Why Didn't my Fat Transfer or Restylane Injections Work?

Question

I had fat transferred to my face six months ago for nasal folds and lines at corners of my mouth; when the swelling subsided; the folds and lines were still very visable; apparently the fat transfer didn't take; now a few days ago I had Restylane injections for the nasal folds and for the lines at the corner of my mouth; the next day the folds were back and so are the lines? Why didn't these two treatments work? Confused and angry!!

Kenneth D. Steinsapir, MD · Answer

It is improbable that you did not work. However it does very much sound like you did not get the effect you need to be satisfied. This might be a function of how aggressive your surgeon is in filling these areas. Generally I very much like Perlane for the nasolabial fold but no question the job can be done with fat, Restylane, and other fillers as well. Consider posting before and after images so we have a better understanding of your concerns.

Michael A. Fallucco, MD, FACS · Answer

Fat transfer around the mouth is less predicatable as it is a moving area and the fat needs to establish a blood supply. This is why it will do better in areas around the cheek or "malar area." Fillers may soften this area but will not be permanent and your surgeon can talk to you about the differences in filler options.

Misbah Khan MD, FAAD, FACMS · Answer

I do not like fat transfers for smile lines. however, Restylene is a good filler for smile lines. its possible u might simply just need some more filler to give u the optimum results. I once had a patient who required three times the amount of filler I would use for other patients. the other option is u might want to try Radiesse for smile lines instead of Restylene

Michael Law, MD · Answer

The survival of grafted fat is variable from procedure to procedure. As it is essentially impossible to quantify the survival of grafted fat as a percentage of the total amount of fat that was transferred, I instead tend to look at it in terms of what percentage of the overall improvement (that is seen early postoperatively) is still persistent at four months postop. If it's still there at four months, then it has a blood supply and will persist long-term. In my experience, most patients show a 50-80% persistence of the early improvement at four months. If less than 50% of the improvement has persisted, most patients need and want a secondary fat grafting procedure. We perform such fat grafting 'touchup' procedures at a significantly reduced cost compared to the initial procedure, and patients are advised of the potential expense before they have their initial surgery. Once in a great while we have a patient who experiences limited fat survival and who has very little long-term change in their appearance following their fat grafting procedure, and for such patients we offer a secondary procedure at no charge. Another way to look at this issue is to ask 'what percentage of patients require a secondary fat grafting procedure in order to get the result they are looking for?'. Because my approach to fat grafting is conservative, I have a fairly high number of patients who return for a second procedure. I would much prefer to have a patient like what they get and return for more, than to have a patient who is unhappy because they feel that their fat grafting was overdone. If you look at reviews posted by fat grafting patients who have had a very negative experience with the procedure, you find an abundance of patients that feel that an excessive amount of fat was placed in their face. They're not just unhappy - they feel disfigured. So a conservative approach is absolutely critical to success with facial rejuvenation by means of structural fat grafting. To be worth a patient's time and money, fat grafting needs to look natural, and not like a trip to the operating room.

Steven Wallach, MD · Answer

Fat injection is not a perfect science in the sense that the fat cells often do not take a 100%. Injecting other fillers in the folds can be very helpful, but they do not usually eliminate the folds or lines totally either.

Sam Lam, MD, FACS, FISHRS · Answer

I am sorry that you had a bad experience.  I never do fat grafting for folds near the mouth because it simply does not work at all.  Fat is too soft and unpredictable to manage small areas like that.  However, fat grafting is literally the most amazing thing to make a face look younger and more attractive.  See my results on my Web site, lamfacialplastics.com, to see how the entire face can look pretty but it won't manage the small folds.

	As far as the downturns are concerned, even fillers won't completely do this.  I always tell my patients that fillers if done well can help turn a downturn toward but may not get there a more horizontally positioned line but not entirely eliminate it.  I also combine it with Botox into the depressor anguli oris (DAO) for optimal benefit.  With repeated Botox and fillers, you can continue to improve it but you will NOT eliminate the fold.

	Now, I always try to get my patients out of what bothers them to what bothers me.  What my patients see oftentimes simply won't make them look any better because they are too darn close to the mirror looking for minor flaws that have limited relevance.  The things that I do to make a face look amazing requires a global perspective on the face, what I call the blink effect.  Malcolm Gladwell wrote about how in a blink of an eye we make our judgments.  You do too.  You see your best girlfriend 20 feet away and you see if she looks good before you can even see these so-called fine lines and folds.  Women in short are too obsessed with their mouth close up.  When women come in for small areas around their mouth I usually steer them away because they simply won't be happy.  Small things are hard to fix on the face, only they can be improved.  

	If you are ever interested to consult with me, I will have to first completely change your brain of what bothers you, or I will not be able to help you look your best.  I know that sounds crazy but my many loyal patients who fly in for me do not think that after they see what I can do even though it is not what you initially wanted.  Artistry, experience, and judgment are the key.  I will ALWAYS explain the limitations of anything you do in excruciating detail because I always say the difference between an education and excuse is that an education is told to you before you spend money and an excuse is the same words told you to after you do.

	best,

	Sam Lam

	Watch the attached video to see how I discuss how fat fails for small surface areas and folds.

Richard Ellenbogen, MD (retired) · Answer

Some folds around the mouth are difficult to eradicate but not impossible .It requires experience with this area. I'm surprised at Dr. Lam's answer It is necessary to start the filling from the iinferior border of the mandible up to the corner of the mouth not just the llne. The line itself wont fill alone. The nasolabial folds can be minimized but not eliminated with a two level approach. I'm sorry for your unfortunate experience

Francis R. Palmer, III, MD (retired) · Answer

Fat transfer simply isn't reliable despite claims to the contraray. Fat, once removed, is dead tissue having neither blood supply in or out and as such can't be living, viable tissue. Fillers like Perlane or Sculptra, on the other hand, are reliable and have been shown effective in filling in the NLF's and Marrionette lines.

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