnel look', and towards the restoration of soft tissue volume.
Here is one patient’s experience with fat grafting posted to RealSelf:

Fat is great when used JUDICIOUSLY and CONSERVATIVELY, but too much of a good thing becomes a nightmare and deeply regrettable. Make sure your surgeon listens, draws up precise operative plans beforehand and makes plenty of time for you and your concerns. Do NOT take it lightly.
I couldn’t agree more with this patient’s response to her experience with fat grafting.  Just like breast implants, or liposuction, or browlifts, too much of a good thing is not at all a good thing.  And cosmetic surgery (and this includes the preparation for surgery) of any kind without attention to detail and a focus on natural-appearing results will leave patients feeling disappointed at best and feeling disfigured at worst.  Now regarding whether or not fat grafting is a surgically sound concept…

For transferred fat to truly qualify as a 'graft' the following must happen: living tissue must be transferred to a new location, and that tissue must gain a blood supply at the new location which provides oxygen and nutrients which allow it to persist indefinitely as living tissue.  We know that with appropriate instrumentation and technique this is achievable, so one of the opinions expressed in this thread that "most of the cells from fat injection are dead " is simply untrue (and structural fat grafting, to be clear, does not involve 'injection' of fat).  MRI studies have shown that with appropriate technique grafted fat persists long-term as living, vascularized tissue in the recipient site.
It is also well-established that adult human fatty tissue contains stem cells that have the capacity to repair damaged or injured tissues, and stem cells can be concentrated during the fat harvesting process.  This effect has applications in both cosmetic and reconstructive surgery.  Fat grafting is now being used, for example, as a means to stimulate the repair of chronic, non-healing wounds.  Several centers have reported on fat grafting immediately below non-healing chronic wounds resulting from radiation therapy for cancer, with rapid improvement and eventual healing of wounds for which no other wound treatment was successful.  The development of stem cell therapies involving the harvesting and processing of viable human fatty tissue is one of the hottest topics in both clinical and experimental medicine today.

When performed correctly fat grafting actually has the capacity to heal, revitalize and rejuvenate the local tissues at the recipient site.  I have treated a number of patients with facial fat atrophy following overly aggressive 'non-invasive' rejuvenation treatments including Thermage, Fraxel and IPL.  Most of these patients report not only an aesthetically  pleasing and permanent improvement in facial soft tissue volume, but also an improvement in the quality and vitality of their facial skin.
I perform extensive facial fat grafting during most of my facial rejuvenation procedures, and it is the very first thing I do - before making any incisions to lift the brows, eyelids, face or neck.  Fat grafting allows me to obtain results that are simply not possible with conventional, subtractive surgical techniques alone.  Patients frequently return for grafting of additional areas after their initial experience with strucutral fat grafting.  To characterize it as the pointless and potentially harmful placement of non-viable tissue is an opinion only, and it is an opinion with which quite a number of plastic surgeons who successfully rejuvenate faces (and breasts and bodies) with fat grafting would vehemently disagree, myself included.

Solid fat/fascia and fat dermis grafts are another means by which facial soft tissue volume may be significantly and permanently enhanced.  As with fat grafting, survival of the grafted tissue is variable and some of the graft material is reabsorbed.  As with fat grafting, potential complications such as infection and cyst formation are possible.  And as with fat grafting, appropriate preoperative planning and surgical technique are required in order to obtain ideal and lasting results.  In my opinion structural fat grafting is more versatile, as fat can be easily and rapidly added to any tissue plane (level); and it has the added benefit of the ‘stem cell effect’ which is difficult to quantify but unquestionably present in many cases.
Both structural fat grafting and fascia-fat (or dermis-fat) grafting can be competently performed (or not) by Board-certified plastic surgeons.  Neither should be trademarked or considered proprietary.

As with any surgical procedure take time researching your plastic surgeon. Schedule several consultation, view many photos from many patients, each from multiple perspectives (start by looking at photos on this website) and speak to former patients of any plastic surgeon you are considering.it is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin.