LAM FACIAL PLASTICS

How long can your patients expect to see a benefit from fat grafting? Why isn't the fat reabsorbed?

Great question. I get this one all the time so I am glad that I have this forum to provide a detailed response that would be commensurate to the importance of the question.

First off, my fat lasts and thrives in the majority of patients. I rarely need to do a touch-up procedure, but that is easy to do if need be. So why does my fat last so much better than the majority of fat grafting out there. Let's break it down.

First of all, I always harvest fresh not frozen fat, which should have better viability and longevity. I perform all of my fat grafting under sedation so that you don't have any discomfort but also I can reduce the lidocaine load which can be unfavorable for fat cells at a high doses. Next, the way that I harvest fat is tremendously gentle. I NEVER use machine liposuction (even though I have the machine that I use for neck liposuction in my OR) since it would kill most if not all the fat cells. I often hear the story that a body plastic surgeon is sucking out fat and decides to "throw a little back into the face". This is a real problem since the fat cells have been traumatically removed and are not healthy to be put back into the face and therefore will not survive and not survive evenly in most cases.

Also, during hand harvesting, I only employ 2 to 3 cc (milliliters) of negative pressure suction so that the fat cells are not additionally traumatized during harvesting. I only use very small 10 cc syringes to harvest too since larger 20 cc or greater syringes can create too much negative pressure and thereby lyse or destroy the fat cells. Next, I take the harvested fat and under absolutely sterile conditions centrifuge the harvested fat cells for a very short time to remove the impurities of blood, lidocaine, and lysed fat cells so that I only inject pure fat cells back into the face. I then "wick" the fat cell column for about 10 minutes to remove further impurities from the fat cells like oil, etc. I also maintain a closed system where fat cells are not sitting open to the air, which can be toxic to the fat as well. My centrifuge time and speed are also limited so that I can just clean the fat without damaging the integrity of the fat cells.

Next, there is very limited time that the fat resides "out of the body". By the time the wicking is over, I have already placed the numbing medicine into the recipient areas so that I am ready to go with the next step which is transplanting the fat. Since I perform this procedure almost every other day, my staff is much better equipped to make sure every tedious step is faithfully and accurately executed to ensure oustanding fat longevity.

The injection method is critical. I don't use any needles under the skin not even for placing the anesthetic into the recipient bed. Needle injection of fat can destroy, lacerate and bruise the surrounding tissues leading to poor fat uptake. Using a microscopic smooth 1.2 mm and 0.9 mm cannula I can put the fat in atraumatically so that the fat rests in natural tissue planes. A cannula, btw, is a hollow bore tube with a soft rounded end and a small side hole where the fat can come out.

Next, I inject the fat in a microdroplet fashion placing around 1/100th of a cc (millileter) around sensitive areas like the eyes for not only an unparalleled smooth result but also to ensure that there is plenty of blood supply to nourish each microparcel of fat. Picture the rough handling of fat that is typical followed by injecting a baseball fist of fat into the face. Besides an unsmooth result, how much blood supply do you think makes it into the lump of fat? How about none?

Next, when I inject fat, I visualize multiple tissue planes. For example, when I am injecting the fat into the cheek, even if I injected that area with microdroplets but put all that fat into the same tissue level it will coalesce into a big ball, meaning no blood supply and loss of fat. Instead, I march through each microlevel of tissue plane so that the fat is gently layered over multiple planes until I reach below the skin surface so that there is literally a scaffold of micofat parcels and thereby plenty of blood supply for the fat.

Furthermore, I do not overfill meaning that your recovery is far shorter than most surgeons who put in routinely 100 to 150 cc into the face. I put about 1/3 to 1/2 the amount because you really do NOT need that much. That is why first my fat survives beautifully since there is plenty of blood supply to nourish each fat cell whereas fat stacked on fat stacked on fat will not have enough blood supply to survive. If it does, you will also probably be in trouble because it will look too puffy and big. Remember that is not the objective in fat grafting. That is why my patients do not look overfilled like pumpkin heads but appear natural and appropriate.

The other point that I have not raised is where the fat is placed. Most other surgeons who "do fat grafting" place fat in completely useless places like lips and lines. The mantra that my staff has memorized is that fat grafting is not good for lips and lines. So exactly where my colleagues place fat is exactly where I do NOT. Fat does not survive in highly mobile lips and when it does it may not look the most natural. Furthermore, the recovery of placing fat into the lips is tremendously distorting if not simply horrific. Finally, placing fat into lines and folds fails in most cases. I think there are a lot easier ways to manage the lips and lines than fat grafting.

Fat also survives the best in women between 30 and 60. Although I get good retention of fat in men and older women. The ideal candidates for fat survival fall into the category above. Also, remember unlike a "touchup browlift" which is a whole browlift again, a touch up fat graft is truly that, an incisionless 30 minute procedure with no knives, bandages, or sutures. If it is a small amount, you could have a much shorter recovery of a few days.

What is interesting is that my fat actually starts to look amazing about 8 months to a year to two after the procedure. This is really hard for most people to grasp who think that fat does not last. When I show patients in my office the ongoing improvement after a single fat grafting session, they are amazed. Why does it take so long for fat to actually look amazing? I don't know. You already look great early on but it is not until after about 8 months to a year that the fat looks simply wow! I think it may be due to two reasons. First, there is a theory that stem cells play a role in making the skin overlying transplanted fat look better but that takes a while and may not be a guarantee to happen. Second, like in a hair transplant a free graft is fully vascularized by 6 months and begins to just blend is the only word I can come up with.

Another common problem is that you simply do not remember how bad you used to look. When someone comes up and says I think I lost all my fat, they are totally wrong. When I compare their before and after photographs in standardized lighting, camera settings, and distances, they are blown away. "I used to look like that?" is the response. The reason is that we ALL forget to a certain extent how we used to look. Since I am not lifting brows in the middle of the forehead, my results are what I like to call subtle but dramatic.

As far as how long would fat grafting last in a typical patient, I say in the majority of cases permanently but with the caveat that it is a free transplanted graft and you may still lose a little of the result. Also, simply put you get older and will lose your own natural fat over time. All you have to do is look at your photos two years ago and you will see the fat loss from that. Just like in hair restoration, the transplanted hair is something you typically do not lose, it is your existing untransplanted hair that you can lose and that may mandate another session in the future.

Think of it this way: what would you rather have in 5 years a fat grafting touchup or another facelift?

Hope that helps.
Best,
SML

Great question-glad someone asked it. I am one of your patients and very happy w/my results. (lips/Botox/fat graft/plasma).

I am about 3 mos. post FT/plasma and love the way I look--your answer to this question actually addressed latent questions I had. THANKS! I had really been curious WHY results really optimize later rather than sooner. DH suggested vascularization and voila--that's (IMO) basically what you imply. Thanks again and look forward to seeing my favorite doctor next month.

thanks. i'm glad that my answer was helpful. Actually, what is interesting is that the plasma resurfacing you had will also continue to improve over a year. The skin texture and tone really starts to look good about 10 months to a year out even though I am sure you are enjoying the result now.

also, if you stay consistent with botox, your wrinkles will also continue to improve with time. after 1 to 2 years of consistent botox use, your wrinkles will start to disappear even more than after 1 to 2 treatments.

all good news,
sml

Do you get immediate results from facial fat grafting or is it something that will take months to get a decent result? I was reading that you said your skin looks better, usually, after 8 months or so. Does this mean that it looks unnatural or distorted for the first several weeks to a month?

Hi,
Believe it or not, I just spent 30 minutes typing your answer then my computer lost its connection. I just got off a 20 hour flight to Hong Kong where I am lecturing. In order to minimize this problem, I shall be typing parts of this answer then hitting the submit button.

Okay, here's your answer. You will look distorted your first week, guaranteed. Unfortunately, most people can only take about a week off from work so they will not be 100% when they return back. That being said, most people come up with 1 of 2 excuses: 1. I had something done (which may not be something you would want to disclose) or 2. I had some bad shellfish or had some allergic reaction (believe it or not, most people believe this since most people are not familiar with fat grafting as a procedure and since there are no incisions they can't figure out what you had done). A lot of that swelling comes down between your 7th and 10th postoperative day so I try to recommend my patients to do it on a Friday and have two flanking weekends if at all possible. That will usually make a big difference when you go back to work.

However, you are still not quite there at that point. Swelling lasts anywhere between 6 weeks to 3 months, but you really are "distorted" the first 1 to 2 weeks. If you look at my video recoveries they can provide a hint at what you look like at one week and two weeks. However, you will most likely be more critical of your face than other people are. As I say, the only thing that I can predict about human nature is that it is unpredictable. That is, sometimes people may still make a comment about the way you look after the second week. I can't promise that.

Most people really like it after the 3rd week but you still have some swelling (usually not noticed by others). Some even love it after their second week and then start to worry that they are in love with swelling, which is the case. Nevertheless, two things: you will still most likely look excellent even if you are in love with your 2 week swelling result. If not, you will still look fabulous and a touchup is very easy to do down the road.

Now the reason that I say that you will look incredible after 8 months is that you really will. There is something magical about the way you look after that period that makes you look even better. I like to use the word "blended" because it is the way that i feel about my results. Again, you look fantastic even after a couple of weeks time but I really like the way you look after a year or two.

I hope this answer helps you in understanding the process better. It is so hard to capture these ideas with words. If you come in for consultation, I can show you a lot of examples of 1 week, 1 month, 6 months, 1 year, 15 months results for example. Once you see these results visually, you will have a better grasp. The reason I can't show you all of these results on the web is due to patient privacy. Although as you can see, many of my patients have been very kind to allow me to use their photos.

Best,
SML