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Why is Fat Transfer a Low Rated Procedure on RealSelf?

Fat transfer or grafting has slid into one of the lowest rated plastic surgery procedures on RealSelf. Under 40% of consumers say fat transfer was "Worth it". Why is this the case?  Is there something wrong with the procedure, patient selection, doctor technique?

Doctor Answers (36)

Fat Grafting: the good, the bad and the ugly

+27
In recent years we have seen "too much of a good thing" when it comes to fat grafting results. if a person looks like they have had fat grafting, or fat injections, I believe that is not an ideal result.  I have included a link to my fat grafting before and after gallery to share some examples of fat grafting that looks natural, and is lasting. Obviously it appears as though there are as many opinions on fat grafting as there are plastic surgeons, and this must be profoundly confusing to prospective patients.  A number of physicians responding in this thread have made dogmatic statements about various procedures that may very well represent their own personal experience and preferences, but that do not necessarily provide interested laypersons with a balanced and accurate view of the options currently available for restoring facial soft tissue volume.
Te link at the bottom of this post will take you to a few examples of my fat grafting patients before and after surgery

I think that the primary reason that fat grafting is rated low in RealSelf is that there is such a wide range of techniques, instrumentation and experience among the surgeons that perform this surgical procedure.  Because of the tremendous variability in all of these factors, there is tremendous variability in fat grafting results.  To perform fat grafting successfully and reproducibly a surgeon must employ careful preoperative planning, appropriate instrumentation and meticulous surgical technique.  It is not something you can 'rush through' or spend just a few minutes on during a larger surgical procedure.  The unfortunate reality is that not everyone who performs fat grafting is willing to put in the level of education, training, investment in instrumentation and operative effort required to produce aesthetically ideal results.

One must also have an aesthetic vision for ideal and youthful-appearing facial fullness.   Just like traditional facelift surgery can be overdone or performed incorrectly to produce an unnaturally tight, pulled, 'windswept' look, fat grafting can be overdone to produce an excessively full and even bizarre postoperative appearance.  Too much fat grafted into any area (or any fat placed where it doesn't belong) looks unnatural.  It's analogous to breast augmentation results: if the surgeons selects an appropriate implant volume and positions the implants correctly, the patient gets a beautiful, natural-appearing breast enhancement.  If the surgeons stuffs a pair of 500cc implants behind the breasts of an average-sized patient, then that patient ends up with a cartoonish 'boob job'.  I think many of the unfavorable results in fat grafting are from the overzealous placement of excessive amounts of fat, which may have been the inevitable response to the recent paradigm shift in aesthetic facial surgery: away from the 'wind tunnel look', and towards the restoration of soft tissue volume.

Here is one patient’s experience with fat grafting posted to RealSelf:

Fat is great when used JUDICIOUSLY and CONSERVATIVELY, but too much of a good thing becomes a nightmare and deeply regrettable. Make sure your surgeon listens, draws up precise operative plans beforehand and makes plenty of time for you and your concerns. Do NOT take it lightly.

I couldn’t agree more with this patient’s response to her experience with fat grafting.  Just like breast implants, or liposuction, or browlifts, too much of a good thing is not at all a good thing.  And cosmetic surgery (and this includes the preparation for surgery) of any kind without attention to detail and a focus on natural-appearing results will leave patients feeling disappointed at best and feeling disfigured at worst.  Now regarding whether or not fat grafting is a surgically sound concept…

For transferred fat to truly qualify as a 'graft' the following must happen: living tissue must be transferred to a new location, and that tissue must gain a blood supply at the new location which provides oxygen and nutrients which allow it to persist indefinitely as living tissue.  We know that with appropriate instrumentation and technique this is achievable, so one of the opinions expressed in this thread that "most of the cells from fat injection are dead " is simply untrue (and structural fat grafting, to be clear, does not involve 'injection' of fat).  MRI studies have shown that with appropriate technique grafted fat persists long-term as living, vascularized tissue in the recipient site.

It is also well-established that adult human fatty tissue contains stem cells that have the capacity to repair damaged or injured tissues, and stem cells can be concentrated during the fat harvesting process.  This effect has applications in both cosmetic and reconstructive surgery.  Fat grafting is now being used, for example, as a means to stimulate the repair of chronic, non-healing wounds.  Several centers have reported on fat grafting immediately below non-healing chronic wounds resulting from radiation therapy for cancer, with rapid improvement and eventual healing of wounds for which no other wound treatment was successful.  The development of stem cell therapies involving the harvesting and processing of viable human fatty tissue is one of the hottest topics in both clinical and experimental medicine today.

When performed correctly fat grafting actually has the capacity to heal, revitalize and rejuvenate the local tissues at the recipient site.  I have treated a number of patients with facial fat atrophy following overly aggressive 'non-invasive' rejuvenation treatments including Thermage, Fraxel and IPL.  Most of these patients report not only an aesthetically  pleasing and permanent improvement in facial soft tissue volume, but also an improvement in the quality and vitality of their facial skin.

I perform extensive facial fat grafting during most of my facial rejuvenation procedures, and it is the very first thing I do - before making any incisions to lift the brows, eyelids, face or neck.  Fat grafting allows me to obtain results that are simply not possible with conventional, subtractive surgical techniques alone.  Patients frequently return for grafting of additional areas after their initial experience with strucutral fat grafting.  To characterize it as the pointless and potentially harmful placement of non-viable tissue is an opinion only, and it is an opinion with which quite a number of plastic surgeons who successfully rejuvenate faces (and breasts and bodies) with fat grafting would vehemently disagree, myself included.

Solid fat/fascia and fat dermis grafts are another means by which facial soft tissue volume may be significantly and permanently enhanced.  As with fat grafting, survival of the grafted tissue is variable and some of the graft material is reabsorbed.  As with fat grafting, potential complications such as infection and cyst formation are possible.  And as with fat grafting, appropriate preoperative planning and surgical technique are required in order to obtain ideal and lasting results.  In my opinion structural fat grafting is more versatile, as fat can be easily and rapidly added to any tissue plane (level); and it has the added benefit of the ‘stem cell effect’ which is difficult to quantify but unquestionably present in many cases.

Both structural fat grafting and fascia-fat (or dermis-fat) grafting can be competently performed (or not) by Board-certified plastic surgeons.  Neither should be trademarked or considered proprietary.
As with any surgical procedure take time researching your plastic surgeon. Schedule several consultation, view many photos from many patients, each from multiple perspectives (start by looking at photos on this website) and speak to former patients of any plastic surgeon you are considering.


Raleigh-Durham Plastic Surgeon
4.5 out of 5 stars 41 reviews

Dissatisfaction with fat injections

+23

At some point, we as plastic surgeons must be realistic. Patients are not, in large part, happy with fat injection results.

Why are they not happy with fat injection?

Fat injection grafts are aspirated through a syringe, centrifuged and then injected. Most of the cells from fat injection are dead when they are first injected into the patient. Study after study, using many different methods (metabolic and cellular) have confirmed this.

We all learned from our professors that graft survival depends on how alive the graft is going in. Why have we forgotten this fact? When we start out with viability rates as low as 5% by metabolic studies (25% in our studies), how do we expect more to survive?

Another tenet is that there needs to be enough surface area to allow the graft to get a new blood supply. We can't simply pack in a huge amount of fat injection and expect it to survive. Our professors would be horrified if we grafted a large piece of tissue with no blood supply onto an area without enough blood supply to sustain it. Why are we so surprised when the fat injection specimens don't survive?

Last, we are taught to remove dead tissue meticululously. The body fights against dead tissue with the defenses of the immune system. Yet we are injecting 75% dead tissue?

The reason survival of fat is so unpredictable is that you cannot tell which of the fat cells are alive and which are dead. This, I believe, accounts for the unevenness often seen with fat injections.

So when different groups of cells are analyzed under a microscope with various staining techniques, there are some areas where the viability is high (up to 50%), and other areas where is is almost zero, right next to each other.

Next, what happens to the combination of live cells, dead cells and free fat that is injected is also variable. Sometimes the fat (liquid dead fat) stays in bubbles and is walled off as fatty cysts. These fatty cysts can be broken by trauma, i.e. pressing on the area. At other times, there is an inflammatory reaction, eating away gradually at dead cells. This is called lobular panniculitis and is commonly seen in fat injection specimens.

We hear a recurrent theme, namely that fat injection is technique dependent. Do some doctors apparently have a monopoly on a vacuum system that sucks cells out of their living milieu without traumatizing them? Are they are so gentle at injecting that the basement membranes of these very delicate cells are not disrupted. The very delicate walls of the fat cells are completely undamaged when they are injected through a needle in some hands and not others?

I think not.

Not a day goes by when I do not see a patient who has had fat injection who is not happy with their result. The 3 main complaints: It didn't last. It is lumpy. It is uneven.

Grafts cannot be better than when they are placed. Therein lies the rub with fat injection, and all its common problems (inconstancy, variability, lack of permanence, firmness).

For the reasons above, we prefer completely untraumatized fat-fascial grafts for facial volume augmentation LiveFill(R).

Brent Moelleken, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 93 reviews

Why is fat transfer the lowest rated procedure on RealSelf?

+15

Great question! Let us begin with the understanding there are many factors that can effect the outcome of ANY surgery. In Fat grafting I will list, in no order, what are the reasons the risk/benefit ratios are SOOOOOO LOW!

1. The procedure is very surgeon dependent. The surgeon MUST have vast experience with Fat grafting. The best Plastic Surgeon doing fat grafting in the US is Dr S. Coleman of New York. After taking his courses and personal conversations with him, the one thing I find is 'take your time'. Over correct by 20%, because fat resorbs. Purify the fats an extra 20 minutes.

2. The nature of the fat also effects the results. I find hip or thigh fat better than abdominal fat to transfer. Maybe the more fibrous the fat the better the survival. Also better separation of 'PURE' fat to be injected also helps. Again more time.

3. Realistic Expectations of the patient and the surgeon can also be a reason of such a low approval rating. What is achieved may not be what is desired. That is way a more experienced surgeon may be a better choice, specifically, one who can say NO, I can not achieve what you want, That is EXPERIENCE or surgical maturity.

4. Medical conditions can cause a poor result. Like Hyperthyroidism, Hyper metabolic states, poor immune conditions. Just to name a few.

5. Poor informed consent. I usually tell my patients Fat grafting is a multiple procedural event. Usually more than one operation, if there is enough donor fat to be harvested. Many doctors think Fat grafting is a one time operative event. NOT TRUE!

Well, I hope I have explained why the response rates are so low.

Best of Luck!

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.5 out of 5 stars 62 reviews

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It is actually 79% but I think the numbers may be somewhat misleading

+8

If you go to the Brazilian Butt Lift Questions. There is usually a picture on the right hand side that asks "Was It Worth It?" The percentage for this procedure is actually 79%

I think part of the problem is that on the ranking system list, it doesn't specify Brazilian Buttocks Lift, it only lists Fat transfer. Fat Transfer can include any other body part that the fat is transferred to, such as the face or breast.

I have performed hundreds of Brazilian Buttocks Augmentations and have never had a single patient come back unhappy. There have been a few that said (at a 6 months or a year post op) that they were very happy, but wished their buttocks was as full as it was when they woke up from surgery. But, I have never had anyone lose all of their fat or complain that they were unhappy.

I think this is a great procedure when well done. But it is somewhat unpredictable. I think that some of the unpredictability has to do with the technique used by the surgeon and some has to do with what patients do after surgery while recovering. Everything has to be optimal to get great results.

Daniel P. Markmann, MD
Baltimore Plastic Surgeon
5.0 out of 5 stars 69 reviews

Many reasons for dissatisfaction with fat transer

+7

I think that fat transfer is a great procedure - when done in an appropriate area, by an experienced physician, with appropriate patient expectations. After looking at the reviews a few problems struck me as being common to many of them.

First, there did not appear to be appropriate patient expectations. While fat is a permanent solution for facial fillers, it can take several applications to obtain the desired results. An excellent article in the Archives of Facial Plastic Surgery from January 2009 indicated that at 18 months, on average 30% of injected fat remained in the midface. Unfortunately the range of amount remaining was from almost 0% to over 90%. The broad range speaks to the variability in results.

Second, several of the responders were unhappy with the immediate postoperative results. When compared to temporary injectables, fat seems to have more swelling, more bruising, and a longer recovery time. I advise patients that bruises after fat augmentation may last for a month or more.

Third, some of the injections were performed for reconstructive purposes. Unfortunately, any procedure performed in a revision circumstance or after trauma will not produce completely predictable results. For cosmetic purposes, I prefer to use fat in the lips, cheeks, tear trough area, and in the prejowl sulcus.

Last, some patients are unhappy with lumpiness of the injections. Unfortunately this is a risk with any injectable substance (fat or temporary fillers). Newer techniques of harvesting, centrifuging the fat before injection, and smaller injection canulas have helped to decrease the risk of lumpiness.

While fat transfer may not be for everyone, a well performed procedure can produce excellent results. Patients must understand though that the recovery will be longer than that experienced with dermal fillers and it may take several injections spaced over time to obtain optimal results.

D.J. Verret, MD
Dallas Facial Plastic Surgeon
4.0 out of 5 stars 12 reviews

Fat transfer works!

+5

One of the interesting things you see is that procedures will be very popular on RealSelf and then they will begin to drop off the charts.  I think this is sometimes related to the fact that when procedures first come out they are performed by people well qualified to do them.

Once a procedure has shown some popularity all kinds of doctors (some with little or no training) will begin to offer those procedures as they try to cash in on the profits.  This is when people begin having lower satisfaction rates.

I think that it definitely has to do with patient selection - part of good training is who to perform a procedure on (this isn't the kind of training you get in a weekend course, but after years of training)

I think it also has to do with technique -- some physicians get good results because they do it well, and others don't get good results because they don't do it well.

Richard H. Fryer, MD
Salt Lake City Plastic Surgeon
5.0 out of 5 stars 82 reviews

Why is fat transfer rated low on RealSelf?

+5

Hi there,

While it is not possible for me to say exactly why those who were unhappy after their fat transfer procedures were displeased, I can give you a few general thoughts...

Fat transfer procedures are probably among the most technique dependent procedures in plastic surgery right now. Everything from the way the fat is harvested, to the way it is processed, to how it is grafted into its new location seems to affect the chances of success. There also seems to be some variability in the success of the grafts between procedures, meaning that fat grafting is more successful for some procedures than for others.

The best advice I can give you is to find a surgeon who has a lot of experience performing fat grafting procedures. Ask to see photos of other patients who have had a similar procedure, and maybe even to speak to them, There are surgeons who reliably achieve excellent outcomes with these techniques, so in the right hands the procedure does work. But you need to do your homework!

Armando Soto, MD, FACS
Orlando Plastic Surgeon
5.0 out of 5 stars 102 reviews

Fat transfer is a process, not a single procedure.

+4

I think fat transfer is low rated because patients do not understand that it is not a single operation but is rather an ongoing process of possible several to many operations.  Fat is a weak flimsy tissue and 50% of the time does not survive the transfer process.  Yes, 50%.  Hopefully this is explained to patients because a lack of understanding this could lead to unhappiness.   I have done over a thousand fat transfer operations and doctor and patient must be happy with 50%.  Like any filler, fat is lost, but the good news is 50% survives.   Then another fat transfer procedure is needed and then possibly another.   We must all understand fat transfer is an on going process.  Even a year or two or five later more fat may be needed from time to time.   Look at the bright side.  All the other fillers disappear 100%.   I strongly suspect that the disappointment is a result of a breakdown in communication between the patient and the doctor.   Fat transfer is a fine procedure but it is what it is and nothing more.  Remember,  50% I think a fair statement is that 99% of fat transfer patients need 2nd, 3rd, and 4th procedures or more.   Not understanding this is the cause of the LOW RATING for a quite reasonable procedure .   Best,    Dr Commons

George Commons, MD
Palo Alto Plastic Surgeon
5.0 out of 5 stars 26 reviews

Naturalfill fat transfer

+4

It is not surprising at all that fat transfer is the lowest rated procedure on this forum. Fat transfer has been a procedure attempted for over 130 years, with the first reported transfer in 1890. After reviewing the literature which encompasses hundreds of studies on fat transfer, the conclusion that can be generally drawn is that fat transfer is a procedure that is widely unpredictable. The reason behind this is that surgeons need to perform liposuction to remove the fat, and with the aggressive nature of liposuction procedures, the majority of the fat is damaged in the removal process. Add to this that doctors are 'processing' the fat to remove the blood, etc... with centrifuges, and the fat becomes even less viable or 'alive.'

This has all changed recently with the invention of the aqualipo procedure, or water-assisted liposuction, where fat is gently 'washed' from the body, thus preserving its integrity and giving a much more viable product. This has been scientifically proven to have a 90% viability, which is markedly better than the 30-70% viability of any other type of fat removal before it. I just recently had the honor to demonstare this procedure on Dr. Oz's show, with a procedure we call Naturalfill, or fat transfer with fat that has been gently washed from a patient with aqualipo. With this newer, better fat, we have been able to show predictable, reproducible, long-term results, and now Naturalfill has garnished a re-birth in the fat transfer procedure. I would assume as time goes on and more doctors accept the better quality fat that the above-named procedures yield, the ratings of our patients will dramtically increase.

Roger Bassin, MD
Orlando Oculoplastic Surgeon
5.0 out of 5 stars 61 reviews

Fat grafting and satisfaction rates

+4
As we understand more about facial balance and importance of  adding more volume to the face during facelift procedures, we realize that we do not have a perfect filling material. We can use one of the available hyaluronic acid fillers, like Juvederm or Restylane, however, they do not last for a long time, especially in deeper layers.  Also they can be quite expensive. The is an ideal filling agents, however, problem with fat is that the survivability is not very predictable. There are varieties of techniques described for fat grafting. Plastic surgeons used various sizes of harvesting cannulas, different sizes of injectable cannulas, different ways of dealing with fat, including spinning it, not spinning it, filtering it, not filtering it, washing it, not washing it, straining it, mixing it with growth factors, using hyperbaric oxygen therapy treatments and many others. Unfortunately, there is no universally reliable technique that allows 100% liability of fat transplant.  The success appears to be very much technique and operator dependent.  In our office, we inform the patient's that results could be somewhat unpredictable and that they may require additional fat grafting sessions. The satisfaction rate is not very high in patients who have only one session of fat grafting. After several sessions, as the patient gradually gets improvement of the facial shape, the satisfaction rate also improves. I still think that the fat grafting is a good technique, however, at least in my hands, it may require more than one session.  Because in our office we also have on-site hyperbaric oxygen therapy treatment center, we are able to offer our patients hyperbaric treatments before and after fat grafting procedures. I believe, with hyperbaric oxygen therapy treatments, the survivability transplanted fat is better and currently we are looking at satisfaction rates between the patient's who have had hyperbaric treatments and who have not.  It is too early to say how much improvement in patient satisfaction rates can be achieved by utilizing hyperbaric oxygen, but for now it looks promising. Sincerely, Boris Volshteyn M.D., M.S.

Boris Volshteyn, MD, MS
East Brunswick Plastic Surgeon
4.0 out of 5 stars 8 reviews

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