There’s the autologous filler — fat — and then there’s an array of other injectable fillers that each have their own strengths and weaknesses. Val Lambros, M.D., of Newport Beach, Calif., and J. William Little, M.D., clinical professor of plastic surgery, Georgetown University School of Medicine, Washington, recently faced off on this question at the annual meeting of the American Society of Aesthetic and Plastic Surgeons.
VAL LAMBROS, M.D.: “In the right hands, volume can be a valuable component of making an older face look better. As certain faces age, they get thinner, and we can make these faces look better by putting something in rather than taking something out. The question is, what kind of ‘tool’ should we use to accomplish this? I do some fat injections in nearly everyone for whom I do a facelift. Fat has advantages, and so do off-the-shelf fillers. Unfortunately, outlandish claims are being made about fat grafting’s efficacy with no evidence to support those claims. Consequently, the use of fat is garnering a fair amount of enthusiasm without users fully understanding some issues surrounding it.
“For instance, injected fat can grow. This will be the greatest long-term problem with fat. I have seen increasing numbers of people who have gained weight after their fat injections: Their faces are growing and it doesn’t look good. What’s more, fat is difficult to remove. You can remove it from certain areas, but if, for instance, someone’s entire cheek has been filled with fat, you just can’t get it all out. I think that, in the future, we are going to see a wave of people who can be identified as those who have had overzealous facial fat grafts. Just like you can tell a ’60s rhinoplasty or an ’80s facelift, you’ll be able to identify people who have had fat grafts that continued to grow because their faces will look like balloons.
“Another issue with the fat is that it’s not reliable. In older people, it tends not to work very well; in younger people, it works better. It’s a perfect example of the catch-22 of facial plastic surgery — the more you need it, the less well it works. Also, the grafts don’t always ‘take,’ so you can do one side of the face and get a beautiful result, while the other side gets nothing. If you are going to rely on injected fat, you have to be fond of ambiguity or at least be able to tolerate it. With fat, touch-up procedures are often necessary.
“Another issue surrounding the use of injected fat is that it takes a great deal of finesse, and physicians tend not to have highly developed aesthetic sensibilities. Oftentimes, patients think bigger is better and they say, for instance, that they want big, full lips. At least with a filler such as Restylane (hyaluronic acid/HA, Medicis), if they decide that they’re not happy with that look after a period of time, it’s easy to remove the product. That’s not the case with fat, especially with respect to lips, where it is particularly difficult to remove it.
“Telling patients that fat grafting will give them a young-looking face that is smooth, round, full and wrinkle-free is only partially true, because if your ‘tool’ gives them a smooth, round and wrinkle-free look by ballooning the face up, you have removed all the definition and delicacy of the face and can’t go back.
“Unfortunately, many newbies are beginning to do more and more fat grafting in the face, and complications can occur. The most common complications of fat grafting happen when it is used in the lower lids. Fat takes here very efficiently and can make lumps in this very noticeable location. Fat in the lower lids is a difficult problem and best avoided. Even experts get problems and irregularities. Here I prefer to use an off-the-shelf filler around the eyes because the eyes are a very emotive area; people spend a lot of time looking at a person’s eyes. If you make a mistake in that area, you want to be able to modify it, and that’s not necessarily possible with fat. Also, I get smoother results around the eyes with things like Restylane and Juvéderm (HA, Allergan). Around the eyes, temples and nose, hyaluronic acid fillers last up to three years, making them a cost-effective — as well as predictable — treatment.
“I don’t tell the face what to do, the face tells me. If the face needs some volume for proportion or to get rid of some hollows, then I do what needs to be done. Typically, at the time of surgery, I’ll do that with fat grafting. Sometimes, I can do it just as well with an off-the-shelf filler. Surgeons often get used to certain tools and will only use them, but I think it’s better to maintain a degree of flexibility. If you can do something a number of different ways, you can provide better treatment. I think the best tool varies with the patient’s face, not with what we like to use, and ultimately while a surgeon can have their favorites, it is counterproductive to be doctrinaire about it.”
J. WILLIAM LITTLE, M.D.: “Structural fat grafting is widely considered the most important advance in facial aesthetic surgery of the past two decades. A growing body of experts worldwide holds that fat grafting brings enhancements to facial rejuvenation that were not previously possible.
“Successful fat grafting, however, is highly technique-dependent and imposes a significant learning curve. Casual efforts have created untoward results, most notoriously a lack of graft ‘take’ or — worse — uneven take with lumps and irregularities that have then been difficult to correct, especially in the unforgiving environment and thin soft-tissue overlay of the suborbital zone. A reduction in cannula size (for both harvest and deposit) has reduced complications and contributed to a resurgence of fat grafting (even with easy-to-use fillers widely available).
“A remaining problem concerns over-grafting, a condition Dr. Lambros has documented and chronicled (the history of our specialty is replete with examples of the enthusiastic over-application of new technologies and treatments). Heavier fat deposits placed in the unsupported midcheek and along the jawline are themselves prone to premature descent and aging, as they may elsewhere bring a leaden quality to the animated face, especially to the smile component at the lateral canthus and to the smile itself (blocked by over-grafting of the pyriform, nasolabial, and upper lip).
“A key preventive of over-grafting comes with limiting the use of fat (or any volume source) for the camouflage of descended facial soft tissues; a more effective (if less convenient) strategy remains the surgical resuspension of these, reserving fat addition specifically to sites of atrophy and attrition. Thus, while I routinely add significant fat to the expressive features of the eyes and mouth (specifically the lower lip, the upper orbital space, and especially the lower suborbital zone), I do so more sparingly to the face itself, at least in typical aging.
“For example, I add fat in moderation (3 cc to 6 cc) to the malar cheek in only 25 percent of my facelifts; to the submalar cheek in almost none (my subcutaneous jowl suspension typically restores volume here); to the jawline occasionally; most often to the chin, often in lieu of an implant; uncommonly to the angle; and almost never to the prejowl sulcus, where effective resuspension of the jowl presents the more youthful and delicate alternative. There remain exceptions to this more typical facial-aging pattern, however, wherein pan facial atrophy accompanies facial descent … most often, but not always, in the elderly. Here, a broader and more liberal application of fat grafting during facelift may bring a transformational result.
“Briefly, the advantages of autologous fat over nonautologous fillers include its prolonged survival, likely a decade-and-a-half or more in practiced hands; its autologous nature (eliminating potential immune reaction); its structural aspects, bringing living integration and support to recipient soft-tissue systems that, in turn, allow broad architectural change; its byproduct enhancements to overlying skin quality through mesenchymal stem cell activity (such as global warming, widely suspected but not universally accepted); and its wide and inexpensive availability. Its relative disadvantages include its requirement for donor harvest and preparation, its technical challenge and associated learning curve, its prolonged survival when irregularities are created (coupled with the absence of simple enzymatic remedies, as exist with HA fillers), and its lesser overall convenience for patient and physician alike.
“Among plastic surgeons who have invested the time and commitment to master the clinical art of structural fat grafting — most at a time when fillers were not yet widely available — almost none, to my knowledge, have later evolved as enthusiastic proponents of the newer materials, with the notable exception of Dr. Lambros. Are there applications where fillers could be preferable to fat? For me there certainly are, such as the younger patient with a focal concern about her emerging marker for facial descent (early nasolabial crease). Here, I would prefer a superficial filler to fat, and would likely continue to do so until progressive aging and descent justified a surgical intervention and resuspension (probably years later). But for the fundamental volume attrition that has exposed a deep tear trough with overlying fat bag, my choice would remain resoundingly fat.
“Overall, I find living fat cells and inert filler materials too fundamentally different, on multiple levels, to be considered ‘alternatives’ in a simplistic fashion. Instead, I applaud the use of each and find it fortunate that the specialty has both at its ready disposal.”
Drs. Lambros and Little report no relevant financial interests.