The patient is a 57-year-old female prior to treatment (left) and 2 years after fat grafting (right).

Although fat grafting is still not perfect, surgeons are continuing to discover new methods of aesthetic improvement through the technique. It is becoming more dependable and convenient in most patients. Most people of average weight have more than enough fat tissue to be used in procedures.

The use of fat grafting in plastic surgery has been around since the 1980s, shortly after liposuction was introduced. Using autologous material, fat grafting is not a novel idea and has been widely used in treating many serious conditions due to disease, trauma, or birth defect.

In the cosmetic surgery realm, fat grafting was considered quite controversial when it was first used, but these days it can be a reliable procedure if it is done properly. Initially, the use of fat grafting was hampered by technologies that have in the past 20 years grown in sophistication.

Popular target areas for fat grafting in patients include the face, breast, and buttocks. When done correctly, fat grafting takes time. These procedures are often performed in an OR, not in the office. Even though fat grafting is considered by many physicians to be similar to working with fillers, these procedures are more complex than injecting Restylane or Juvéderm.

In addition, some patients are not good candidates for fat grafting, as they must have enough fat to harvest from one area of the body to be placed in multiple sessions in another area of the body.

Most of the residual controversy surrounds the use of fat grafting to the breast. The procedure definitely works and can achieve a fairly significant increase in breast size, although multiple grafting procedures are often necessary to achieve significant change.

As fat grafting is the type of procedure that is constantly under development and can be used with technologies that have improved quickly in the last few years, there are surgeons and physicians who may not have kept up with the latest developments.

To provide insight into some of those latest developments, PSP spoke with Samuel Lam, MD, FACS, a double board-certified facial plastic surgeon and a board-certified hair restoration surgeon based in Dallas; and Todd K. Malan, MD, a Scottsdale, Ariz-based physician who is a well-known speaker and educator on body sculpting, fat transfer, and adipose-derived stem cell therapies.

The patient is a 60-year-old female prior to treatment (left) and 1 year after fat grafting (right).

PSP: Recent advances in fat grafting have allowed physicians to begin to realize the full potential of using fat as a filler and body-shaper. What do you think accounts for these changes? Is it the mechanics or technology? Is there growing acceptance of it?

Todd K. Malan, MD: I think change in the technology, the advances in minimally invasive liposuction using microcannular liposuction, low-pressure vacuums, nonsharp cannulae—and using things such as the ultrasonic device, the BodyJet [device], or the nutational liposculpture device [Tickle Lipo]—are all methods that help to loosen the fat. We are now able to harvest fat without creating so much trauma to the tissue. This is fantastic not only for liposuction results, but this also leads to obtaining beautiful tissue for grafting.

When some of these newer instruments became widely available, physicians quickly recognized the ability to use this new technology for fat harvesting. Suddenly, physicians that had really shied away from fat transfer for many years were now trying to think of new, creative ways to use fat because they had good, reliable fat to play with.

Samuel Lam, MD, FACS: Fat grafting is permanent if done well. I think the misconception is fat is like Restylane—it is a temporary filler. That absolutely is not the case. If done well, it is not only permanent but it changes over time metabolically.

I liken it to a hair transplant. If you take a piece of hair from the back of the head and put it to the front, as a micro parcel of hair, over time that hair takes about 6 to 18 months to grow. What I have noticed with my fat grafting results is that it improves over a period of months because the blood supply is formalizing and improving.

In the book Hair Transplantation by Walter P. Unger, MD, FRCP(C), FACP, ABHRS, I looked at new vascularization for hair grafts and it takes about 6 to 18 months. So, I likened the fat grafting process to be very similar. With very careful photographic review, I noticed that that is the case.

PSP: In your practice, how are you applying the new technologies and what tools have you opted to use?

Malan: Well, we have played with a little bit of everything. We use the water-jet device, the laser device, and the Tickle Lipo device. All these devices seem to be doing a fairly good job of helping to break up fat or loosen fat to use for harvesting capabilities. It has been a wonderful opportunity to start using this fat to replace traditional fillers.

No longer are we stuck using fillers in the face that have limited life. We now have the ability to use fat as a body-shaper or body-contour so patients can use fat as an alternative to implants in their buttocks, calves, and breasts, and not have to undergo procedures with potential risks.

Lam: Fat grafting is the equivalent of using a very soft filler. It is not like Restylane, Perlane, or Radiesse, which are much firmer. If you try to use fat to lift up a little crease or a wrinkle or fold or a line, it is very difficult to do because it is too unpredictable to lift something up. Plus, it is a graft, so you can’t promise that the graft is going to have 100% take in that area; so much so that the defect is ameliorated to the point that the patient is really happy.

My mantra is fat is not good for lips and lines. What I mean by that is that in highly mobile areas like lips, the results tend to be poor. For areas that are very firm—like deep creases, folds, wrinkles, and lines—I think it’s just too difficult to get a result there. I use fillers to manage those areas. I use fat to manage the contour of the face.

What is interesting to me is that most fat grafting in the past has failed for two reasons. One is that most physicians are using it exactly in those two areas—lips and folds—where I think it has the highest failure rate because of mobility and the difficulty to contour a deep crease. Second, I think it failed because physicians can’t quite get it to work due to overfilling or underfilling, or graft replacement in areas where they can get contour problems or absorption. The problem with this is that patients don’t follow long-term results, so when fat cells tend to shrink a little bit after the third month and the physicians are not doing studious evaluations, they tend to think that fat grafting has gone awry.

A big negative is when patients get touch-ups in the third month. I have talked to a lot of patients who have had fat transfer done elsewhere. When a patient goes back in a year-and-a-half, the physician is surprised that the fat has taken where they didn’t think it took at 3 to 6 months. I call that “the dip,” because it is a time when the fat reaches a nadir in terms of volume time, and that’s when people tend to touch it up. I totally disagree.

PSP: Is the future of the fat grafting technique something you think will eventually bounce back and forth until we figure out the proper approach, or do successful outcomes truly depend on how well the patient responds to the procedure?

Lam: I think fat grafting is a beautiful technology, but the real risk is in physicians not understanding it.

If you just use it like a filler, eventually you will run into problems. You will have problems somewhere between 2 and 6 years down the road. If you can treat it carefully, I don’t see my patients having problems later on because I am very careful in selecting my patients. I have had a few patients that have gained 30 or 40 pounds. In those cases, I don’t like looking at my work. It doesn’t look good. It almost looks distorted. Those patients, when they lose the weight, they start to look great again. So, it is very important to understand that.

PSP: What about the future of fat grafting in conjunction with the use of stem cell-based treatments?

Lam: I think that there is a 50-50 mix in terms of people that believe in stem cells and those who don’t. I personally am more conservative in this. I believe that the way the light strikes the face after fat is applied starts to make tissues look better. This is because the way the light reflects on this skin looks better compared to, let’s say, someone who gets pulled and tucked up. The shadows that come down from above like the sun, in room lighting, exacerbates the shadowing effect. This can make your skin look worse, sometimes.

I don’t have a clear view on stem cells. My concern is what is a stem cell injection going to do to the patient’s face down the road? Is there some negative adverse reaction that we don’t know about since we’re injecting some kind of mutable product into the skin? Therefore, I would rather use the technology that has been around.

Malan: Currently, the wealth of information worldwide on the use of fat adipose-derived stem cells has been in the aesthetic arena. Sometimes people question why are these stem cells so magnificent and why are we wasting them on aesthetic procedures? The reality is that physicians who harvest the fat, who are the first in line to be able to obtain those stem cells, are also trying to use those for the benefits of their patients.

When patients have a liposuction done to remove fat, we want to use those cells to benefit them immediately from an aesthetic standpoint. Having the ability to store those cells or bank those cells will pay off in the long run for the patient who may suffer from heart disease or other medical problems.

What I see in the not-too-distant future is that we will continue to improve upon our fat harvesting and transferring techniques, and improve our understanding of how adipose-derived stem cells function and how to use them in an aesthetic environment.

More important, we are going to start seeing patients who will routinely want to store their stem cells. I can imagine a doctor telling a patient, “Hey, you really may want to save those stem cells and store those stem cells and save them for later in life.”

Another thing we will see in the not-too-distant future is a patient coming to us early in their lives to have small amounts of fat harvested for the purpose of harvesting stem cells. We know as we age, our stem cells become less potent at being able to differentiate or to change into other cell types. We also know that as we age, diseases such as diabetes directly affect the capability of the stem cells and the potency of the stem cells. So, the younger your stem cells are, the better they are able to function.

If we can remove those stem cells at an early age and store them for use later in life when the patient really needs them, there is really a limitless capability to really begin to focus in on regenerative and restorative medicine versus our current model of medicine in the United States, which is just to fix problems as they occur.

Rima Bedevian is a contributing writer for PSP. She can be reached at [email protected].