For optimum contouring should I have fat grafting during facelift or later?

Cost and downtime are NOT the biggest consideration for me; results are. Since I was told that fat cannot be grafted in areas where skin is undermined is it preferable to wait until all the areas of my face that need volume can be grafted without the need to avoid some areas? Or was the information I recieved about limitied access due to skin undermining incorrect?

Doctor Answers 24

Facelift First Fat Grafting Later For Best Result

Thank you for your question. Your surgeon is correct in that fat grafting should not be done beneath skin that is undermined during a facelift. In addition you want your surgeon to concentrate on achieving the best facelift result and not be concerned about avoiding areas that need to be fat grafted.

Another good reason to delay fat grafting as a second procedure 3-6 months following a facelift, is that any recurrent laxity of the facial tissues, especially in the mid face region, at 3-6 months after your facelift, can be improved with fat grafting done at a later date.

Fat grafting and facelift have no place together. (Same thing with laser resurfacing.)

Since facelift operations involve detaching the skin from the underlying tissues, the level of dissection is a critical component of preserving blood supply to the skin while avoiding damage to deeper structures such as the facial nerves that supply innervation and animation of the facial muscles. Even when surgeons tighten the deeper layers, what we are "lifting" and rejuvenating is the SMAS (superficial musculoaponeurotic system), which is the layer of "gristle" on top of the facial muscles, and continuous with the temporalis fascia and platysma fascia. The facial nerve branches are deep to the muscles, which themselves are deep to the SMAS.

Fat grafting, when done to restore facial volume lost in the aging or weight loss process, is done by placing small living fat globules within the living layers of facial fat that provide oxygen and nutrients to the transferred fat as it heals and develops its own blood supply. This takes small grafts in well-vascularized recipient tissues.

If a facelift is done skillfully and thoroughly, there is fairly extensive undermining and detachment of the skin and a small layer of adherent fat from the deeper fat, SMAS layer and muscles--the very plane into which fat grafts are placed. You can't put grafts into a cavity (even a virtual one) until it has adhered and healed enough to provide circulation to the grafts. If you try to place them in the areas you just "lifted," they have no immobilization and no encompassing tissue for viability.

Which means that IF grafting is being done at the same time as facelifting, either the dissection is "less" than optimal to preserve the graft recipient areas, or the grafting ends up being largely a "sham" operation (or the grafts are being placed deeper where there is risk for damage to the facial nerve branches--not really smart or advisable). There are certain types of facelift that could simultaneously support fat grafting, but deep-plane facelifts have their own issues.

The same thing applies to laser resurfacing. Lifted facial skin has already had its circulation compromised. Lasering the surface can fatally damage skin that has had its healing capabilities diminished by lifting it away from part of its blood supply. Sure, this (facelift plus laser) CAN be done, but only if the facelift dissection is limited (suboptimal) and the laser resurfacing is extremely limited (suboptimal). Or if you're willing to risk dead skin and potentially-horrible scarring. So if you'll pardon the usage, half-baked facelift plus half-baked resurfacing, plus half-baked fat grafting is NOT a "trifecta:" it is hobbling all three horses and proclaiming the last three to finish in a horse race to be "better" than completely and skillfully-performed SMAS facelift, followed by full healing, and then (once the swelling has healed and the surgeon can adequately assess the amount and location of volume deficiency to be corrected by grafting) the proper grafting procedure can be completely and skillfully executed. Laser resurfacing would be optimal when all swelling has resolved and facial lines and residual wrinkles are fully visible and completely-treated by the laser--NOT some half-baked, limited-energy (but usually full-priced) promise for improvement.

Grace, you asked about optimum--and the above is the answer your gut was telling you was correct. I truly believe that in this specific case and example, you are much better off having separate procedures. Doing everything at once is more about maximizing profit for the surgeon and saving you time (and possibly some money) at the expense of the best possible result. I'm not accusing surgeons who do both or all three together of being unethical or inappropriate, just being willing to accept less than "optimal." Best wishes! Dr. Tholen

Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon
4.9 out of 5 stars 255 reviews

Fat grafting during facelift or after?

Depends... fat has to be deposited into tissue that is able to accept it and keep it alive, and not let it slide around during the healing phase. A surgically dissected area is not the best home for a fat graft. Fat grafts are usually placed into other areas such as deeper, or away from the surgical area. By the way, fat grafts are rarely part of routine facelifts.

Robert E. Zaworski, MD
Atlanta Plastic Surgeon
4.8 out of 5 stars 62 reviews

Fat Injection Grafting and Facelifts

Fat grafting can be done at the time of a facelift and where it may be needed can affect the way the facelift is done. It can not be placed in areas of skin undermining and this is most relevant in the midface near the cheek area. Depending upon the amount and location of loose skin, the cheek area may not be undermined so that the buccal spaced can be injected. Central facial areas such as the nasolabial folds and lips can always be injected.

Barry L. Eppley, MD, DMD
Indianapolis Plastic Surgeon
4.7 out of 5 stars 72 reviews

Fat Grafting is a component of facial rejuvenation surgery with experienced plastic surgeons - The Proof is in the Photos

The contemporary approach to surgical rejuvenation of the face consists more and more of an attempt to restore facial volume and contour, in an attempt to emulate youthful facial features. My personal approach to facial rejuvenation is to first maximize repositioning and recontouring of facial aesthetic areas, and to remove only as much tissue as is necessary.

Lifting skin and trimming the excess has been the standard approach to the treatment of facial aging for centuries, but when performed without some means of restoring the youthful fullness of facial soft tissues, the result is an older-looking person with tighter skin. The word 'rejuvenation' means literally 'to restore youthfulness' or 'to make young again', so if the goal of surgery is to rejuvenate the face then it cannot be accomplished solely by means of redraping the skin and removing the excess.

In my practice fat grafting is not an afterthought that is thrown into the surgical plan for the occasional patient. It is a key component of almost every major facial rejuvenation surgery that I perform. It is in fact that very first part of the surgical procedure for my patients undergoing a full facial rejuvenation surgery.

 The importance of restoring facial volume is readily apparent when I review with a patient a number of photographs from their twenties and thirties. The meticulous addition of soft tissue volume by means of fat grafting is one of the most powerful means now available for 'turning the clock back.'

If a physician is new to fat grafting, and especially if they are not confident about their instrumentation and technique, then they may tend to over-graft thinking that a large amount of the fat probably will not survive. However if a large amount of that grafted fat does survive, the patient is left with an unnatural and sometimes bizarre look. Another part of the problem can be the physician's aesthetic vision and understanding of facial aging. There are facial areas where adding volume restores a more youthful appearance, but others where adding volume creates a distinctly unnatural appearance. Balance and overall facial harmony is important as well - for example, overfilling the jawline and lower face will create a heavy, square-jawed, masculine appearance.

Additionally, there are facial areas where naturally-occurring fat, which increases in volume with advancing age, ideally should be removed: the area above the nasolabial folds, the area lateral to the corner of the mouth, and the jowl area. As I described above for removal of excess fatfrom a prior fat grafting procedure, excess naturally-occurring fat can also be removed by gentle aspiration (suction) using larger-diameter fat grafting cannulas. Failure to reduce these naturally full areas at the time of a fat grafting procedure can also contribute to an overly full or 'heavy' post-fat grafting appearance.

I try to create the greatest aesthetic improvement possible without creating an unnatural appearance. This concept is critical: the nature of fat grafting is that fat survival often is not 100%, and therefore some patients will require secondary fat grafting procedures to build on the results of the first one. If a physician's approach to fat grafting respects this reality, then that practice will offer secondary fat grafting procedures at a very reasonable cost, which allows patients to achieve their desired endpoint in volume enhancement without appearing overgrafted and without assuming an excessive expense.

Fat grafting (and simultaneous strategic fat reduction) is very much like sculpting, and the sculpture is not always complete after the first session in the artist's studio. Secondary sessions, usually quite minor compared to the initial procedure, are sometimes required to perfect the result. In many cases, a series of two or three structural fat grafting / strategic fat aspiration procedures can simulate the results of a more invasive facelift-type procedure, particularly in the cheek and jawline area - as long as the overlying skin tone is good.

If a physician's approach to fat grafting is that the procedure is a 'one-shot deal' and 'you get what you get', then that practice does not respect the scientific basis of fat grafting and patients will tend to get disappointing and unnatural-appearing results.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 120 reviews

Fat grafting and face lifting

Fat grafting can be performed at the time of facelift but only in areas that not being elevated and undermined during the facelift procedure. For many examples of face lifting results, please see our facelift photo gallery link below

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 145 reviews

Fat grafting and facelifts?

Fat grafting can be performed at the same time as your facelift or later -- the decision is between you and your surgeon. You are correct when you say that fat can't be placed in areas that have been undermined or dissected; it has to be placed in areas where it can receive a blood supply and not move around. However, some surgeons will routinely perform fat grafting at the same time as the facelift, while others will prefer to wait till later. I would suggest that you discuss what option would be best for you with a board certified plastic surgeon. Good luck!

Anureet K. Bajaj, MD
Oklahoma City Plastic Surgeon
5.0 out of 5 stars 18 reviews

Fat grafting durring or after the facelift?

I think that the best time to have the fat transfer procedure is during the face lift. The areas typically treated with fat grafting are not undermined during the facelift. This way the entire face is treated simultaneously with the fat and the lift.

Andres Bustillo, MD, FACS
Miami Facial Plastic Surgeon
4.9 out of 5 stars 117 reviews


Can you post a picture of your face? That way we can recommend procedures for you. In general, fat grafting can be done at the same time, but it depends on where the fat is going to be placed. This is where your picture would help as I could tell you where you need the fat.


Asif Pirani, MD, FRCS(C)
Toronto Plastic Surgeon
5.0 out of 5 stars 35 reviews

For optimum contouring should I have fat grafting during facelift or later? #facelift #fat grafting

Thank you for your question. Typically, I perform fat grafting at the time of my facelifts. It will take approximately 1 hour to obtain the fat and then inject it into the regions of interest. The injections are typically deep and will not be affected since the injected spots are not undermined. It is a trend in plastic surgery to re-volumize the face which adds youth to your end results. The amount grafted can range from patient to patient and surgeon to surgeon. Often, I may transfer up to 50 or 100 cc's of fat at the beginning of the operation while the tissue has been un-affected. I hope this helps.

Joel B. Beck, MD, FACS
Bay Area Plastic Surgeon
4.9 out of 5 stars 112 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.