Autologous fat grafting (AFG) is increasingly utilized in aesthetic and reconstructive surgery owing to its biocompatibility, regenerative properties, and ease of harvest. However, inconsistent graft retention rates pose a persistent clinical challenge. This review explores contemporary advancements aimed at improving fat graft survival and volume retention. Biological enhancements, such as platelet-rich plasma (PRP), stromal vascular fraction (SVF), and adipose-derived stem cells (AdSCs), have demonstrated efficacy in promoting angiogenesis, reducing fibrosis, and improving graft integration. Emerging strategies, including vitamin E (VE) augmentation, compact fat grafting, and soluble molecule preconditioning with agents like deferoxamine (DFX) and vascular endothelial growth factor (VEGF), have shown promise in experimental and clinical models. The synergistic use of PRP and AdSCs yields higher growth factor expression, enhancing tissue viability. Innovations like Botulinum Toxin-A (BoNTA) for muscle immobilization, concentrated de-oiled fat (CDF), and biodegradable scaffolds further contribute to improved outcomes. Site-specific adaptations - for craniofacial, breast, and gluteal regions - demonstrate tailored approaches that enhance regional graft viability. Despite these advancements, standardization remains a barrier due to methodological heterogeneity in harvesting, processing, and application. Furthermore, while preliminary results from clinical trials are encouraging, long-term data and larger cohorts are required to validate safety and effectiveness. Future research should focus on optimizing stem cell enrichment protocols, biomaterial integration, and understanding molecular pathways that govern graft survival. Collectively, these evolving strategies represent a significant leap forward in maximizing the functional and aesthetic benefits of fat grafting, heralding a new era of regenerative plastic surgery.