Fat Transfer - 10 Months out - New York, NY

My results are mixed, but keep in mind I am very,...

My results are mixed, but keep in mind I am very, very picky. When I look around here I have to say that I faired very well, which makes me sad to say because I really feel terrible about others who now don't want to show their face.

I had fat transfer done ~10 months ago. Age/sex is late 20-something year old male. I mainly wanted to restore the 'baby fat' of my mid face, as well as make my under-eye area look rested, full, and healthy. I had a good face to start with, one that people would guess as being early 20s, but I myself could see changes I wasn't comfortable with. Mainly that if I was at my target weight then my mid face looked too thin, and if I was at a higher weight then my jaw/neck looked too undefined. I needed a method of selective volume.

I found a surgeon in NYC after much research and I liked his method. Many doctors say that proprietary methods are silly and never better, but I liked his, it was elegant, based on real R&D, and was designed to require nearly no over-filling, due to a higher predicted survival rate. For me the procedure and recovery were a walk in the park.. within 3 days I looked normal enough to be out and about, no one seemed to notice, not even people who knew me. I think it helps when you are younger, because the added volume doesn't look to striking, it blends in better because I had more to start with. I looked maybe a little odd, swelling caused a complete absence of nasal labialfolds for example, and my cheeks/under eye area looked tightly full.. Otherwise I managed to escape most all bruising, I'll never know if it was the Arnicare they had me take orally 3 days before and a week after, plus using it topically.. but in any case I faired very well. For those first three days I did almost nothing but rest, keeping ice packs sometimes gently on my face where it felt the most tight. I drank a lot of water, and was good about the anti-biotics they had me get. (getting those 3 hours after the procedure was really the most hard/embarrassing part of the whole thing!)

For awhile I was very pleased. He put the fat just where it needed the volume (he had a younger picture of me for reference) and his own work was as good as a doctor can do really, or so I feel.

At 3 weeks out I looked best, swelling was gone, and I looked like I was 16 years old. After that it starts to get disconcerting, as if it wasn't so enough after a sharp change in looking better, which is not natural to this level, you now get to see it continue to change in a direction that is less pleasing for 3 - 6 months.. Every day I'd look in the mirror first thing, trying to gauge the changes, if any.. it isn't a healthy thing I know, but I was a little paranoid since I knew to expect some to go away, yet no idea how much would. 3 months out it was clearly still of help, but had decreased a bit in areas. During this time I had also noticed that under my left eye there was one hard cyst, you could feel but not see it. Under the right-eye, where my cheek bone was lower (asymmetrical to my left-side) and had been built up a bit with more fat, I could feel 3 hard, small cysts, again not visible. (All around the size of a small to medium caper.) In all cases they are right along the very rim of the sub-orbital bone. They are beyond where he put any fat, which means they are really bits that made it past his attempted boundary, or they merely migrated. The body, especially under the eye, will sometimes deal with these by encapsulating them, thereby becoming a harder scar tissue. This bothered me of course, but I knew there was hope of them going away, I read that you can sometimes crush them too. I managed to succeed at this with the single one under the left eye, and it became nearly undetectable. If I really hunt for it I can feel something very flat but firmer, sitting on the bone..

8- months out, I've had my ups and downs, days where I was down and felt like a bit too much of the fat had gone away, but I also had to remind myself that I've gotten used to my fuller face, that my standard has changed and that it is hard to remember exactly what volume had been like pre-op in each area. Pictures are difficult, I think it is why many don't post pictures here for this. The reason is you can, with zero changes to your face, in the same 5min span, take pictures that make you look wonderful, and others that look terrible, without changing lighting or anything more than changing your mental attitude, and the angle of your face to the light and the camera.. it is all very subjective and extremely hard to make fair comparisons unless in a very scientific controlled manner take proper before pictures, and do the same for after.. Even doctors fail at this often though, I've seen many where the lighting and other aspects had changed. I myself have not posted pictures because I won't risk people I know finding them, I am prominent enough that it is a risk.

I think the worse part from 6-months on is that I started to know that now as I see the final result and have mapped it all out in my head, that I can see how it could use a touch-up here or there. Things others do not likely see, but I do. The fat survival was not completely even, a couple of the cysts can slightly be seen, not by height, rather by it appearing somewhat more white in those spots. This is due to having more buffer between the skin and the muscle.

I think overall it looks good, and the few people I told are the ones I know would tell me if it looked worse now. They genuinely can say that I do not look worse in any way, and believe that I look a bit better, but that it is subtle to them.

My fears now are long term, due to things I have read, I am wondering if this fat could behave in a strange manner as I get older and lose fat in my face.. The doctor claims it is no different than any other fat in the face, but I am not convinced. For example, if someone is doing a graft to compensate for a malar fat pad (either due to atrophy or position) then how can it be expected that micro-pearls of fat are going to act normally with muscle movement as an original fat pad, which is solid and attached with ligaments and such? It seems logical that the behavior would be very different. I think using fat grafts for certain areas, when well thought in a way that it won't bunch up or interfere with muscle moment, or cause the skin to have an 'Orange-peel' texture is OK. But I don't see how it could behave and compliment the major fat pads in a natural way.. I wish I could get a doctor to talk with me about things like this, but they never seem to have interest in talking to a patient about the really granular details and hard to answer questions.

Final thoughts:

There is no doubt, after all my research that fat transfer is unpredictable. It is the nature of it, I can't say still if it should be reserved for those who need it most, or not done at all until it can be improved.. Partly because sometimes the ones who need it most are the ones who it is least likely to take well, and blend in with existing soft tissues to look natural.. In theory It is a fantastic answer to volume replacement, my main reason I did it was because synthetics of all kinds, any of the typical 6-month fillers were just not at all appealing. The cost in the long run with those is incredible for the amount of volume you get, especially in the US, and they don't feel natural under the skin. In the end I still don't hate or love it, I think it, like most medical practice is still very crude, despite how intelligent and technical the science of it seems, the actual work is a gamble every time. It is not possible, no matter how skilled, for any surgeon to predict what your body will do with a graft like this. There are too many variables, there are different types of fat, there are different degrees of bleeding and other fluids between people that will mix with it, and so on.

Feel free to ask me questions. I will ignore the really bitter people who seem to get mad at anyone who didn't have a terrible experience.. I understand that you are upset, but you have to realize, even though it makes it harder for you to bear that something that ruined your face can in fact work wonderfully on someone else.

2.5 years out

Quick update: It is very hard for me judge if this was a good or bad choice, which means the risks are not likely worth it. I would say that I have some improvement in the way I was looking for, but it also changed my look as over time it has become a bit fuller in parts, causing an imbalance and my face to be a bit too rounded. This is despite keeping a low weight/BMI. I think fat grafting for this reason is risky in young patients now, because it isn't adaptable as the face ages, and the live graft has the risk of changing in volume. I also have to wonder if the extra weight of the fat will increase the rate of ptosis with age.

It is a tough problem indeed, mostly due to the cost of fillers, and repeated risks since you have to do them over and over. But if not for those factors I would say stick to HA fillers if you can afford it, with a great injector who above all else has an eye for art and beauty and understands the WHOLE face. Don't get hung up on any specific part of the face, address everything a little bit, not acute fixes.
New York Plastic Surgeon

See the experience section. I believe he is a very good and skilled doctor. He is trying to be the best he can be at what he does. He also personally answers my emails most of the time, but he is busy and I have burdened him with many questions, so I understand that he doesn't always get back to me.

5 out of 5 stars Overall rating
4 out of 5 stars Doctor's bedside manner
4 out of 5 stars Answered my questions
3 out of 5 stars After care follow-up
4 out of 5 stars Time spent with me
4 out of 5 stars Phone or email responsiveness
5 out of 5 stars Staff professionalism & courtesy
5 out of 5 stars Payment process
5 out of 5 stars Wait times
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Hi, thanks so much for your review. I was wondering, in your experience, if you think this procedure would be a good one to fill hollows under my eyes and did you like your doctor?
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Thank you so much for your review. I rarely leave comments, but when I read this it was like reading my own mind. We have the exact same logic and thought process. You addressed all the questions and concerns I had in a way that made perfect sense and has been incredibly helpful. Hope to hear more updates on how your results turned out in the long run.
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Thank you so VERY much for your intelligent, well-worded, and thorough review. You posed some of the very questions and considerations that i think a TON of patients have, and I agree that it is nearly impossible if not entirely to find a doctor who will help answer such questions. Isn't that odd? You would think doctors would want to answer them, if only for their own research! You will definitely remain in my memory as someone whose review I would return to, to explain how a person feels and thinks after a surgery -- even a "good" one. Take care, and thank you again!
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Another thing, did the fat transfer restore the look of having "baby fat"? I lost mine completely to thermage, and want to get it back but have noticed that older women with fatter faces don't have that soft "baby fat" look anymore. Thanks!
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Hi Juliabars, Does thermage really help to get rid of fat graft? How strong that would need and approximately how many time of thermage u have undergone to achieve that? Appreciate your response...
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Hey Fox_M, I have another question: Where did you get your fat drawn from? I often wonder if the bad results in some fat transfer patients is a result of where they had their fat withdrawn, as recent studies have indicated that the lower body (thighs, flanks) fat behaves differently than abdominal subcutaneous fat does (lower body multiplies with weight gain, ab fat cells swell). Also, how are the results 1 year out? And what's your opinion on why some fat transfers go horribly wrong?
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good review. thank you!
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I already had very good skin and in my case the evidence showed that nothing more than the volume itself improved the skin. The skin did not seem to improve in any other way, I am not convinced about the stem-cell theory. Perhaps in older patients there could be other results. I also found that one small drawback is it made my pores more visible. On the other hand the overall texture always looks nicer on skin that is more taut.
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Hi Fox M, thanks a lot for your sharing, i am exactly one year away from my surgery and i totally agree that the fluctuating result and unpredictability of fat graft can be depressing sometimes, i used not to have worried about a swollen face in the morning becox i got really sharp contour but now this issue bothers me everyday the first thing i wake up. I wonder how it looks for you now? i especially hate those fat between my nose cheek under my eyes which is way too much and well settled... that it actually flatten out my face. hope to hear from you soon,
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Have you seen improvement in your skin as in texture and tone?


Good review. Please keep us updated!!

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For for my typos. The line "As far as people who strictly" meant to be "As far as people who strictly have atrophy"

A couple more notes, doing fat transfer in phases is a good thing if you can deal with going through the sessions several times. Also learning to sleep on your back after for 3 months or so, and to not put pressure on your face is very good.
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Hi Juliabars,

I'm not a doctor but it my observation and often seen that the younger you are the more forgiving and better healing the body is to trauma and possibly faster at giving the fat a blood supply and fighting chance. . The other part was to do with existing structure, position and amount of soft tissue. This varies greatly from person to person but basically if someone has little soft tissue to blend with, and/or its position and shape have changed a lot with age, or if they have have weak structure, then the fat graft will have to be compensating for more than just atrophy, may not look as natural if done to try so.

It is important that the injector doesn't try to go too far to compensate for other factors of aging by using volume. The result may arguably still be an improvement when strictly focusing on that zone and comparing what we consciously associate with aging, but overall it won't quite look right. A young face has a combination of soft transitioning contours but also curves that are defined and structural that will be lost and overly rounded off if a lot of fat is placed there. There is such a thing as 'structural fat grafting', that usually uses non-lipocytes, but I don't know a lot about it. They take other types of tissues like fascia from the body to use, but I would be worried because it isn't performed by many and so less is known.

As far as people who strictly, I cannot say. I've read things that make it sound as though they have a propensity for the body to just absorb much of what is injected. Plus because of the amount they may need it usually needs to be done in phases to achieve the most predictable and even outcome.

But what I have in mind for someone who has lost a lot of fat may not be your case at all. I can say that the under-eye area benefits in a dramatic way from fat transfer, yet is also the most risky! There is no doubt that adding lost volume there will make lax skin feel and look tighter if the fat lasts. It will look lifted and closer to where is once was, and you will look more rested even when feeling tired, and it masks dark circles. (Has to do with angle and how light hits it. The actual dark circles are where no fat should ever be injected, rather it is injected just up to where the skin changes type, near the suborbital rim.) It can be dramatic there, but again it is also where nearly everyone seems to get cysts. So beware and consider carefully. These things are always getting better so wait as long as you can stand.
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Thank you for your reply. Firstly, you obviously have researched this well prior to making your decision - what was your method of researching and you have any recommendations for primary or secondary research sources? I find it to be quite difficult to find trustworthy sources on the Internet and most most surgeons I've spoken with rarely go into depth about risks and potential long-term side effects. With regards to the comment about not injecting in the tear trough, could you elaborate on why you've found it to be a bad decision? The fillers and fat transfers I've seen injected there seem excellent and rejuvenating in comparison. I have been considering doing fillers under the eyes, and maybe even elsewhere, because it is temporary and thus can act as a preview for fat transfers. But I'd like to do more research before I follow through.
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Thank you for the thorough, well-said, and well-researched review. Perhaps one of the best reviews on fat transfer I've read thus far. I'm in my mid-20's and have been considering a fat transfer after fat atrophy that resulted from a radio frequency facial.  I know you mentioned you had young looking skin already, but did you notice any lifting of your face after the fat transfer? It seems that with my face, due to the fat atrophy, I have a bit of sagging in the transition between my lower eye lids and my cheeks, which I would hopefully be able to correct simply through regaining the fat in my cheeks. Another thing, you mentioned fat atrophy victims logically wouldn't take well, would you mind elaborating? And your theory on those who need it most? Again, well thought-out and we appreciate your review! Thank you very much. 

- Julia
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