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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?

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Fat Grafting: the good, the bad and the ugly - Look at LOTS of Photos

Please see a link to my fat grafting before and after gallery below. Without photographic evidence, information about fat grafting doesn't mean much

There are three common complaints voiced by fat grafting patients who are dissatisfied with the outcome of their surgery:
1. The fat did not last and I don’t see any difference
2. Too much fat was placed and I look unnaturally full
3. The fat-grafted areas look lumpy and irregular in contour

All of these undesirable outcomes are avoidable. If you are considering fat grafting surgery and think you may have found the right physician for you, before you go any further you need to review as many photographic examples of that physician’s work as possible. A doctor can make a multitude of claims about their training and experience on their website and in online forums, but the one thing that really matters to you as the consumer of these services is an objective demonstration of your surgeon’s skills.

Look at photographic examples of the doctor’s work and decide if the aesthetic ideal is consistent with your own. Make sure that the ‘before’ and the ‘after’ images have the same perspective, the same lighting, and the same amount of make-up applied. ‘Before’ photos taken in the early morning (and without any makeup applied) placed next to ‘after’ photos taken later in the day and in full makeup are meaningless for the evaluation of a surgical result.

If you are looking for a natural-appearing enhancement, and what you see is a series of over-filled faces, or faces with irregular soft tissue contours, or perhaps there just aren’t many photos to evaluate, then you need to keep searching.

1. THE FAT DID NOT LAST AND I DON’T SEE ANY DIFFERENCE:

Achieving survival of grafted fat requires appropriate instrumentation, meticulous surgical technique, and a willingness on the part of the surgeon to put a significant amount of time and effort into mastering the procedure. The fat must be harvested in a manner which ensures fat viability, and it must be grafted in a manner that permits revascularization (i.e. blood supply) of the grafted tissue.
Areas that already have some soft tissue fullness, such as the cheeks, are relatively easy to expand with grafted fat, as a robust ‘scaffolding’ exists to hold the grafted fat. Thinner areas are more challenging: the temples, the lower lid / cheek junction, the nasal dorsum; these areas frequently require more than one fat grafting procedure to achieve the desired degree of volume enhancement. One can only add but so much fat in a single treatment when the ‘scaffolding’ is limited.
There really are no ‘shortcuts’ that a surgeon can take when performing fat grafting surgery. Every step in the process must be performed with great attention to detail. Make sure that the surgeon you choose provides some description of their fat grafting technique, provides some indication of their level of experience with fat grafting, and demonstrates to you a high level of success in terms of fat survival and natural-appearing results as represented by ‘before and after’ photography.

2. TOO MUCH FAT WAS PLACED AND I LOOK UNNATURAL:

This is probably the most common complaint that is voiced online, and ironically it is perhaps the most easily avoidable problem. Just as breast implants can be used to create both natural breast profiles and excessively large / obviously fake breast profiles, so can fat be used to create natural-appearing and quite unnatural-appearing facial contours.

An unavoidable reality of fat grafting is that the degree of fat survival cannot be completely predicted nor can it be guaranteed. Fat survival will vary somewhat from patient to patient and from procedure to procedure. My impression is that many surgeons ‘manage’ this issue by overdoing it when they perform fat grafting surgeries, assuming that a significant amount of the grafted fat will not survive. This leaves patients vulnerable to an unnatural, over-grafted appearance if fat survival is greater than the surgeon expects.

Excessively full cheek volume is currently seen quite a bit in the media, and it is probably a consequence, at least in part, of the widespread popularity of temporary soft-tissue fillers such as Juvederm and Restylane. Full cheeks are fine, to a point, but if overdone it can produce an extremely odd and unnatural appearance. It appears particularly unnatural on animation, as when the cheek volume increases with a full smile. Look carefully for excessively full cheeks in your surgeon’s ‘before and after’ photos, as the fullness you’ll get from fat grafting surgery is not temporary.

My approach is to graft fat to the point that the soft tissue contour is, in my opinion, aesthetically ideal but still quite natural-appearing. This eliminates any concern of an ‘over-grafted’ and unnatural appearance. In my practice we offer secondary fat grafting for areas that I have previously treated at a significantly discounted cost from the initial procedure. That allows patients to go into their surgery with confidence that (1) they will not have unnatural appearance after recovery from surgery and (2) any areas that require additional volume enhancement can be treated at a very reasonable cost. Areas which have thinner soft tissue thickness preoperatively - such as the lower-lid cheek junction - are the areas that are most likely to require secondary (and occasionally tertiary) fat grafting procedures.

3. THE FAT-GRAFTED AREAS LOOK LUMPY AND IRREGULAR:

This unfortunate outcome is most likely to occur, as you might expect, in areas where the skin and soft tissue coverage is the thinnest, such as the lower lid / cheek junction, and in areas where fat often must be placed superficially as well as deep, such as in the vermillion (red part) of the upper and lower lips.

Avoiding ‘lumps and bumps’ involves attention to detail in every part of the process: harvesting with cannulas that produce small fat globule size for grafting, meticulous placement of fat using very small grafting cannulas (internal diameter of 0.7 to 0.9 mm), and avoiding superficial placement of grafted fat in areas where the soft tissue coverage (skin and subcutaneous fat) is excessively thin.

Experienced fat grafting surgeons should rarely, if ever, face the situation of needing to remove grafted fat from a patient who perceives that their postoperative volume enhancement is excessive. If absolutely necessary, fat can be removed from over-grafted areas (by means of aspiration with fat grafting cannulas that have larger internal diameters) where the soft tissues are relatively thick, such as in the cheeks. Thin areas such as the lower lid / cheek junction, on the other hand, are not amenable to fat removal by aspiration, so treatment of over-grafting in these areas is extremely challenging.

The best means of ‘treatment’ for lumps and bumps, by far, is avoiding it in the first place.


Raleigh-Durham Plastic Surgeon
4.5 out of 5 stars 48 reviews

Dissatisfaction with fat injections

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 103 reviews

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Why is fat transfer the lowest rated procedure on RealSelf?

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!

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

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.

Many reasons for dissatisfaction with fat transer

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 13 reviews

Fat transfer works!

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 121 reviews

Why is fat transfer rated low on RealSelf?

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!

Fat transfer is a process, not a single procedure.

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

Fat grafting and satisfaction rates

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 9 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.