Why is Fat Transfer a Low Rated Procedure on RealSelf?

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).

The reason this procedure is rated poorly is due to patient expectations with postop course and final result. It is incredibly important for patients to have multiple conversations with their patients about what to expect regarding postop swelling and the final amount of fat that survives. Well informed patients will be extremely satisfied with this procedure.

You are quite perceptive and I am surprised that even 40 percent are happy.  Perhaps they don’t want to admit it was a waste of money.  I have rarely seen a fat transfer to the face that I thought looked better.  In most cases the fat gradually dissolved, or worse, forms lumps.  I know many plastic surgeons promote it and push it very well.  My opinion?  Save the money and hassle..

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.

So all of your points come into play when discussing and assessing results of fat transfer. Patient selection is definitely key. The way you process the fat and the way it is injected also have implications. Fat transfer is a relatively new procedure for facial volumization so we are learning more and more.A large factor is also patient expectations. I explain to all patients that the results take time and it is not uncommon for us to do 2 procedures separated 6 months apart for optimal results.The benefits are clear though. They are the most natural and long last results we have.Continue to do your research and be sure to see a surgeon that does a lot of fat grafting.Hope this helps.Best of luck,DrC

Fat grafting can be tricky.  Speaking only from my experience, there is a learning curve as far as being able to give consistent results with fat grafting.  Only after performing hundreds of fat grafting procedures can I say that I can now, more or less,  "predict" what the result will appear like.  Fat grafting results typically are not as dramatic as the results of a facelift or breast augmentation.  Expectations need to be metered appropriately.  In my experience, patients who have facial fat grafting have it in conjunction with another facial procedure.  The "gestalt" of the multiple procedures is what results in a happy patient.  In addition, the final result from a fat grafting procedure can sometimes take upwards of one year.  Your result typically looks the least impressive on the first and second month after the procedure.  As the surviving fat cells volumize over the course of the year, you result only should improve

The great thing about fat transfer is that it "kills two birds with one stone" as both the areas from which the fat is taken, and where it goes are improved.  Having said that, if patients are unhappy, it is often because they become disappointed with the amount of "take" of the fat grafts.  Often, patients are happy soon after the procedure when they are still swollen, then become disappointed when the swelling goes away and part of the fat is resorbed.  This can be avoided if the doctor prepares the patient for this phenomenon.Like all procedures, the patient's expectations need to be appropriate and he or she needs to follow postoperative instructions carefully to maximize the take of the fat.Although not all the fat will survive, I have not seen patients in whom none of the fat makes it.  This, combined with the benefits of the liposuction, produces happy patients.Hope that helps!

There may be a number of reasons why it is low rated on RealSelf.  It certainly is a good procedure with real results. We have been using it for 20 years for enhancing the face, eyelids, breasts and buttocks and other areas with many happy patients.  Meticulous technique is a requirement.  How one processes the fat prior to transfer and also the transfer technique can significantly affect the volume that results.  Postoperative care of the area where fat was transferred to can also play a role in the end results. But I think patient understanding and expectations may be the major reason why some rate fat transfer low on RealSelf. Not all of the fat by volume survives when it is transferred. The fat that becomes permanent may range from 20 to about 70% of the volume transferred, depending where on the body or face it is transferred to.  That means that some of the fat will go away following a procedure.  There is usually a little inherent disappointment in the first few weeks following fat transfer when some of that "Wow" fullness one had immediately after their procedure starts to go away. But this eventually stops and there is a fullness that was not there previously. Sometimes it requires a glance at the preoperative photographs to remind patients of the improvement that they have made. Certainly there are limitations with the procedure. A well-informed patient with regards to realistic expectations can make this a very satisfactory procedure. Also the knowledge, that sometimes more than one treatment is necessary if the patient has a specific goal.

Fat transfer has been a hot topic the past few years and
because of that a lot of surgeons have tried to perform the procedure without
proper training or experience. When fat
grafting was first being performed many surgeons did not appreciate the fine
and subtle techniques that are needed to achieve the results that patient’s
desire.



Also like any new topic I think people used it as an answer
to any problem and thought that it could replace implants and magically fix any
problem. As with any new product or
technique it has settled down to a realistic procedure that has its place in aesthetic
surgery.



I do think for patients to get the results they are looking
for they need to have the procedure done by an experienced board certified
plastic surgeon that performs a tremendous amount of fat transfer.



This is important because the surgeon will be able to be realistic
with you about the results that are possible from fat transfer and tell you
whether you are a good candidate for the procedure or not.



A surgeon that performs a lot of these procedures also has a
system in place that allows him or her to process the fat and shape the body in
the best possible way.



I would advise you to see a board certified plastic surgeon that
performs a lot of fat transfer procedures.
In my practice the Brazilian Butt Lift is one of the procedures where
patient are extremely happy after surgery.