Why is Fat Transfer a Low Rated Procedure on RealSelf?

Fat transfer results can be a little unpredictable. The procedure involves harvesting fat from a ‘donor’ site, and then transferring it to another part of the body (often the face). This requires the fat cells to take up a new blood supply and ‘survive’ in their new location, which doesn’t always happen - or at least it can happen to varying degrees. Sometimes all of the fat will survive, sometimes none of the fat will survive and usually something in between happens, which means you do not have accurate control of the result. The usual fat survival rate is around 50-70%.  There can also be issues with fat transfer forming lumps, which can be very difficult to treat. Fat transfer is also subject to change, depending on weight gain or loss in the future. So, it is possible to have a highly successful fat transfer but then gain weight a few years later and what started out as a good result ends up looking too much. Because of this, many doctors are now doing less fat transfer and preferring to use long lasting HA fillers as an alternative. These fillers (like Juvederm Voluma) are less invasive with less down time, more control, more predictable and they are also reversible. 

Fat transfer is a wonderful way to naturally and beautifully restore lost facial volume. Although there are numerous options to revolumize, fat transfer has some major advantages: it is the longest lasting option to restore volume in the face, functioning essentially as native facial fat once it is transferred; it is your own fat being used, thus is 100% biocompatible; there is an abundant amount available on almost everybody, so there are no limitations to getting the volume you need and achieving full correction; fat is one of our best sources for stem cells, called adipocyte derived stem cells, which yield additional benefits due to the growth factors contained and their effects collateral tissue growth that extends well beyond just the zone of transferred fat, helping contribute to a global improvement in the facial aesthetic.
An extensive amount of planning goes into the fat transfer process, with a comprehensive look at the balance and proportion of the face being blended with the aging changes and anatomy of each individual patient.
The procedure itself is performed utilizing local anesthesia with or without sedation. Fat can be acquired from numerous sites, but choosing a site is usually best planned to help contour the body in the process, thus the abdomen, thighs, and waist are commonly utilized. 
After the fat is acquired, it is processed and prepared into micro- and/or nanofat, which have different properties and are chosen based on the desired areas to be treated. Transfer is then performed with blunt tipped cannulas, as opposed to needles. Different providers will likely have different processing protocols, but I prefer to maximize the stem cell content of my fat, further magnifying it’s benefit. This is a time-consuming and intricate process, thus some people take shortcuts, but the long-term benefits are well worth the extra effort in the preparation process. I also utilize other regenerative medicine modalities, such as platelet rich plasma, to improve the outcome from the fat transfer and expedite the recovery time.
Recovery from fat transfer includes swelling and some firmness that is subtle and can last several weeks to months after the procedure. The transferred fat establishes a blood supply in its new location, a very favorable process which contributes to that inflammation and swelling. 
It is key that the physician performing the fat transfer is well-versed in panfacial volumization, allowing an equal balance and harmony to be created and maintained in the face. Fat should not just be utilized in large volumes in a few spots, but instead utilized in strategic volumes over multiple areas of the aging face.
Overall, fat transfer provides an incredible option to restore volume that is very natural, long lasting and has the added benefit of a healthy dose of stem cells to rejuvenate aging tissues. 
To ensure you are receiving the highest level of care, seek out a modernly trained, new-school dermatologic surgeon, oculoplastic surgeon, facial plastic surgeon or plastic surgeon who is board certified and fellowship trained in one of these “core four” cosmetic specialties. Membership in organizations like the American Academy of Facial Plastic and Reconstructive Surgery help to identify a highly trained surgeon.
Cameron Chesnut
#realself500 Physician

That's a good question and I wish I had a good answer.  Fat grafting among doctors is incredibly variable regarding technique and results.  Results can vary based on patient selection and volume.  We are rather selective on choosing patients and will recommend fillers or lifts when fat grafting isn't the best option.  When we do graft, I generally put high volumes (up to 60 cc) since we can expect some of that fat won't incorporate.  In the right person with the proper technique, fat grafting will yield the happiest patients.