In the quest for facial volumization, dermal fillers have long been the gold standard, the first tool in a doctor’s arsenal to add back lost volume and restore youthful contours. But they’re not the only option. Injectable fat transfer offers an alternative, a treatment that’s slightly more involved (given the fat harvesting required), though it offers more longevity. And in a world where filler fatigue is a very real thing, fat transfer continues to grow in popularity.
But doctors have lots to say about the differences between fillers and fat transfer, with many expressing strong favor toward one or the other. So for this latest installment of Doctors Debate, we asked Dr. Hooman Khorasani, a board-certified dermatologist in New York City, to explain why he is such a fan of fat transfer. We also asked New York City board-certified facial plastic surgeon Dr. Jennifer Levine, who has a much more skeptical take on the procedure, to share her thoughts.
The case for fat transfer: “It’s the most permanent option for volumizing that you can ask for”
According to Dr. Hooman Khorasani, a board-certified dermatologic surgeon in New York City
“Both fat and filler can be used to volumize and contour the face and body. But fat transfer has several unique benefits.
“It’s your body’s own fat, so you don’t have to worry about ever dealing with immune or inflammatory issues that can sometimes arise with fillers—for example, when people develop sudden swelling in the area of filler injection after they catch a cold or have a vaccine.
“There is a misconception that it’s a one-and-done treatment, and that’s not the case. Typically, only about 50% of the fat transferred survives, so it is important for patients to realize that they may need to come in for two or even three treatments. However, while harvesting the fat is expensive and time consuming—and it does make the most sense to do this if you’re already undergoing some other type of procedure, particularly a body contouring one—harvested fat can be frozen and used over time, as long as it’s stored in the right type of cryogenic freezer. It’s very rare these days that I perform liposuction and end up throwing the fat away.
“The added benefit is that even the most fit patients always have some area of their bodies that they’re self-conscious about, so they then love the results from the fat harvesting as well.
“And while there is more of an upfront cost, it can end up being a more economical option in the long run. Once you achieve the desired result, those effects are essentially permanent. Yes, we will still lose fat naturally as we age, but it’s much more permanent than having to come back for regular filler injections.
“The first fat transfer I did was 18 years ago; I recently saw the patient and couldn’t believe how good the results still looked. Not to mention that for older patients who need a lot of volume, fat transfer is absolutely the most economical choice. That’s also the case if you’re treating any areas on the body, such as the buttocks, where the sheer amount of product needed to make a difference makes fillers [like Sculptra] extremely costly.
“But I’m performing fat transfer in younger patients too. They’re good candidates because they often need just a little added volume and don’t have other issues that really do require a surgical facelift, which neither filler nor fat could address.
“In the hands of the right provider, we really can use fat in the same way as we use the various fillers that are on the market. During the purification process, we can filter it and manipulate it to create different densities, making it thicker and creamier for areas that need more volume, like the temples, or getting it to a thinner, more gel-like consistency for spots like the tear troughs. The issues that we see with fat transfer, such as lumps and bumps, occur when the fat isn’t manipulated correctly for the area where it’s being injected.
“There’s a safety factor to consider as well, particularly when you’re injecting vascular spots such as the forehead, under the eyes, and around the nose. The cannulas used for fat are bigger than the caliber of these blood vessels, meaning it’s harder to puncture them.
“In my opinion, you can look at fillers and fat transfer synonymously, in terms of how they work. Fat transfer will have more of an up-front cost, but it’s more permanent and less likely to cause issues, whereas fillers are cheaper, not permanent, and more likely to incur complications.”
The case against fat transfer: “There’s too much variability to promise any kind of consistent long-term outcome”
According to Dr. Jennifer Levine, a board-certified facial plastic surgeon in New York City
“Fat transfer may be longer-lasting than injectable fillers, but there’s a lot of variability that can affect the results. Not all of it may take, and even the fat that does take doesn’t always behave in a predictable way. It’s all dependent on the provider, their injection technique, how the fat was harvested, where it came from—there are so many variables at play that comparing one fat transfer to another is never like comparing apples to apples. There are people who do store fat to use over time, but that’s another factor to consider. The idea that you could store and freeze it and then inject it later and still have it be viable is tricky, not to mention that this could also raise issues of sterility and potential infections.
“I also wouldn’t say that the safety profile is any better. It’s still being injected, and if you’re talking about the under-eye area, you have to consider how thin the skin is here and how much any even slight irregularities are going to be very noticeable.
“When you’re injecting both sides of the face, it’s also possible for the fat to take differently on one side from the other and, again, be left with irregularities. You may also need it more superficially on one side and deeper on the other, which adds another level of nuance. And unlike hyaluronic acid–based fillers, which can be easily dissolved, the only way to correct any problems is to surgically remove the fat.
“I don’t think it’s necessarily a money-saving option either. The only patients I’d recommend it for are those who are already undergoing a surgical procedure and are extremely volume deficient and those who don’t want something foreign in their bodies because yes, it is an analogous product.
“But I don’t think it’s appropriate for younger patients. A younger person won’t need that much volume replacement, so why inject something that’s not undoable without a secondary aggressive procedure? If anything, the benefit of fat is that the stem cells and growth factors in it can help improve skin quality, but it’s older patients who need that.
“The data just isn’t out there for fat transfer. It’s too variable and can’t be standardized for us to make any kind of promises in terms of results. You could be happy with the results, but the idea that you do a fat transfer once and then are never going to have to touch it up or fix it is erroneous, because our faces are dynamic structures that are always changing.
Fillers offer predictability, control, sterility, and, in the case of HA fillers, the safety net of reversibility. Fat transfer is a good idea in theory, but in practice it’s more questionable.”
The bottom line
Both fillers and fat transfer offer their own unique sets of pros and cons. Which one you choose will be largely dependent upon your specific needs, preferences, and budget.
If you do decide to go the fat transfer route, however, it is important to seek out a provider experienced in the technique who understands both the harvesting and injection nuances required to achieve the best end result. And keep in mind that while it is a very long-lasting option, it may still require a few rounds of treatment.
Setting the head-to-head comparison aside, the point on which the doctors we spoke with unanimously agree—and underscore as more important than deciding between filler or fat—is understanding that simply adding volume to the face isn’t always the right solution. It’s not a substitute for the type of lifting that a surgical facelift can produce, and relying on either injectable to add volume when something else is needed leads to an unnatural appearance.
