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Fat Transfer to Face

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WHY I LOVE FAT It is liquid gold

I do tons of fat grafting to the face, and I LOVE IT. As you age you lose facial volume, and your skin tone becomes bad: large pores, cobblestoning, fine wrinkling.  Even though you may be getting fatter around the belly, you are losing it in your face. In the office I do lots of fillers, and they work well to reverse volume loss.  But they are not as elegant as fat. I can’t feather them, inject them into the skin, place it all over the face, and do the volumes I can do with fat.  Fat is also a living substance, so what you get can last for years. And fat has STEM CELLS, which improve the quality of the overlying skin.  I was an early adopter, a follower of Dr. Coleman in NY and Dr. Khouri in Miami.  I have been doing fat transfer to the face for over a decade now. My technique has evolved, and if anything I am a bigger advocate for it now. It just does something nothing else- surgery, lasers, peels- can do.  It is a huge part of my practice.  There are no scars (I use a small needle for access).  I see even, smooth fat survival.  It improves the quality of the overlying skin, and many patients are asked by strangers “what skin care products do you use?” because their skin looks so good.

Have I told you how much I love fat grafting?

Fat transfer is a booming area of plastic surgery. Why? Because we have come to realize facial aging is a combination of

And we are discovering the abilities of stem cells. What I have found with my younger patients (read anyone under age 50) is much of their facial aging is volume loss. This accounts for the popularity of nonsurgical soft tissue fillers to the face: Restylane®, Perlane®, JUVÉDERM®, and Sculptra® among others. These have been deemed the liquid facelift or nonsurgical facelift.

A facelift or eyelid lift can tighten the skin, but it does not correct volume loss. You see this in people who have tight skin but still look old. Why? The surgery only addressed the skin. If you look at a child they have a full face. Not plump or fat, but full. This fullness of youth is part of what needs to be fixed when doing surgery. Thus volume must be part of a successful rejuvenating surgery for the face and eye.

How to add volume?

Again, non-surgically we have been doing this for years with HA fillers like Juvederm,® Voluma,® Restylane,® and Sculptra®. What has happened though over time is the improvement in fat transfer techniques–how to remove the fat, process the fat, and inject the fat to insure the fat survives and incorporates into its new place. When you do fat grafting, you need the fat cell to live in the new location. I use techniques I have learned to minimize damage to the fat cell and place using a micro fat injection technique. A recent journal article detailed the best way to inject fat into the face, and it is the technique I have used for years.

  • Microfat transfer. I use this technique primarily to add the volume back to the face.
    • I use small gauge cannulas to inject the fat.
    • The amounts are tiny, so issues like lumpiness are not seen.
    • I use a small needle to access through the skin, so there are no scars.
  • Nanofat transfer. This is to help combat those deeper wrinkles which are etched into the skin. This is micronized fat. I “break up the fat” into smaller sizes, as we want the stem cells, not the volume. Micronized fat has been shown to be even more effective to reverse photoaging, thicken collagen in the dermis, and improve vascularity in the skin.
    • This is a newer technique where I inject into the skin itself.
    • This is particularly good for the deep forehead wrinkles, the “11” between the brow, neck lines, and some deeper lines around the mouth and lips.
    • I LOVE this for the fine lines around the mouth and the necklace lines in the neck. It is pure magic.

The other benefit of fat? *hint stem cells*

Not only is it using your own tissue to reconstruct you (and you get a little liposuction sculpting to boot), but it has stem cells. Stem cells are currently the fairy magic dust of plastic surgery. We don’t quite understand what happens when we transfer the fat with stem cells- how it does it and how to optimize it. But we do know fat has a rich store of stem cells. And we do know we see things we can’t explain just from the volume alone of the grafted fat– the area fills, but the skin looks better. This change is slow and subtle, but there.

I too was a skeptic, but I had a patient who I experienced the magic of fat transfer with first hand. She was a woman with tough acne scarring on her cheek. She had asymmetry of her cheek volume, so years ago I did fat transfer to try to even out the volumes of her cheek. My technique then was not as refined as now, but it worked. The amazing part was the change in her skin. I had the opportunity to work on her cheek again about 4 years after her initial fat transfer. Not only were the acne pits shallower and cosmetically improved, but her skin — which had been hard and leathery before– was now soft and stretchy. I can’t account for that change by volume alone. I attribute it to the stem cell effect. There are clear studies which show with histologic biopsies this stem cell effect. Nothing else does it.

People worry the fat may be lumpy or uneven. I do not see this. There are scientific studies which also support fat survival is consistent and even within a patient. Please see someone who does a lot of fat transfer.

Fat Transfer Blogs

WHAT ARE THE KEYS TO FAT GRAFTING?

ANTIAGING OF THE SKIN BY FAT TRANSFER- WHY DOES IT WORK?

PROTEIN RICH PLASMA “PRP”- DOES IT HELP WITH FACIAL REJUVENATION?

SKIN REJUVENATION AND VOLUME AROUND THE EYE AND MOUTH

IS THERE A BEST WAY TO HARVEST AND PROCESS FAT FOR FAT TRANSFER?

Fat Transfer Blog

Where to transfer fat?

  • Cheek
  • Cheekbone
  • Jawline
  • Lip border
  • Chin
  • Nose (to straighten, lift the tip, and hide the bump)
  • Temple
  • Area between the brows
  • Lateral eyebrow (to lift the brow)

I find I am using it as a stand alone procedure and as an adjunct to my surgical procedures like eyelid surgery and facelifts. You need to think of fat grafting to the face as a surgical procedure. I perform the surgery in the operating room, as I need sterile technique and the centrifuge. The procedure is usually done under local anesthesia. Recovery is not painful, but you will have swelling and some bruising. For those of you with busy lives, this swelling means you may want to take a week off work or work from home.

Stem cells Take time to work

This photo shows pre fat grafting and 3 months after microfat and nanofat (micronized fat). No peel or lasers were done. Look at the change in the skin quality. It is pinker, smoother, with less wrinkling.

This effect is just starting at 3 months. Patients say maximum effect is seen 9 – 12 months out. People approach my patients and ask them “What skin care products do you use?”

Pretty skin makes everything else look better.

Beware of any noninvasive procedures which tighten the skin. (Ultrasound, microcurrent, or other). Their tightening is TEMPORARY. But they can kill the subcutaneous fat, and that fat loss is PERMANENT. If you have done fat transfer, please discuss any noninvasive skin tightening or lifting treatments with Dr. Greenberg before you do them. You may lose your newly transferred fat.
*Individual results may vary

who is not a good candidate?

Are there people who are not good candidates for fat transfer to the face? Sadly, yes.

  • If you do not have fat (and crazy enough, in the Bay Area there are women with truly no fat)
  • if you have had prior injections with fillers which create scar (like Sculptra and Radiesse). Think of it like throwing clay in your soil.  The newly transferred fat won’t do well. NOTE: HA fillers like Juvederm and Restylane seem to be fine.
  • If you are anemic. Again, when we plant the new fat cells, it needs a good blood supply to do well.
  • If you have diabetes.  There was a study in diabetic mice which found poor fat survival. (see my blog here). BUT I had a patient with diabetes for years who begged me to do the fat grafting just to try it, and she had a great result. So maybe there are more factors than what was seen in that study.
  • If you are a smoker. I won’t do fat grafting on an active smoker, and this means smoking anything (marijuana, vaping, cigarettes). If you have a history of smoking you have affected the small blood vessels which bring blood to the newly transferred fat, so it may also affect survival.
  • if you have had prior fat transfer and it didn’t work. There are things we don’t understand, but there are studies which show everyone has a “quality of their soil,” and some people the fat does not survive well. This did not correlate with BMI, gender, age, or other factors.

who is an ideal candidate

Can I just say everyone?

I love this procedure. It is subtle, but not subtle. It makes your skin look fresh and dewy again. It is just the bomb.

My prototypic patient is:

  • In their 40s and older (though we do see volume loss in younger patients, or those with a genetic problem area like the tear trough being hollow)
  • Has fat to donate
  • Has had volume loss (but you see this in everyone as they age)
  • Does not have some of the contraindications listed in the box next to this one.

It does not work equally for everyone. As the studies have shown, some people have better fat survival than others, and we still do not know exactly why. But it works, and what it does is great.

facial fat transfer the procedure

Facial fat transfer is a procedure I do in the operating room. Why? Because I have to harvest fat, process the fat in a centrifuge, and then inject it in the face. Though it does the work of a filler (I think way better than fillers, since I can do more, it can last for years, and it has those stem cells), unlike a filler which is a quick visit to my office with no recovery, fat transfer is a surgical procedure with a recovery.

fat grafting recovery

Fat grafting recovery is odd because you don’t have a ton of pain, but you look funny.

  • First Week: I call this the cabbage patch week.  Your face will be super puffy, and you won’t look like your end result. I excel at natural results- my patients look like time just reversed- but they don’t look like that right after surgery.
    • You may have some bruising, though usually not much.  The places you will bruise the most are where you had the nanofat done: usually around the mouth, the forehead, “11” lines in the glabella, and the neck.
    • No pressure on the fat (for you side sleepers I have tips for you)
  • Second Week: I call this the LA week.  (Think the overdone look of some people you see in LA- Sorry ladies from LA, I know there are natural looking girls in Southern California).  You still will not look like yourself.  Your cheeks are too cheeky, your lips are too full.  You look puffy.  This still is not real.
    • Many people will work from home this week.
    • If you need to see people, wear glasses- it will distract people from the other changes.

When do you see your results?

What you have at six weeks is close to your end result, but three months is really when you can see what your changes really are.  The stem cell changes in skin quality just start to be seen at three months.  I get calls about “random people complementing me on my skin” when people are 9-12 months out.

fat graftingcost

Fat grafting is something I encourage my patients to do anytime they are doing any form of liposuction.

DON’T THROW FAT AWAY!

Fat grafting in my practice is a vital component of any facial procedure: eyelid surgery (blepharoplasty) particularly of the lower eyelid, or facelifting. I frequently do fat grafting in any of my patients who are over the age of 40 and having liposuction, abdominoplasty, or breast lift and reduction- all of which usually involve me doing liposuction for contouring. As such, when it is an add on, I charge slightly less. It usually adds about a half hour to the procedure. It adds no time to their recovery.

Cost for fat grafting to the full face as a stand alone procedure is usually around $6-7,000.

Remember if you are doing filler,

  • each syringe of filler costs $750 or more,
  • you may require multiple syringes,
  • every time you have an injection you run the risk of bruising,
  • it needs to be redone every six months, and
  • it doesn’t have the stem cell effect of fat transfer.

I just want to encourage people to do it. It is low tech, it is you reconstructing what was lost, and it gives results no peel, laser, or product ever gave.

For more information of fat and stem cells, please see my many blogs on the topic. You will find many of the fat grafting and fat transfer blogs in the breast augmentation section as I do fat transfer for breast augmentation as well. Stem cells and fat transfer tenets are the same regardless of where I put the fat.

This is a growing interest and part of my practice. It seems most of my colleagues are now jumping on the bandwagon. At our recent aesthetic meeting, many topics were all about fat and the benefits of transfer.