Fat Transfer to the Face

Fat transfer, or fat grafting, is performed to minimize the appearance of wrinkles and restore lost or deficient facial volume.  As discussed frequently on my website, one of the three D’s of the aging face is deflation.  Although genetics play a significant role in native facial fat volume or fullness, we typically lose facial fat volume as we age.  How often do you see an elderly person with fat or full cheeks?  Rarely.  Fat transfer is an excellent option for rejuvenating the face without using unnatural substances. More commonly volume restoration involves the use of synthetic products such as Juvederm, Radiesse or Artefill.  Reasons for choosing to utilize commercially prepared dermal fillers over autologous fat include the lack of fat grafting training by non-surgeon physicians engaged in aesthetic medicine, relative ease of using commercially prepared injectables and the cost and potential “down-time” of fat grafting.  Reasons to choose fat transfer over commercially prepared fillers include the typically high availability of a patients own fat reserves and the potential long-term result of the transferred fat.

Autologous fat transfer utilizing isolated and concentrated adult fat derived stem cells is the beginning of a revolution in the fat transfer process and ultimate success of the procedure.

Adult stem cells, primarily mixed with a patient’s fat, are being increasingly used today to help build facial volume as well as to improve unsightly scars.  Adult stem cells are stem cells found in adult tissues. Stem cells are the master cells that can take on the characteristics of other cells. They serve the purposes of maintaining the natural turnover of cells, repair, and differentiation into specialized cells.  Unlike the embryonic stem cells that caused controversy during the Bush administration, adult stem cells, derived from a person’s fat, can do just about everything their taboo cousins could do, namely, to take on the characteristics of the tissue they are injected into.

Adult stem cells happen to exist in high concentrations in fat, especially around the abdomen. Adding stem cells to the fat dramatically improves retention of the transferred fat because the stem cells vascularize (bring in a new blood supply), building a network of capillaries to keep the fat alive as well as differentiate into surrounding cell types to supplement aging areas with new, healthy cells.   The stem cells actually become new fat cells themselves.  In addition to retaining more viable fat, other improvements related to the transferred fat may include an overall improvement in the quality of the skin, its volume, its color, the wrinkling, even pores decrease in size.

This cutting edge process involves harvesting the fat by the surgeon, then delegating the fat to an onsite medical firm that immediately processes the fat. The process involves treating the fat with enzymes to release fat derived messenchymal stem cells from the extracellular matrix.  The fat is partially digested, the stem cells released, then cleaned, filtered and remixed with the patient’s fat.  The result is that you can produce and count a huge number of viable stem cells, between 500,000 and 1 million per every cc of fat. The distinct benefit of this technique involves the greater survival and viability of the transferred fat.  

The most common areas for facial fat grafting are the midface (cheeks and nasolabial folds.  However all areas of the face including the lips, brow, forehead, lower eyelid region and jaw line are suitable for augmentation.

When carefully performed, fat transfer will be a permanent solution to deeper lines, wrinkles and a sunken facial appearance. Typically treatments without using adult stem cell concentrate results in about 40% transferred fat survival.  Multiple fat transfer sessions are usually required to achieve the ultimately desired result.  By using adult stem cell modified fat a greater survival rate is expected.  It is possible that one or two fat transfer sessions are all that is needed to achieve the desired result by utilizing the stem cell rich fat compared to three or four procedures utilizing non-enriched fat.    

Any adult with reasonable goals and expectations may be a candidate for facial fat grafting.  Acceptable physical health is also a prerequisite before undergoing any elective, cosmetic surgery.  Whether one desires more fullness to the cheeks or plumper lips, fat transfer can accomplish these goals.  Most adults 40 years and over have signs of facial aging that can be amenable to facial fat grafting.

Both fat transfer and synthetic dermal fillers are intended to add volume to the face.  Both types of materials are attempting to improve or correct the same facial deficiencies.  Both fat transfer and dermal filler substances are injected through syringe technique into the facial layers.  Fat transfer is considered a permanent filling substance when injected properly and after repeated injections.  Artefill, a synthetic filler, is currently the only FDA approved dermal filler on the market in the United States.  Both fat transfer and synthetic dermal fillers are performed using local anesthetic.  Sedation or General anesthesia is an available option for fat transfer procedures. Differences between fat transfer and synthetic dermal fillers include the fact that fat transfer involves using your own natural tissue for volume replacement while all other dermal fillers are synthetically derived.  While it’s rare to experience an allergic reaction to synthetic fillers, an allergic reaction to your own fatty tissue is non-existent.  Another difference between fat transfer and synthetic fillers is that synthetic fillers come pre-loaded in syringes while fat transfer requires a second fat harvesting site.  The re-infiltration cannulas required for fat transfer are slightly wider than the needles used to inject commercial dermal fillers and the fat transfer procedure is more invasive versus other dermal fillers.  Dermal fillers typically have no to little recovery period whereas a fat-transfer procedure may result in two or more days of recovery.  The recovery period after a fat transfer procedure depends on the number of areas treated and amount of fat transferred.  The harvest site typically has only mild post-operative discomfort.  This second site has advantages and disadvantages.  The disadvantage is that the patient requires a second and sometimes a third procedure site.  The advantage to having these harvesting sites is that the patient will get a mini-liposuction as a bonus to the fat transfer.  A further difference is the cost.  While synthetic dermal fillers may initially be less expensive than using transferred fat, the long-term cost of fat transfer should be less if permanency of the fat grafting upholds.  In addition, synthetic fillers are sold by the cc.  One cc is one fifth of a teaspoon.  While this amount may be reasonable for small volume deficient areas, many times, a patient requires much more volume to achieve the desired outcome.  People’s fat reserves are usually plentiful and more than enough fat can be harvested for use. 

Most fat transfer procedures can be performed comfortably in an office-based setting.  Using local anesthetic techniques both the fat harvest and the subsequent transfer is performed with minimal discomfort.  Larger cases or in those patients desiring sedation or general anesthesia, the procedure can be performed in an accredited outpatient surgical center.

Autologous fat is harvested similar to how liposuction surgery is performed.  The harvest site is chosen by agreement between the surgeon and patient.  Tumescent anesthesia (dilute local anesthetic) is slowly infiltrated into the harvest location using a cannula 2mm in diameter or less.  Then, using specially designed fat harvesting instruments, the fat is gently removed into 10cc syringes.  This process is meticulous and will not leave an unsightly indentation at the harvest site.  In fact, the harvest site may actually be more aesthetically pleasing due to the fact that the area has been sculpted during the fat removal process.

Once the fat has been removed and treated it is meticulously re-implanted into the selected facial areas.  Pre-operative planning using photographs, drawings and skin markings help to guide the re-implantation process.  Re-implanting fat is similar to injecting commercially prepared fillers.  The re-implantation cannulas are slightly wider however in order to allow for atraumatic passage of the intact fat cells into the tissue.  The fat is placed into the selected site in small aliquots (fractions) along the site and at various depths.  This portion of the procedure is also completed using local anesthetic.  Sedation or General anesthesia is an option for patients making that request.

A fat transfer procedure can take from 45 minutes to three hours depending on the number of areas to be treated, amount of fat to be harvested and transferred and if stem cell assisted fat transfer is utilized.  Preparing the fat by using your own fat derived stem cells adds 45 minutes to the case while the fat is being processed for use.

It is important that you be sufficiently prepared for your post-fat transfer recovery period.  Complete written post-operative instructions will be provided prior to your procedure. Unless your fat transfer is performed using local anesthesia, the day of the procedure you will feel sleepy from the anesthesia.  The discomfort experienced from fat grafting is mild and occasionally moderate.  Pain medication will be prescribed.  The first follow-up appointment is at one week, however we are available to see you sooner if the need arises.  The patient typically experiences some amount of swelling and or bruising in the face for the first week.   The amount of post treatment swelling is largely dependent on the extent of fat transfer performed.   For larger cases the first day or two you should eat a soft diet until your swelling and soreness resolve.  Most patients resume a normal diet on the first day after the procedure.  Cool compresses applied intermittingly to the face are recommended for the first 48 hours after the procedure. Ice bags should NEVER be used against the skin, as the area may be numb due to local anesthesia and swelling.  Applying ice directly to numb skin may result in skin death.  Showering with warm water is allowed on the first post procedure day.  Your normal shampoo may be used. Pain medication and prophylactic antibiotics are usually prescribed and should be taken as directed. Sleeping with the head elevated will help reduce post-procedure swelling and bruising.

As with any surgical procedure, risks and potential complications include post-operative bleeding, infection, and scarring. Temporary sensory nerve loss may occur. Typically the sensation returns to normal within one month. Motor nerve damage (nerves that control movement) is a very rare complication of fat transfer. Typically decreased movement is temporary. Under or over correction of the area is possible. With fat transfer procedures, it is typical to require more than one session in order to achieve the desired outcome.

Dr. Mitchell is a Board-Certified Facial Plastic and Reconstructive Surgeon.  Dr. Mitchell has successfully treated hundreds of patients for both premature and mature aging of the face and neck.  Dr. Mitchell’s skill, artistic ability, thorough knowledge of facial anatomy and physiology translates into reliable and consistent success using both medical and surgical forms of facial rejuvenation.