ORIGINAL ARTICLE

Introduction of an Easy Technique for Purification and

Injection of Autogenous Free Fat Parcels in Correcting of
Facial Contour Deformities
Shouduo Hu, MD, Haiming Zhang, MD, Yuejian Feng, MD, Yu Yang, MD, Xing Han, MD,
Xinming Han, MD, Yani Zhong, MD, and Jun Shi, DM

Received July 14, 2006, and accepted for publication, after revision, September 16, 2006.
From the Plastic Surgery Hospital, Chinese Academy of Medical Sciences
and Peking Union Medical College, Beijing, China.
Reprints: Haiming Zhang, MD, Vice-Director of the Plastic and Cosmetic
Surgery Center of Face and Neck, Plastic Surgery Hospital of CAMS and
PUMC, 33 Ba-Da-Chu Street, Shi-Jing-Shan District, Beijing 100041,
P.R. China. E-mail: aiia523@yahoo.com.cn.
Copyright 2007 by Lippincott Williams & Wilkins
ISSN: 0148-7043/07/5806-0602
DOI: 10.1097/01.sap.0000248110.59452.49

ffective as well as simple procedures for correcting facial

contour deformities, especially the mild or moderate depressions of the facial contour, are still demanded in clinical
practice.117 Facial contour deformities discussed in this
article included 3 portions: facial depressions caused by
congenital underdevelopment, facial bone fracture, and sheetlike scars; aging process-related fat tissue redistribution,
deflation, or atrophies, which included glabella or cheek
wrinkles and deepening of the nasolabial fold; and mild chin
retrogression as a specific facial contour deformity.
As a means of enhancing facial contour elements,
augmentation with autologous tissues1 such as fat pearl
grafts2 and dermal grafts or alloplastic implants such as
silicone,3 and so on, had been used in clinics for more than
100 years. However, these treatments could be only used for
special cases because of their limitations such as residual scar
remaining in the donor and recipient sites or less ideal
bioreactivity. In the 1980s, with the creation of liposuction,
Illouz4 and Fournier5 also introduced the fat parcels injection
technique, which was indicated for those facial or body
contour deformities caused by congenital, trauma, operation
procedures, or the aging process.
In the practice of injection of fat parcels, how to
increase the postoperative volume of injected fat tissue has
been always a frequently discussed issue. Many authors
considered the operative techniques of minimal injury very
important such as the use of blunt suction cannula, lower
suction and injection pressure, and so on to reduce the
mechanic injuries to fat parcels.6 10 In the purification of the
suctioned fat parcels, many plastic surgeons used special
centrifuge machines8,12 or neuropad.8 10 Carpaneda et al11
thought that the size of each mass of injected fat parcels
should be limited within 1.5 mm3 to ensure an optimal
survival rate of the living, vascularized fat tissue. However,
other authors711 emphasized that fat parcels must be deposited in a linear and multilayered ways to maximize the
contacting surface for the injected fat parcels to their recipient
alive tissue so as to increase the tissues diffusion respiration
and eventual successful deposit of the fat parcels. On the
other hand, some researchers also demonstrated that the basic
fibroblast growth factor,13,14 or the1-receptor inhibitors,15
could increase the survival of fat parcels and thus were added
into the suspension fluid. Other opinions7,12,16 also indicated

602

Annals of Plastic Surgery Volume 58, Number 6, June 2007

Background: Facial contour deformities usually result from congenital abnormalities, trauma, and the aging process. All depressions
in the face, including glabella wrinkles and mild retrogression of
chins, fall in this category. Local injection of autogenous fat parcels
has been introduced for correction of these facial deformities for
almost 20 years.
Method: Using common materials (gauzes and cotton sticks), a
simple technique was used by us to purify syringe-suctioned fat
parcels followed by a multilayered injection of the purified fat tissue
into implantation sites to treat the facial contour deformities in 152
sites of 50 cases with successful outcomes.
Results: Thirty-nine sites in 17 cases were followed up from 13
months to 37 months (average, 22.8 months). The injected fat
parcels deposited successfully and the increasing volume maintained
well. The impact factors on the successful deposit of the injected fat
parcels included the extent of mechanical injuries to the fat cells
during liposuction and lipoinjection, application of the purification
procedure, and postsurgery immobilization as well as the bloodnourishing situation of recipient sites. Postoperative complications
included undercorrection, overcorrection, small fat mass, unevenness, or irregularity.
Conclusion: The introduced purification and injection techniques
provided a comparative simple and reliable method in facial recontouring treatment. The local volume could be increased successfully
by means of controlling the influencing factors of fat parcel deposit.
Key Words: fat parcels, fat parcels injection, purifying technique
of fat parcels, facial contour deformity, facial recontouring
(Ann Plast Surg 2007;58: 602 607)

Annals of Plastic Surgery Volume 58, Number 6, June 2007

Purification and Injection of Autogenous Free Fat Parcels

TABLE 1. Clinical Materials of Facial Contour Deformities Treated by Fat Parcel Injection

Forehead
Temporal depression
Buccal
Zygomatic
Infraorbital
Nasal root
Upper eyelid
Eyebrow
Scar depression
Lips
Nasolabial fold
Wrinkles
Chin

Sites

Causes

Volume of Fat
Parcel

Times of Follow Up

Times of
Reinjection

1
29
32
4
12
1
10
12
7
18
12
11
3

Congenital
Congenital
Congenital aging
Congenital
Congenital fracturing
Operative
Operative traumatic
Congenital
Trauma skin grafting
Congenital or aged
Congenital or aged
Aged
Congenital

18
810 ml
810 ml
78 ml
34 ml
1.5 ml
34 ml
45 ml
37 ml
24 ml
23 ml
0.52 ml
46 ml

0
1637 months
1437 months
0
0
No
1524 months
1318 months
14.523 months
0
1734 months
1634 months
0

2
13
24
01
01
0
12
01
23
12
2
0
0

that the epinephrine or the residual blood existing in the fat

parcels might be harmful to fat parcel survival.
On the basis of these previous publications and our own
clinical experience, we designed a simple but effective technique for purification of the suctioned fat parcels and the
accompanying procedures to increase the deposits of implanted fat tissue.

Complications
Irregularity
Small fat bulk, undercorrection
Undercorrection
Undercorrection
Unevenness
Undercorrection
Undercorrection or overcorrection
Undercorrection
Undercorrection
Existence but milder than before
Overcorrection or unevenness

Operation Procedure
Preoperative Preparation
Preoperative planning involved identifying and marking the contour deformities to be corrected and potential fat
harvest sites. Photographs were taken before and after marking the skin and they were posted for intraoperative reference.
A permanent, color-coded marker was used to designate areas
where aspiration and injection could or could not be safely

Clinical Materials and Results

One hundred fifty-two sites in 50 cases were included
in this study. Among them, 48 were females and 2 were
males. The age ranged from 19 to 48 years (average, 27.4
years). The deformity causes were congenital, traumatic,
secondary to skin grafting, facial bone fractured, and aging
(Table 1).
Thirty-nine injection sites in 17 cases were followed up
for 13 months to 36 months (average, 15.3 months). The
volumetric maintenance matched the demands both of us and
the patients with good deposit in static areas such as the
temporal areas and poor deposit in the mobile areas such as
the lips. When undercorrection occurred, reinjection was
usually given after a 3-month operation interval.
Irregularity (Fig. 1B) and undercorrection were the
common complications. Irregularity and unevenness of contour often occurred in forehead. Undercorrection could happen in many areas. Reinjection would reduce the occurrence
for both complications. Small fat bulk might occur in the
subcutaneous tissues, which could be palpable but unseen.
Overcorrection happened only to 1 patient (Fig. 2A, B).
This patient had local atrophy of subcutaneous fatty tissue in
2 sides of the mandible border induced by intrascar steroid
injection. Six months after injection of the fat parcels, the
contour of her left mandible border was chubbier than that of
right side, which looked nice in contour. Local examination
showed that the skin texture was good and there was no tissue
mass under the skin. One year later, some fatty tissue was
suctioned away and the contour of her left mandible border
was improved well.
2007 Lippincott Williams & Wilkins

FIGURE 1. A, Basal view before surgery. She had the moderate

depression of her left temporal fossa, because the majority of
the previously injected polyacrylamide hydrogel was removed.
B, Basal view 17 months after the fat parcel injection (4.5 mL
of left side and 2.5 mL of right side, 1 time and 2 layers).

603

Hu et al

Annals of Plastic Surgery Volume 58, Number 6, June 2007

performed. Common aspiration sites included the periumbilical area, the inner and outer thigh, the buttocks, the inner and
back arm, and the waist. In addition, entry wound sites were
marked, considering cannula length, to allow maximum access to tissue while minimizing skin incisions. A map of all
injection sites was then drawn for intraoperative volume
estimation and tabulation.

Anesthesia
The tumescent fluid created by Klein19 was injected
subcutaneously in the donor sites. The subcutaneous diffusive
anesthesia, in which the limited volume of anesthetics was
used, or the local nerve blocks were taken in the recipient
sites. Although some researchers7,12 thought that epinephrine
might hurt fat parcels, use of epinephrine still held many
advantages, eg, reducing the occurrence of hematomas and
decreasing the dosage of anesthetic drugs. Thus, epinephrine
was regularly used in our liposuction procedure and could be
mostly removed in our purification procedure of dry gauze
absorption.

Choosing of the Donor Fatty Tissue

No special considerations were required in choosing
liposuction donor sites. The principle usually was to comply
with patients requests.

Harvest of Fat Tissue

After anesthesia, a stab skin incision was performed. A
blunt suction cannula 3 mm in diameter was attached to the
20-mL syringe and passed through the incision site into the
subcutaneous fat layer. The operator laid his or her 1 hand to
feel and guide the position and movement of the cannula
while the other hand radically suctioned the fat tissue in an
even and smooth manner. In each direction, only 1 round
going-and-backing suction procedure was taken. To maintain
the vacuum pressure minimal, the plunger of the syringe
should be slowly withdrawn in a gentle manner.

Purification of Fat Parcels

FIGURE 2. A, The profile view before surgery. This patient had

a local atrophy of subcutaneous fatty tissue of the left mandibular area caused by the intrascar steroid injection. B, The contour of her left mandibular area 27 months after injection of
the fat parcels (6 mL, 2 layers). C, The profile view of the right
mandibular area before operation. D, The same follow-up time
of the right side after injection (1.5 mL, 1 layer).

604

The syringe filled with fat parcels was let standing

upward statically for 5 minutes to allow it to separate into 4
layers (Fig. 3A). The bottom layer was Ringers lactate liquid
mixed with lidocaine and blood. The second lower layer was
ruptured fat tissues. The third was fat parcels. The top layer
was composed primarily of fatty oil from the ruptured fat
parcels. Then, the lowest 2 layers were drained. The residual
2 layers (approximately 6 7 mL) were decanted onto a piece
of folded dry gauze (6 4 cm2) (Fig. 3B). The fatty oil
remaining on the fat parcels was sucked away by cotton
sticks. The purified fat parcels were then collected into a
5-mL Luer-Lok syringe (Fig. 3C).
An experiment was done to measure how much water a
piece of gauze could absorb. Approximately 2.5 mL saline
solution was dropped to completely wet a piece of gauze, which
indicated that in every 7 mL of the fat parcels, approximately 2.5
mL of water mixture could be absorbed away by the gauze.
Additionally, oil materials and the ruptured fat cells18 could also
be absorbed by the gauze (Fig. 3B).
2007 Lippincott Williams & Wilkins

Annals of Plastic Surgery Volume 58, Number 6, June 2007

Purification and Injection of Autogenous Free Fat Parcels

FIGURE 3. A, The purification procedures of fat parcels. The syringes

were filled with suctioned fat parcels. B, Those suctioned fat parcels
were decanted on to pieces of dry
gauze. C, Two minutes later, those
fat parcels on the gauze were decanted freely back into a 5-mL
Luer-Lok syringe to which a 12gauge needle (the red needle) was
attached.

Compared with other purification techniques such as the

use of centrifuge,8,12,18 this purification technique was very
simple in materials used gauze and cotton stickand practical
in clinics. The time spent was only approximately 10 minutes.
Although the fat parcels were exposed to the air,8,16 but our
clinical results proved that the fat parcels still deposited well.

Injection of Fat Parcels

A 12-gauge needle was connected to the 5-mL LuerLok syringe with purified fat parcels inside. An access point
was chosen through which the whole designed injection area
could be reached easily. If necessary, the second access
point could also be used. Fat parcels were injected into the
needle tunnel in the deep derma and/or the deeper layer
while withdrawing the needle slowly. After finishing of
injection, some pressure was put on the access point and
any fat parcels seating at the access points should be
removed, because the fat parcels could postpone the site
healing of the accessing skin.
Several principles should be followed for the lipoinjection
procedure. First of all, an evenly distributing injection was
2007 Lippincott Williams & Wilkins

required. Usually a small amount (0.3 0.5 mL) of the purified

fat parcels was placed evenly into the length of each needle
tunnel. Too much injection of the fat parcels would cause the
central part of fat tissue dead or absorbed.4,7,11 The distance
between every 2 injection tunnels was limited within several
millimeters. We did not do crossover injection because we
thought that it would be difficult to control the injection amount
in that way. If a deeper depression existed (Fig. 2A, B), the
moderate overfilling principle should be followed, which meant
the contour of the injection area should look higher than its
normal comparing site after injection.

Postoperative Nursing
The skin stab incision at the donor site would heal naturally. Gauze covering was performed over the lipoinjection area
for immobilization purposes and removed 3 days later.

Reinjection Interval
Chajchir20,21 suggested an interval for reinjection of 4 to 6
weeks. However, we considered this interval might be too short

605

Hu et al

Annals of Plastic Surgery Volume 58, Number 6, June 2007

FIGURE 5. A, Frontal view before surgery. Her bilateral upper eyelids became depressed (arrows) severely and unnaturally because her majority of the orbital septal fat was removed in a procedure of eyelidplasty in 2001. B, Frontal
view 29 months after autogenous fat parcel injections (3.5
mL, 1 layer, 2 times, and under the muscles).

to allow the swollen tissue to recover well. From the observation

for our cases, the ideal interval for reinjection should be over 3
months. After going through a 3-month recovering period, most
injected areas would become normal again and the injection
outcomes also got more stable and could be evaluated whether
a rejection was needed (Figs. 4 and 5).7,18

DISCUSSION
During the past 6 years, the previously described procedures for purification and injection of autogenous free fat
parcels had been applied in correcting various mild or moderate facial depression deformities in 50 cases (152 sites)
(Figs. 1, 2, 4, and 5). From our experience, we summarized
that the following influential factors were associated with the
deposits of the injected fat parcels.

Minimization of the Injury to Fat Cells

FIGURE 4. A, Frontal view before surgery. This woman was 27
years old. In 2001, she had a sharp contour of face: the protrudent zygomatic areas, the moderately depressed temporal fossas and cheeks, the bilateral deepened nasolabial grooves, and
the mildly depressed suborbital areas; because of this, she
looked older and doleful. The donor sites of fat parcels included the anteroposterior sides of the upper arms, the upper
and lower abdomen, the bilateral waists, and the lateral thighs.
B, Frontal view 25 months after the fat parcel injection. From
2001 to 2004, her temporal fossas (2 times, 2 layers), cheeks
(3 times, 2 layers), nasolabial grooves (2 times, 1 layer), and
suborbital areas (2 times, 1 layer) were filled with her own purified fat parcels in different volumes. The interval between the 2
operations was more than 3 months.

606

To minimize the mechanical injury to fat parcels, blunt

suction cannulas were used in liposuction procedure. The
suction/injection pressure were both controlled carefully in a
mild manner, and the collected fat parcels were purified by
the previously introduced method (without centrifugation).23
Some authors7,8,18 suggested that excessive exposure was an
important factor in causing cells death. However, our experience indicated that a short time air exposure of fat cells
would not affect their successful deposits.

Purification of Fat Parcels

As stated previously, much content that existed in the
mixed fat parcels liquid solution such as anesthesia drugs, dead
cell fragments, excessive swelling solution, and so on were
potentially harmful to the survival of fat parcels.8,16 Therefore, a
2007 Lippincott Williams & Wilkins

Annals of Plastic Surgery Volume 58, Number 6, June 2007

Purification and Injection of Autogenous Free Fat Parcels

purification procedure must be performed before lipoinjection.7,18 From our experience, the gauze absorption could remove those useless or harmful materials effectively and efficiently. With approximately 50% of the volume reduction of the
mixed suction solution, the desired effective fat parcels were
greatly enriched, which was the key for successful treatments.

the recipient sites could become fatty after the injection when
the patients were gaining weight.

Postoperative Pressure Applied and Active

Immobilization
Lipoinjection was a special form of fat tissue grafting. It
was believed that a suitable pressure placed on the implanting
sites and a reasonable immobilization could enhance the formation of blood supplies for the fat parcels at its bedding environment.22,24 Thus, these 2 principles must be complied with during
the first 3 days after the operations. Otherwise, patients active
matching was more important than the passive immobilization
and pressure adding.10 The results of our clinical observations
showed that the well matching of the patients would let them get
a better deposit of fat parcels.

Injection Location
The mobility feature of the injection areas was another
influential factor determining whether the injected fat parcels
successfully deposited. The less frequently the injection areas
moved, the more successfully the fat parcels deposited. In our
studies, the deposit of fat parcels at the relatively static locations
such as the forehead and temporal fossa (Figs. 2, 4, and 5) was
better.

Blood Supply
Like other free grafted tissues, the fat parcels would
only deposit well at the recipient sites with a rich blood
supply. In our studies, good recontouring results are usually
achieved for the congenital facial deformities. There was a
less successful deposit of fat parcels for the deformities
causes by operation, infection, or trauma because of the
existence of the scar tissue with poor blood supply.

Indications
The best indications for the free autogenous fat parcel
injection were those facial depression deformities caused by
the congenital underdevelopment (Fig. 4) and traumas or
after surgery (Figs. 1 and 5). The glabella wrinkles and the
nasolabial fold depression (Fig. 4) were also good indications
for a small-volume lipoinjection treatment. Dramatic results
would be achieved for those cases of mild chin retrogression.

Contraindications of the Procedures

Secondary atrophies of the local soft tissue, skin grafting areas, and spotted or linear depressed facial scars were the
relative contraindications.

Potential Problems
The fat parcels used in the procedures were collected
from the body portion or extremities. These were the places
for humans to deposit their energy. It would be possible that

2007 Lippincott Williams & Wilkins

CONCLUSION
The reported technique for the collection, purification,
and injection of fat parcels was quite simple and can be
completed in a short time period. The volumetric maintenance was enough to improve the facial contours in our
studies by application of this technique. The results achieved
by this procedure were very reliable and reproducible.
REFERENCES
1. Neuber F. Fettransplantation. Bericht uber die Berhandlungen der Dt
Ges f Chir. Zentralbl Chir. 1893;22:66.
2. Ellenbogen R. Free autogenous pearl fat grafts in the facea preliminary
report of a rediscovered technique. Ann Plast Surg. 1986;16:179 194.
3. Brown JB, Fryer MP, Randall P. Silicones in plastic surgery. Plast
Reconstr Surg. 1953;12:374.
4. Illouz YG. The fat cell graft: a new technique to fill depressions. Plast
Reconstr Surg. 1986;78:122123.
5. Fournier PF. Microlipoextraction et microlipoinjection. Rev Chir Esthet
Lang Fr. 1985;10:36 40.
6. Brandow K, Newman J. Facial multilayered micro lipoaugmentation. Int
J Aesth Restor Surg. 1996;4:95110.
7. Coleman SR. Facial recontouring with fat parcels. Facial Cos Surg.
1997;24:347367.
8. Billings E, May JW. Historical review and present status of free fat graft
autotransplantation in plastic and reconstructive surgery. Plast Reconstr
Surg. 1989;83:368 381.
9. Tzikas TL. Lipografting: autologous fat grafting for total facial rejuvenation. Facial Plast Surg. 2000;20:135143.
10. Cook T, Nakra T, Shorr N, et al. Facial recontouring with autogenous
fat. Facial Plast Surg. 2004;20:145147.
11. Carpaneda CA, Ribeiro MT. Percentage of graft viability versus injected
volume in adipose autotransplants. Aesthetic Plast Surg. 1994;18:17.
12. Abergel RP, David LM. Aging hands: a technique of hand rejuvenation
by laser resurfacing and autologous fat transfer. J Dermatol Surg Oncol.
1989;15:725.
13. Eppley BL, Smith PG, Sadove AM, et al. Experimental effects of graft
revascularization and consistency on cervicofacial fat transplant survival. J Oral Maxillofac Surg. 1990;48:54 62.
14. Eppley BL, Sidner RA, Platis JM, et al. Bioactivation of free fat
transfers: a potential new approach to improving graft survival. Plast
Reconstr Surg. 1992;90:102.
15. Ayhen M, Senen D, Adanali G, et al. Use of beta blockers for increasing
survival of free fat grafts. Aesthetic Plast Surg. 2001;25:338 342.
16. Aboudib JHC, Cardoso de Castro C, Gradel J. Hand rejuvenescence by
fat filling. Ann Plast Surg. 1992;28:559 564.
17. Novaes H, Norair dos Reis, Campinas RB. Counting method of live fat cells
used in lipoinjection procedures. Aesthetic Plast Surg. 1998;22:1215.
18. Coleman SR. Hand rejuvenation with structural fat grafting. Plast
Reconstr Surg. 2002;110:17311744.
19. Klein JA. The tumescent technique for liposuction surgery. Am J Conm
Surg. 1987;4:263267.
20. Chajchir A, Benzaquen I. Liposuction fat graft in face wrinkles and
hemifacial atrophy. Aesthetic Plast Surg. 1986;10:115.
21. Chajchir A, Benzaquen I, Wexler E, et al. Fat injection. Aesthetic Plast
Surg. 1990;14:127.
22. Peer LA. Loss of weight and volume in human fat grafts. Plast Reconstr
Surg. 1950;5:217.
23. Chajchir A, Benzaquen I, Moretti E. Comparative experimental study of
autologous adipose tissue processed by different techniques. Aesthetic
Plast Surg. 1993;17:113.
24. Rudolph R, Ballantyne DL. Skin grafts. In: McCarthy JG, ed. Plastic
Surgery. Philadelphia: WB Saunders Co; 1990:252.

607