COSMETIC

Prospective Controlled Study of Chin

Augmentation by Means of Fat Grafting
Filipe V. Basile, M.D.
Antonio R. Basile, M.D.
Ribeirao Preto, São Paulo, Brazil
Background: Although fat grafting is a valuable tool for different areas of plas-
tic surgery, its use in the chin area has never been evaluated. A variety of
methods are available for adjusting suboptimal chin morphology, and they
each present drawbacks.
Methods: A prospective controlled study was performed to evaluate whether
fat grafting increases the chin volume and sagittal projection and to determine
the magnitude and nature of the observed changes. Forty-two consecutive pa-
tients underwent chin augmentation by means of fat grafting between October
of 2014 and January of 2016. All patient images were analyzed using a software
program (Fiji package of ImageJ), which creates a three-dimensional version
of the chin that is used to produce reliable estimates of the volume and gain
in sagittal projection.
Results: All 42 patients showed an increase in the sagittal projection and to-
tal volume at 4 weeks and 6 months after surgery. The sagittal projection in-
creased from 4 mm to 12 mm (average, 8.9 mm) and from 3 mm to 11 mm
(average, 7 mm) after 4 weeks and 6 months, respectively. The total volume
increase ranged from 3 to 11 ml (average, 8 ml) after 4 weeks and from 3 to
8 ml (average, 7.4 ml) after 6 months.
Conclusion: Fat grafting to the chin area is a reliable method for improving
chin volumes (to a maximum of approximately 10 cc in our study) and sagit-
tal projections (to a maximum of approximately 11 mm in our study).  (Plast.
Reconstr. Surg. 140: 1133, 2017.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

C
hin augmentation remains a popular cosmetic
surgical procedure in the United States, and
17,451 procedures were performed in 2015.1
The correction of sagittal deformities of the chin
presents a seemingly simple surgical challenge. How-
ever, despite the simplicity, a variety of methods are
available to adjust suboptimal chin morphology, and
they range from osseous genioplasty to autologous
osseous implants, alloplastic implants, and inject-
ables.2–12 Alloplastic chin augmentation remains the
most common method.13 Each method presents
advantages and disadvantages that require the sur-
geon to perform individual evaluations to determine
the method that will yield the best aesthetic results.14
Recently, a critical appraisal of chin anatomy has
brought more attention to preoperative morphology
and anatomical details, such as left chin weakness
and other asymmetries that are frequently present
but overlooked.15 Clearly, sagittal advance and frontal
From private practice.
Received for publication December 18, 2016; accepted June
23, 2017.
Copyright © 2017 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000003895
symmetry are essential to surgical success. However,
focusing on all anatomical particularities could pres-
ent a challenge for corrections that use prefabricated
implants. Several authors have reported negative
sequelae from chin surgery, such as palpability and
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
Supplemental digital content is available for
this article. Direct URL citations appear in the
text; simply type the URL address into any Web
browser to access this content. Clickable links
to the material are provided in the HTML text
of this article on the Journal’s website (www.
PRSJournal.com).
A Video Discussion by Bernard Markowitz, M.D.,
accompanies this article. Go to PRSJournal.com
and click on “Video Discussions” in the “Digital
Media” tab to watch.

www.PRSJournal.com 1133
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • December 2017
implant visibility,4 and the frequency of this surgery
has decreased by 35 percent from 2000 to 2015,
whereas the total cosmetic surgical procedures
decreased by only 10 percent in this period.1
The use of autologous fat injections has been
anecdotally reported for the augmentation of chin
contours and, despite the proven efficacy of fat
grafting as a contouring tool, it remains a relatively
unpredictable technique. Reported graft reten-
tion rates vary from 10 to 90 percent when injected
into different locations, such as the breast and but-
tocks.13–16 Fat injections to the chin region have
never been systematically evaluated. However, this
method is considered to be simpler than implant
placement or osseous genioplasty, and it may be
used as a primary form of augmentation or as an
adjunct to more traditional augmentation surgery.
This study was performed to ascertain whether
fat grafting increases chin volume and sagittal
projection and to determine the magnitude and
nature of the observed changes. Clinical findings
regarding the safety and complications of such
procedures were also evaluated.
PATIENTS AND METHODS
Forty-two consecutive patients underwent chin
augmentation by means of fat grafting, and the proce-
dures were performed by the authors between Octo-
ber of 2014 and January of 2016. All of the patients
agreed to participate in the study, and institutional
review board approval was obtained. The primary
surgical motivation was to correct deficiencies in the
sagittal dimension at the pogonion (the most ante-
rior point on the contour of the chin) with or with-
out width deficiencies lateral to the symphysis. Cases
requiring vertical augmentation were not included in
this study.17 Secondary cases and patients with dental
occlusion problems were not included in this study.18
To increase reproducibility, the inferior abdo-
men was the donor site of the fat graft for all 42
patients. (See Video, Supplemental Digital Content
1, which demonstrates the surgical technique of chin
augmentation by means of fat grafting, available in
the “Related Videos” section of the full-text article
on PRSJournal.com or, for Ovid users, available at
http://links.lww.com/PRS/C432.) All of patients were
treated as outpatients under total intravenous seda-
tion using propofol infusion. Patients were prepared
with chlorhexidine solution. The donor site was
infused using a solution that consisted of 100 ml of
normal saline with 50 mg (0.05%) of lidocaine and
0.1 ml of epinephrine. Liposuction was performed
using a 2-mm blunt cannula. A 20-cc syringe was used
to collect the fat, which was subsequently subjected
1134
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Video. Supplemental Digital Content 1 demonstrates the sur-
gical technique of chin augmentation by means of fat grafting,
available in the “Related Videos” section of the full-text article on
PRSJournal.com or, for Ovid users, available at http://links.lww.
com/PRS/C432.
to gravity separation by decantation for 5 minutes.
Decantation was performed in the same syringe
used for aspiration to avoid further manipulation
of the fat. No washing, centrifugation, or additional
manipulation was performed. The syringe plunger
was consistently retracted until the 10-cc mark and
locked in this position to produce the same nega-
tive pressure in all 42 cases. After decantation, the
fat was transferred to one or more 3-cc syringes for
injection. The fat was then injected into the chin
on a supraperiosteal (subcutaneous) plane with a
blunt 2-mm cannula using a fanning technique.
The shape and volume of the injected fat was deter-
mined individually by the injection technique and
the desired aesthetical goals in each case. The vol-
ume of the injection was recorded in each case. The
volume needed in each case depended on visual
and skin pressure assessments by the surgeon. Gen-
erally, two ports were used, including one lateral
and one caudal port. Steri-Strips (3M, Two Harbors,
Minn.) was used for draping around the injected
area. The patients used no special garments. The
patients were instructed to resume normal activity 1
day after surgery, including work, eating, and driv-
ing. Exercise was not to be performed for 15 days
after surgery. No antibiotics were prescribed.
Image Analysis
Three sets of eight photographs were taken
from every patient before surgery and 4 weeks
and 6 months after surgery. Photographs were
integrated, matched, and analyzed using the Fiji
(Fuji Corp., Tokyo, Japan) package of ImageJ
(National Institutes of Health, Bethesda, Md.).19
Several plug-ins were used to analyze the images.20
 Volume 140, Number 6 • Chin Augmentation through Fat Grafting

The software allowed us to stack the images and
create a three-dimensional version of the chin,
which was used to generate a reliable estimate of
the gain in volume and sagittal projection.21 The
basic surface landmarks used to calculate the vol-
ume and sagittal projection are shown in Figure 1.
The geometric properties of the chin (e.g., vol-
ume, projection, and surface area) vary depend-
ing on the size, sex, and ethnic background of
the patient.10 Although measurements of the chin
projection length and width can be performed
directly and fairly easily, direct volume measure-
ments can be difficult. Thus, we used a computer
three-dimensional reconstruction in the Fiji pack-
age of ImageJ to evaluate the chin volume and
surface area based on the normal chin geometry.21
Considering that the chin has an oval shape, we
produced a chin shape modeling tool in which
the chin’s curvature can be calculated from sev-
eral points around the edge of the chin and the
chin’s projection and volume can be calculated
assuming that the shape formed follows the ellip-
soid rules for the volume calculation of solids.22
The coefficients and mathematical formula used
in these models can be used to precisely calculate
the shape, volume, and surface area of the chin
from digital images as shown in Figure 2.
Morphometric Analysis
The two parameters used to evaluate chin aug-
mentation were the sagittal projection and total
volume variation (which includes sagittal and fron-
tal gains). The preoperative sagittal projection and
total estimated volume were compared preopera-
tively and at 1 and 6 months postoperatively. The
total volume variation was defined as increases in
the volume, which was measured using the previ-
ously described methods, as shown in Figures 1
and 2. Variations in the sagittal projection were
defined as increases in length, which was mea-
sured using the previously described methods.
Analyses of the volume of fat grafted in each
case and the postoperative volume gains were
also performed. In addition, the injection vol-
ume was correlated with the absorption rate. All
of the patients were clinically evaluated at 1 week,
4 weeks, and 6 months postoperatively, and any
complications were recorded.

Fig. 1. (Left) Lateral landmarks. Me, menton; C, commissure; Pg, pogonion; BL, baseline
(a vertical line tangential to the ocular globe that forms a 90-degree angle with a line
parallel to the floor was used as the baseline for changes in anterior projection); SP,
sagittal projection (the distance in millimeters from the baseline to the anteriormost
point in the chin, the pogonion). (Right) The lateral area used for the volume calcu-
lations was bound by a horizontal line from the commissure to the anterior profile
and from the anterior profile at the height of the commissure to the menton and a
line from the menton to the commissure. Volume was measured using a three-dimen-
sional projection created based on the areas shown in the figure.

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 Plastic and Reconstructive Surgery • December 2017

Fig. 2. Images were stacked using ImageJ to recreate a three-dimensional version of the chin before and after fat grafting. The
figure shows the grid unities in pixels and an example of an actual patient before (left) and after (right) fat grafting to the chin.
The patient is horizontal with the chin facing superiorly. Approximately 8 cc of fat was injected to obtain the results shown. Final
volume variation was 7.4 cc after 6 months.

Statistical Analysis RESULTS

All of the statistical analyses were performed
with the SAS software program version 9.2 (SAS
Institute, Inc., Cary, N.C.). Comparisons between
the sagittal projection and the volume before and
after the intervention were evaluated using an
analysis of variance, which compared the volume
and projection at different postoperative times.
The Pearson coefficient was used to analyze pos-
sible correlations between the injected fat volume
and the absorption rates. Statistical significance
was set at p < 0.05.
All 42 patients showed an increase in sagit-
tal projection and total volume at 4 weeks and 6
months after surgery. Details regarding the pro-
jection and volume are depicted in Tables 1 and 2.
Data regarding the fat volume injection and
absorption are depicted in Table 3.
The sagittal projection increased from 4 mm
to 12 mm (average, 8.9 mm) after 4 weeks and
from 3 mm to 11 mm (average, 7 mm) after 6
months. The total volume varied from 3 to 11 ml
(average, 8 ml) after 4 weeks and from 3 to 8 ml

Table 1.  Dispersion of the Sagittal Projection over Time*

Time No. Average (ml) SD (ml) Minimum (ml) Median (ml) Maximum (ml)
Before 42 21 3.2 15 21 28
1 mo 42 30 3.7 19 30 39
6 mo 42 28 3.6 17 28 36
*Sagittal projection was defined as shown in Figure 1. The average sagittal projection was 21 mm before surgery and increased to 30 mm after
1 mo (range, 19–39 mm) and then to 28 mm after 6 mo (range, 17–36 mm).

Table 2.   Dispersion of Chin Volume over Time*

Time No. Average (ml) SD (ml) Minimum (ml) Median (ml) Maximum (ml)
Before 42 21.2 3.2 17 20.5 30
1 mo 42 30.1 3.3 23 30 39
6 mo 42 27.4 3.3 22 27 36
*The average chin was 21 ml in total volume before surgery and increased to 30.1 ml after 1 mo and then to 27.4 ml after 6 mo.

Table 3.  Position, Dispersion Rate, and Absorption Rate of the Injected Volume*
Variable No. Average SD Minimum Median Maximum
Injected volume 42 7.5 ml 1.3 ml 4 ml 8 ml 10 ml
Absorption rate 42 17.70% 11.60% 0% 16.70% 32.90%
*Variation in the volume of fat injected is shown. On average, 7.5 ml of fat was injected (range, 4–10 ml). The absorption rate was 17.7% on
average (range, 16.7–32.9%).

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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 140, Number 6 • Chin Augmentation through Fat Grafting

Fig. 3. (Above, left) Variation in the sagittal projection of the chin over time. (Above, right) Variation in chin volume over time.
(Below) There is no relationship between the volume injected and the fat graft absorption rate.

(average, 7.4 ml) after 6 months (Fig. 3). The
total fat injected ranged from 4 to 10 ml (aver-
age, 7.5 ml) (Fig. 3). Mean percentage of fat sur-
vival was 82.3 percent in our study after 6 months.
Patient ages ranged from 19 to 50 years (mean, 28
years). The study included 32 female patients and
10 men.
The most common complications, in descend-
ing order, were as follows: mild postoperative ery-
thema [two cases (4.76 percent)] and contour
irregularity [one case (2.38 percent)]. Figure 4
shows three cases of the 42 included in the study.
DISCUSSION
In the authors’ practices, silicone implants
and osseous genioplasty are the methods of choice
for chin augmentation. Fat grafting was initially
implemented in the chin as an adjunct measure
for improving the results associated with the more
traditional methods listed above. After achiev-
ing satisfactory results, this technique became an
important tool used by the authors for improv-
ing the profile with primary chin surgery or as a
complement to face lifts and rhinoplasty. Weak-
ness of the chin may be associated with almost 30
percent of rhinoplasties, depending on the popu-
lation examined.3 Nevertheless, many rhinoplasty
patients are not ready to commit to an implant
to improve the chin area, and the authors found
that in these cases, the patients are much more
likely to accept fat grafting to improve the chin
contour. This finding is consistent with observa-
tions of other procedures in recent years, with
many patients rejecting gluteal implants and mov-
ing toward fat grafting, which is usually perceived
by the public as a less invasive procedure.23–28
­Figure 5 shows a case of fat injection to the chin
associated with rhinoplasty.
The main goal of this study was to evaluate
the predictability of this method. Different meth-
ods of evaluating fat grafting have been used;
however, objective preoperative and postopera-
tive measurements have been reported in only
21.1 percent of articles focused on fat grafting.16
Although several studies have provided clinical
data and subjective evaluation of fat transfer to the
buttocks and breast, objective measurements are

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 Plastic and Reconstructive Surgery • December 2017

Fig. 4. (Above) Lateral photographs of a 25-year-old woman before (above, left) and
6 months after (above, right) a 9-ml volume of fat was injected into the chin. This
patient’s fat injection volume was similar to the mean injection volume (7.5 ml) for
all study patients. In this case, the variation in final volume was 7 cc and the sagittal
projection gain was 10  mm. The photographs were matched for size and orienta-
tion. (Center) Lateral photographs of a 32-year-old woman before (center, left) and
6 months after (center, right) a 7-ml volume of fat was injected into the chin. The
variation in final volume was 5 cc and the sagittal projection gain was 8 mm. (Below)
Lateral photographs of a 28-year-old woman before (below, left) and 6 months after
(below, right) a 5-ml volume of fat was injected into the chin. The variation in final
volume was 4 cc and the sagittal projection gain was 5 mm.

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 Volume 140, Number 6 • Chin Augmentation through Fat Grafting

Fig. 5. Lateral photographs of a 25-year-old woman before (left) and 6 months after
(right) open rhinoplasty plus an injection of 9 ml of fat into the chin. The variation in final
volume was 7 cc and the sagittal projection gain was 10 mm. The photographs were
matched for size and orientation.

not common.16,24–28 Many authors agree that stan-
dardized protocols are needed to correctly predict
and evaluate the fat graft response.16 Photography
was meticulously standardized relative to patient
position; camera position; focal length of the lens;
and the angle and position of the patient chin
with respect to the floor, the cervical area, and
the camera (lateral rotation). Furthermore, three
sets of preoperative photographs (taken at least 1
week apart) of 12 patients were used to compare
chin volumes as a calibration before the study was
started and never produced a difference greater
than 2 percent (average, 1.6 percent). Despite
the use of magnetic resonance and other imag-
ing methods, evaluating the fat graft response is
problematic for many areas of the body, such as
the buttocks and the breast.24–29 The chin area,
however, is particularly favorable compared with
the gluteal area in the reliability and feasibility of
measurements and evaluations. Because only a
small area of subcutaneous fat tissue overlies the
bone of the chin, increases in volume and sagittal
projections are easily evaluated. The use of mor-
phometric analyses has also improved our ability
to accurately evaluate volume changes, and this
approach could be expanded to other areas of the
body. Thus, evaluations of fat absorption following
grafting will be based on more precise and reliable
data. We believe that the widespread use of more
direct methods of measurement (e.g., morpho-
metric analysis) and hard data instead of subjec-
tive appearance might improve the results in the
field of fat graft research. Our 17.7 percent aver-
age resorption rate was consistent with the results
of a number of studies focused on fat absorption
in different areas of the body using different meth-
ods16–26; however, our study is the first to evaluate
fat absorption in the chin region.29 The standard
deviation of 11.6 percent shows that the method
provides consistent and predictable results.
In addition, we were able to evaluate the
relationship between the injected volume and
absorption rate. The authors feared that with a
higher volume of injected fat, the pressure inside
the tissue and local conditions would eventually
lead to higher rates of fat reabsorption because of
cell damage. In our study, however, the volume of
injected fat was not related to the absorption rate,
as shown in Figure 3.
As expected, the volume after 4 weeks of
injection was greater than the initial total volume
injected, and this finding is clearly related to tissue
edema that eventually disappeared after 6 months.
Few complications were reported. Mild postopera-
tive erythema [two cases (4.76 percent)] was treated
conservatively, and contour irregularity [one case
(2.38 percent)] was treated with additional fat
grafting in the office under local anesthesia.

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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • December 2017
Asymmetry was not a complaint after fat graft-
ing to the chin in our study. We actually were able
to correct minor asymmetries using this technique
that are difficult to correct with an implant.
In addition, three of the 42 cases returned for
additional fat grafting in the office under local
anesthesia because they felt that the increased
sagittal projection did not meet their expectations
(although all three of these cases gained more
than 6 mm in sagittal projection). These patients
considered their results satisfactory after the addi-
tional procedure.
The average patient age was 28 years in our study,
and our patients mainly were women (32 women and
10 men). We feel that another important issue is the
evaluation of changes to the chin with age. Further-
more, it is important to remember that patients of
different ages may respond differently to fat grafts to
the chin area. These questions should be addressed
when using fat grafts to both the face and other parts
of the body as a surgical tool.
The 6-month period used for the final assess-
ment was not selected randomly. The majority of
recent clinical studies evaluating fat grafts use a
6-month postoperative time as a reference.30 We
understand that the principal pathways for tissue
regeneration using fat grafts and the metabolic
pathways that may affect the resorption rates of fat
grafts are incompletely understood. However, sig-
nificant evidence suggests rapid resorption follow-
ing ischemia and an acute inflammatory response.
Greater than 90 percent resorption occurs within 4
weeks of the procedure.30–33 Thus, the results after
6 months will not differ significantly from those at
12 months or 5 years. Furthermore, it is important
to remember that the grafted fat is live tissue that
may increase or decrease in size following weight
gain and thereby alter the graft volume.
CONCLUSIONS
Fat grafting to the chin area is a reliable
method for improving the chin volume (to a
maximum of approximately 10 cc in our study)
and sagittal projection (to a maximum of approxi-
mately 11 mm in our study). This procedure can
be used as a primary method of chin augmenta-
tion and as an adjuvant to traditional surgery,
and it is easily accepted by the patient as a tool
for improving chin projection associated with
rhinoplasty and face lift. Three-dimensional mor-
phometric measurement is an effective method to
evaluate changes in volume after chin fat grafting.
This method may also be considered in evaluating
fat grafting of other areas of the body.
1140
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Filipe V. Basile, M.D.
Av Prof Joao Fiusa 2300
Ribeirao Preto, São Paulo, Brazil
fibasile@gmail.com
PATIENT CONSENT
Patients provided written consent for the use of their
images.
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