The Role of Fat Grafting in Plastic Surgery

Fat grafting also known as fat transfer is a rapidly evolving field within plastic surgery. It does what few other fillers can accomplish by replacing “like with like”–reshaping, changing and augmenting parts of the body in a way that literally sculpts with a patient’s own tissue. Although it sounds too good to be true, fat grafting takes fat from one area of the body where it is unwanted, and puts it into another area where more volume is desired. Highly technique dependent, it is a specialized focus at Park Cities Cosmetic Surgery. Breasts, Buttocks, Hands/Lips and Face are some of the most common areas for fat grafting.

Fat Grafting to the Breast

Fat grafting to the breast in place of a breast implant has been an area of intense research for over a decade. Plastic surgeons were initially excited about offering women interested in using their own tissue, a more “natural” alternative, however some questions and challenges linger. At this point in time, even the biggest proponents agree there are obstacles to making this a mainstream procedure. One of the biggest challenges is consistency. When you graft fat from one area to another you are asking the fat to “live” where you put it and fat is not 100% predictable. This is particularly important when you are striving for symmetry between breasts. In addition, the blood supply available in the breast may prohibit a large amount of fat to be grafted and ultimately supported, so those expecting to go up several cup sizes could be disappointed. Another consideration is that candidate’s anatomy. Do they have enough fat to “transfer”? The best treatment for patients is determined by their anatomy and surgical goals.

The more common situation in which I use fat transfer to the breast is to complement an implant. Today’s breast implants have come a long way in quality, safety, and the sheer number of options available. I like the predictability of implants for the best aesthetic result. Adding fat to improve the appearance of the chest wall or cleavage can deliver an extraordinary outcome. Women who are undergoing breast reconstruction may be the best candidates for fat grafting along with an implant. Overall my recommendation tends to lean towards creating volume, shape and projection with an implant and fat in unique cases.

Fat to the Buttocks (Brazilian Butt Lift)

The large surface area of the buttocks makes it ideal for fat grafting. More area means more fat can be grafted and potentially “live”. No matter where in the body fat is grafted, it requires biologic support. It is critical to understand what the patient wants. Not everyone wants a Kim Kardashian or Jennifer Lopez butt. Individual anatomy coupled with the changes a patient would like to achieve dictate the amount and location of the fat transfer. Fat plays a great role in shaping a beautifully curved torso regardless of size. Often, I don’t have to use a lot of volume to create a dramatic change. The best outcome is predicated upon patient compliance post-operatively since they must be conscientious to avoid any pressure to the area for 6 weeks.

Lips and Hands

Lips and hands can both benefit from fat transfer, but are a challenge. Lips, by nature are dynamic–eating, drinking, talking–always moving, which can cause potential sheering and metabolic breakdown. I consider the lips less predictable when it comes to long-term results. I’m more likely to suggest fat grafting to the lips in patients that are opposed to filler or having an implant removed. Injecting silicone into the lips or any other anatomical site should be avoided at all cost.

The challenge with hands is the “recipient bed.” Think about the top of the hand–the bones, tendons, thin skin and visible veins. There is minimal subcutaneous tissue so the grafts are a bit trickier. Similar challenges exist with filler. The big benefit to using fat in the aging hands is its intrinsic rejuvenating properties. Even if 100% of the graft doesn’t live, there are powerful stem cell properties that seem to influence the underlying tissue.

Fat Grafting to the Face

Most patients have good results using fillers early on, provided they are going to an “injector” that understands facial aging, anatomy and aesthetics. It is important to be seeing the right person to know when it is time to “graduate” to facial surgery. As the face ages, the facial support system weakens and begins to sag most noticeably in the mid face and the junction between the lower eyelids and cheekbones. A “liquid facelift” does nothing to suspend that weakened support system–it actually has the opposite effect–requiring more and more filler, which in turn creates the sag it was supposed to correct. Fillers and fat expand the tissue. There is weight associated with fillers and if you continue to add that weight, the problem of descending tissues is exacerbated, not alleviated. Fillers are best used for volume after the deeper tissues have been suspended and tightened.

What a high SMAS facelift does is lift and structurally re-suspend the tissues. Facial surgery is done to recreate more youthful positioning of the deep tissue. In contrast to a “liquid facelift”, the SMAS is a more anatomic, sensible correction versus camouflage. Fat grafting to the face is typically done as a complementary procedure to a facelift–never as a substitute for a facelift. Fat is a very artistic component and good adjunct but must be used cautiously and meticulously. The treatment for each patient must be individualized. Some patients don’t need any grafting at all while others may require grafting at multiple sites. Commonly grafted with fat are the temples, cheeks, and areas around the mouth. The benefit to using a patient’s own tissue is any reaction is minimized or diminished. It is a permanent “fix.” One of the drawbacks to using fat in the face is that if a patient gains weight, then they will gain weight in their face, which can influence the result. There is also the question of symmetry if the grafts “take” more in one side of the face than the other. For these reasons I like to use fat to build up the deeper tissue and then put filler on top. Filler is more predictable and I know exactly how much to use. The patient gets the benefits of both which I find to be an appealing approach for the best overall result.