Dr. Sam Lam Plastic Surgery Forum

Hello,

I'm hoping you can help. I have attached a picture of my face pre-op and post op after my Rhinoplasty. As you can see I have lost all the fat from my cheeks, temples and down the sides of my cheeks. Some surgeons say fat grafting will fix it and others say it will only last a few years. Do you know if fat grafting is my only permanent option or will custom made implants do the job?

Some surgeons say the fat will last as long as the surrounding tissues. But seen as my fat has all gone how will the new fat survive? I don't understand how it all works? Can you please explain?

It won't let me add the pic of before my Rhinoplasty, it says my file is too big. Is there another way I can sent it?


Thanks

hi,
you can send the photo to me personally at drlam@lamfacialplastics.com if you would like. yes, fat grafting is permanent in my hands, which is a good and a bad thing. the problem with fat is that if you gain significant weight (20 pounds plus) you can look too full. you will also continue to lose fat (not my transplanted fat but your native fat) as you age. that is something you need to know. for those reasons, in general, i am not as big a fan of doing fat transfer in someone in his/her 20s if possible unless you know the stated risks. i personally hate cheek implants for many reasons. first, the procedure is fraught with problems, most get infected over time. also, they don't age well because as you lose soft tissue you will have an implant that becomes more exposed over time. the good thing is that they can easily be removed if you use silicone.
best,
sml

So even now all my fat seems to have dissapeared the new fat will still stay? Why do so many surgeons say it only lasts around 3 years? Is there any studies / scientific proof this proceedure produces permanent results? I just need to be sure I'm picking the correct proceedure before spending my money.

Is there any temp fillers that will give me the volume to fix this and how long will they last?

I will email my pre-op pic now so you can see my face before this happened.

If the surgeon was very aggressive during my rhinoplasty and caused a lot of swelling could this have caused cell death?

hi,
i have reviewed the photos you sent me. you have lost some volume in your face but it is truly hard for me to believe that it is rhinoplasty related. it just does not make sense. because of that, i would be hesitant to rush and do a permanent filler like fat transfer because i don't want you to have an issue in 6 months to a year if it comes back for some reason. in general, i would wait at least a year before considering permanent fillers.

fat grafting is definitely permanent, no question. my own mom is over 4 years out and still looks amazing. people who say that it only lasts 3 years must be totally insane. how does a graft get up and leave after 3 years? it is impossible. a graft will either have blood supply or it won't, period. it will live or die period.

as far as alternatives to fat, there is something called artefill, which is permanent. in general, again i am not a big fan to be aggressively filling a face as young as yours with a permanent filler but push comes to shove if you realize that there are some risks of how that will age for you, then i would consider it judiciously. artefill is every expensive, $950 per 0.8 cc syringe. it is good in my opinion to hit little areas like the eyes or cheeks but to build a whole face can be cost prohibitive.

temporary fillers like restylane, etc. are fantastic around the eyes and cheek because they are very long lasting. because you are younger, they would be "cheaper" than fat since you probably do not need a ton of syringes. they are also "reversible", i.e., they can be dissolved but sometimes at the expense of dissolving some of your own tissues that can linger for many months so i am hesitant to dissolve areas but the point is is that it can be reversed if need be. that may be a good option if you are in the process of facial change since if the volume comes back then the filler could be dissolved. also, there is a built in safety mechanism long term for you since it is "reversible". the only problem in general is i am not a big fan of putting restylane in and then converting immediately down the road to fat because since it is temporary putting fat grafting on top of a temporary filler on the way out is in general not a great idea. i liken it to building a house on sand so to speak.

in short, there is no clear answer of what would be ideal for you. if you want something global and can wait until a year has gone by since the rhinoplasty and are willing to accept the long-term risks of fat transfer in terms of weight gain, then i would consider fat transfer. if you want something of the highest safety margin that can last you a long time typically i would go with restylane. hope that helps a bit.
best,
s.

It has already been 18 months since I lost the fat so I don't think it's coming back.
If I went for the fat transfer or the artefil how long would I need to stay in the area for? And approximate how many syringes of artefil would you say I would need?

If u do artefill u could leave the same day. If u do fat transfer u need to come one day earlier then fly out the day after surgery. Two nights in a hotel that is. The hotels in Dallas are pretty cheap, I think less than $100, with free shuttles to and from the office. Artefill can be anywhere from 2-3 syringes for a good result to 8 to 12 for an excellent result depending on how global you want to correct.

With the fat transfer option is there definate evidence or studies that show the transferred fat survives. I read that the ucla in 2007 said there was no evidence of the cells surviving. Have there been other studies since?

yes, my colleague mark glasgold did a 3-D volumetric study that showed fat survival after a year but it was variable in his study. also, i have removed fat from lips 10 years afterward and fat came pouring out. there is ZERO DOUBT that it survives. my own mother is over 4 years out. if you would like to see some of my patients who have been overfilled by my colleagues and who look like puffy balloons 10 years after fat grafting they would beg to differ. i have no way of treating these patients who look overfilled and ridiculous. the UCLA study is bunk. this is why i am not worried about it not surviving. i am worried about it surviving. everything i have explained to you regards not the risk of it going away but it staying. i have truly repeatedly emphasized weight gain and life long risk after fat transfer in someone as young as you. i can do it for you beautifully. however, i really want to make sure that you do things safely. remember that the more you google things, the more you will be confused. spend 5 more hours googling, and you will find 50 conflicting answers. the main reason is that docs do not know how to do quality work so they say it does not last. if you do quality work, it lasts. hence i am more cautious about overfilling than under filling. it is always easy to add but almost impossible to remove. be more concerned that it stays not that it goes away. quality work is the key and pre consultation safety considerations that i have outlined are critical.
best,
sml

Just to clear up one last thing I have been reading about, and no surgeon has ever mentioned. It states on serveral sites that all fat cells have a life span, and a certain percentage per year die and are replaced with new cells. Is this true and if so, does this happen to the fat that is grafted or is this why many surgeons say it only lasts several years. Because once the life span has ran out the grafted fat doesn't grow new cells?

The other thing I thought might fix my problem is cheek implants. I know they are more risky but at least once they are in I won't have the worry that the volume can reduce. Will cheek implants fill the area enough would you say?

1. i have never heard such a thing. i have actually heard the opposite. when we are at puberty, we gain a certain # of fat cells and then for the rest of our life they are with us whether we like it or not.
2. fat if done well is permanent. i have taken lumps of fat out of bad lip jobs 10 years later and it is not scar tissue and it is not lip tissue it is globs of yellow fat. i have seen people over done with fat transfer and they are in misery 10 years out. it is permanent if done well (or poorly i guess). my fat holds well. however, you will continue to lose your own fat as you get older, i.e., the untransplanted fat. that is part of aging.
3. i personally hate cheek implants for two reasons. one, about 10% of them get either infected or malpositioned. it is a flawed procedure at best. second, it does little to solve the real problem which is soft tissue loss. applying more boniness (which is what a cheek implant does) only makes the bony part of the face look even bonier.
read this blog:
http://www.lamfacialplastics.com/celebr ... -implants/

Hello Dr Lam,

I am thinking of going for the Artefil option, then at least once it's done it will be there for good and I won't have the worry of is disapearing with time.

Do you personally have experience in using Artfill in large volumes? If not do you know who does. I've heard that people with HIV suffer from a simalar thing, do you use Artefil to correct their faces?

The only bad thing I can find about Artefil (PMMA) is you can develop foreign body granulomas. Are these serious if they occur? Do they have to be removed or if you leave them do they cause any harm. To be honest it's just a few little lumps on my face I can live with that more than I can live with hollow cheeks.

I know you have to have an allergy test first, could I have that in the UK first or do I need to come to the US for that?

Do you personally have experience in using Artfill in large volumes? YES, I HAVE PUT MULTIPLE SYRINGES INTO THE FACE. I HAVE NOT PUT MORE THAN 6 AT ANY ONE TIME BUT THAT IS DUE TO COST. I COULD PUT 50 IN THERE WITH EASE BUT NO ONE NEEDS THAT MANY. If not do you know who does. I've heard that people with HIV suffer from a simalar thing, do you use Artefil to correct their faces? I DON'T WORK WITH A LOT OF HIV PATIENTS BUT I HAVE FILLED SEVERAL WITH DIFFERENT PRODUCTS PRETTY EASILY.

The only bad thing I can find about Artefil (PMMA) is you can develop foreign body granulomas. Are these serious if they occur? YES, BUT THEY ARE EXTREMELY RARE. I HAVE DONE PROBABLY A THOUSAND SYRINGES AND NEVER SEEN IT. THE STUDIES SHOW THAT THE ODDS ARE 1:5000 CHANCE AND FEW CASES WERE VERY MILD. Do they have to be removed or if you leave them do they cause any harm. To be honest it's just a few little lumps on my face I can live with that more than I can live with hollow cheeks. A GRANULOMA IS NOTHING MORE THAN PRODUCT THAT BECOMES INFECTED AND NEEDS 6 WEEKS OF ANTIBIOTICS AND INJECTABLE 5FU. THAT CAN HAPPEN WITH ANY INJECTABLE FILLER INCLUDING RESTYLANE BUT IT IS VERY VERY VERY RARE AND TREATABLE.

I know you have to have an allergy test first, could I have that in the UK first or do I need to come to the US for that? YES, ABSOLUTELY. THAT WOULD BE THE EASIEST THING TO DO. I HAVE EXTENSIVE EXPERIENCE WITH ARTEFILL AND VERY UNIQUE WAYS OF FILLING THE FACE USING MICRO CANNULAS. HOPE THAT HELPS TO ANSWER YOUR QUESTIONS.
BEST,
S.

why is it not as risky using fat graft in a person age 40 versus 20..wouldn't the same risks apply possible weight gain and looking to full?

Why are so many surgeons against Artefill? I've been reading things saying they can cause facial deformity etc. Is this really true? I really want my face plumped back up permanently, but I'm worried about all these bad reports. If these Granulomas appear, are they huge or generally just little lumps under the skin?

any injectable product can cause a granuloma. a granuloma is a reaction to a product that is a manifestation of an infection. if it does not get infected then you won't get one. the odds are about 1:10,000 according to long-term studies with Artefill. it is about the same or less than other fillers. the reason doctors believe there is a problem (and I was one of them) was that the less pure product Artecoll and prior to that Arteplast were much more likely to create this problem because the particles were not uniform. i have done probably 2,000 syringes and not seen one case of it.
s.