Does Analogous Fat Transfer Lead to Sagging Facial Skin?

Question

Once the injected fat dissipates, will the skin then sag?  It stands to reason that delicate facial skin can remain stretched out after the injections are reabsorbed.  Typically, what percentage of the transferred fat will remain permanently?

Ron Shelton, MD · Answer

The facial skin would fall back to its origin prior to the fat transfer or be better than before. When liposuction is done on the neck underneath the chin, the skin actually retracts via collagen formation and contraction. The skin seems to get sucked back and up, rather than falling.
Fat transfer is a graft. Some fat cells actually live so don&rsquo;t imagine that all will be digested, but the cells that do go away don&rsquo;t leave an empty cavity that allows the skin to fall away. The cells that dissolve are leaving a scaffold of collagen behind that pulls the skin more taught when they go away.
Fat transfer is one filler that can produce long term results for many years because it is a grafting technique. It is the most capricious procedure I perform, in that the results are not predictable.
Some patients have several treatments (most have at least three, done several months apart) but some patients can end up with no improvement and others close to full correction many years after the last treatment. There is not even a consistency with the results in the same patient when comparing the different numbered treatments.

Nima Shemirani, MD · Answer

Dear NoPlasticFlower,

	The amount of take on a fat graft procedure varies widely.  There are certain techniques that lead to higher yields, as well as patient factors.  The acceptance of fat as normal tissue can range from 20-75% depending on the patient and technique.  You are best to go to an experienced fat transfer surgeon for more accurate results and photos.  As far as sagging, this doesnt happen.  It is almost like blowing up a balloon that is partially deflated, it will fill up and hold.  It does not move or drop due to gravity.

	I think it is an excellent, natural permanent filler in the correctly selected patients.

	Best,

	Nima Shemirani

Scott C. Sattler, MD, FACS · Answer

There is just not enough facial volume augmentation to result in skin stretching if and when the fat graft resorbs.

Thomas A. Lamperti, MD · Answer

While not all of the injected fat survives during a fat transfer procedure, the facial skin doesn't become overstretched and lead to more sagging. If the procedure is performed well, the skin should appear less saggy do the replaced volume. 

	It's hard to comment on how how much fat survives during a transfer procedure. Gentle handling of the fat grafts during the procedure helps to ensure maximal survival. Also, careful 3-dimensional placement within the facial soft tissues helps to maximize the available surface area for blood vessel in-growth.

	An important thing that I tell my patients is that the process of fat graft "take" occurs over many months. Around 6 months after the procedure you'll see a low point (where the swelling has dissipated but the fat graft hasn't yet fully taken hold). From this point on up to about 18 months after the procedure you'll find a gradual improvement as the fat cells blood supply matures.

Sam Naficy, MD, FACS · Answer

Your concern is that the initial swelling form the fat injection will stretch the skin and as some fat resorbs that it will cause sagginess. This is not true since the amount and duration of swelling from the fat (even with planned overcorrection) is not enough to stretch the skin.

Ross A. Clevens, MD, FACS · Answer

Since fat grafting adds volume, it does not create saggy skin. Rather the opposite is true, it adds volume and 'inflates' the saggy skin. We often remark that the aging face is like a deflated beach ball, but the youthful face is full and round like an inflated beach ball. 
Essentially, the fat transfer procedure harvests fat from one part of the body where an excess exists and then places it in another part of the body where the additional bulk is used for cosmetic and aesthetic purposes. Fat transfer -- which is also known as fat grafting, fat autografts, autologous fat transplantation, fat injecting or microlipoinjections is utilized in facial plastic surgery to restore lost volume to the face.  The youthful face is round, full and heart shaped. The aged face becomes more gaunt, deflated, square shaped and bottom heavy. 
Fat grafting achieves a more youthful volume and fullness to the face. Fat grafting may be performed alone or in conjunction with other more traditional rejuvenative procedures such as facelift.

William Bruno, MD · Answer

It is unlikely that a fat transfer will cause the skin in that area to sag later in life. The skin will sag due to the effects of gravity and aging, not due to the volume restoration that you can achieve with fat transfer. You may require more than one session of fat transfer as a certain percentage of the fat cells will not survive. That percentage depends on the technique and can be as high as 50% not survivng in some studies. Especially in the face, with its robust blood supply, the chances of the fat surviving are quite good. There are no long term studies at this time to determine the status of the skin 10 or 20 years after the procedure.
Best wishes,
Dr. Bruno

Michael A. Persky, MD · Answer

Hi Kung Fugeisha,
I have had excellent long term experience with fat transfer.  The reason for these results are three fold. 
 First, meticulously placed micro-fat grafts can have up to a 40-60% survival in terms of the volume placed.  Secondly, the process of passing the micro-cannula back and forth repeatedly causes some fibrosis and increased tightening of the skin as it heals in micro-adhesions.  Lastly, it has been postulated that there are stem cell like effects on the overlying skin after fat transfer with improvement of skin tone, texture, and even the disappearance of scars.
Although the dreaded process of aging will continue its relentless march, the fat transfer process does not cause skin sagging.  
Be well and happy holidays.
Dr. P

Brent Moelleken, MD · Answer

This is the big question, how much fat survives.
My theory has been that no more fat can survive than you start out with initially.  Our studies have shown that 75+% of fat injections are dead.  Other metabolic studies show up to 96% of injected fat is dead. 
People talk about stem cells somehow creating new fat, but the number of stem cells is minimal in normal fat injection specimens.  I am told by my colleagues at UCLA who have published in this area that in order to harvest stem cells from fat in the research laboratory, you need to harvest liters of fat. 
In our practice, we prefer LiveFill, nontraumatized fat gfrafts that are placed directly into hollow areas of the face.  With this technique, you are starting out with 88% alive, not 25% alive, cells.
In any event, the loosening effect on the facial skin is not known.  We know patients who gain and lose weight do suffer looseness of their skin, and that it differs from patient to patient depending on genetics.  My guess from experience is that the effect is small but not zero.

Michael Law, MD · Answer

The face should not be overfilled to such a degree that the skin is compromised. In fact, often patients report much better skin quality following fat transfer. There is a stem-cell efect  to the skin following fat grafting surgery.