By Dr. Amiya Prasad, a board-certified cosmetic surgeon
Is facial fat grafting better than fillers?
As a facial cosmetic surgeon patients often ask if transferring fat to the face is a better way to treat age-related volume loss in comparison to cosmetic fillers, particularly because they like the idea of having a more permanent solution.
They also perceive that using their own fat is much more natural than using commercially available injectable fillers.
I’ll discuss how I counsel my patients about the choice between facial fat grafting and injectable fillers in my practice.
Before the introduction of hyaluronic acid fillers in the US around 2005, the only fillers we had were Zyderm and Zyplast, otherwise known as collagen injections. These were purely dermal fillers, which due to their origin from cows required skin testing two weeks prior to treatment in case of allergy.
Fat grafting was at the time the holy grail for facial volume enhancement. There were so many courses and presentations in our professional activities to improve fat grafting outcomes.
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How Fat Grafting is Done
Fat grafting involves first harvesting fatty tissue using liposuction from areas such as the abdomen and hips. Once harvested, this living tissue no longer has a blood supply.
The fatty tissue is processed for implantation and then placed into a new location like the cheeks, using micro cannulas.
Facial Fat Grafting Before and After
Issues of Fat Transfer
One of the significant issues is the percentage of fat that actually survives this process.
It’s generally accepted amongst my peers that about 30 to 70 percent of transferred fat does not survive, resulting in fat cells falling apart and inducing inflammation before being disposed of by your body.
This means that there will be asymmetry and limited results after the healing process of several months to a year has transpired.
Some of the fatty tissue does not get completely absorbed, which results in the formation of scar tissue, characterized by lumpiness and irregularities.
A second procedure is often necessary to try and deal with the undercorrection and asymmetry of the first procedure.
So the expense of typically two surgeries and a high level of unpredictability led me to be more conservative with using fat grafting as part of a facial rejuvenation strategy.
A distinction should be made about defining the aspects of facial aging which are responsible for issues such as loss of cheek volume.
Although facial aging is characterized by diminishing soft tissue involving the skin and the underlying fat, the most significant area of volume loss is actually at the bone level.
Based on this understanding, the placement of fat under the skin is actually not addressing where the most deficient area is, which again is at the bone level.
This is one of the reasons why someone who’s had fat grafting often looks swollen and pillowy instead of defined and youthful.
A more predictable alternative to facial fat grafting prior to the mid-2000s was the placement of facial implants, such as cheek implants and chin implants.
These implants are placed at the bone level and provide much more predictable improvement in comparison to fat grafting. There are risks with facial implants such as displacement and infection as well as dissatisfaction requiring surgical removal or replacement.
Hyaluronic Acid Fillers
The introduction of hyaluronic acid fillers such as Restylane in the mid 2000s changed the way I approached facial soft tissue deficiency.
As time went on, thicker and longer lasting hyaluronic acid fillers such as Juvederm Ultra Plus and Juvederm Voluma became available.
Hyaluronic acid exists naturally in your body such that we can place this type of filler without having to perform skin testing prior. These fillers are also easily metabolized by your body.
Another advantage is that hyaluronic acid fillers are reversible. Should there be any issue requiring removal, hyaluronic acid can be easily dissolved with an enzyme called hyaluronidase.
Hyaluronic acid fillers are very effective for the enhancement of soft tissue such as in the area of the lips.
I routinely use thicker hyaluronic acid fillers at the bone level comparable to the facial implant placement and I’m able to create a natural and defined look.
Hyaluronic acid fillers are typically placed within the skin for wrinkles and acne scars. For volume enhancement in areas such as the cheeks, fillers are conventionally placed just below the skin, similar to the way fat grafting is performed.
This placement can enhance projection but the nature of the filler and the intrinsically weaker tissue below the skin results in the filler not staying where you intended but rather spreading out and creating a softer less defined appearance.
Specialized Techniques to Restore Volume
In order to address the most significant cause of volume deficiency, I use specialized techniques to restore volume at the bone structure level.
This is where it’s most impactful.
It’s because between the bone structure and the overlying muscles is a space where an implant such as a cheek or chin implant can be placed.
I apply this surgical principle for the precise placement of thicker hyaluronic acid fillers to create a result comparable to a facial implant.
The significance of this technique cannot be overstated.
I now routinely use hyaluronic acid fillers to enhance areas such as the jawline, cheekbones and chin in a way that previously was only possible with facial implant surgery.
I’m able to perform these procedures in my exam room in about 30 minutes and my patients go out and about right afterwards typically without any sign of having had anything done.
This concept we refer to as Structural Volumizing when performed as a combination of the cheeks, chin and jaw angle it’s called a Y-Lift.
You cannot do this type of procedure using fat nor can you get these kinds of results using conventional filler placement techniques.
I routinely see my patients after two weeks to see if any additional volume would be a benefit.
Fat Grafting Drawbacks
Surgical fat grafting for a period of time showed a lot of promise for facial volume enhancement. Ultimately the lack of predictability, the prolonged healing process, the high frequency of undesirable results and the need for repeated surgical procedures could not be overcome, in spite of many years of research and clinical practice optimization.
Although the potential of longevity is the basis for continual application of fat grafting by some of my colleagues, in my opinion this limited potential benefit has a low probability of success and does not justify the unpredictability and significant rate of complications which have a much higher probability of occurring in comparison.
Time and technology has allowed me to help my patients with an approach that is highly predictable, safe and reversible without surgery.
This structural volumizing with long lasting benefits using safe hyaluronic acid fillers aligns very well with modern life, which as we all know is characterized by limited time and a little tolerance of avoidable complexity.