Firmness in grafted fat tissue can occur on occasion postoperatively, but fat that feels “hard as a rock” is distinctly unusual. In most cases, facial areas that have received autologous fat grafts should feel soft and supple, although there may be some mild to moderate ‘firmness’ for the first week or two as the relatively modest postoperative edema (swelling) subsides. Also, the feeling of firmness may vary with the amount of fat grafted into a given area. 2-3cc of fat in the anterior cheek should feel fairly soft in most patients, while 4-5cc will feel noticeably firmer. Again, firmness should subside gradually over the first two to three weeks after surgery.
Hardness in grafted fat tissue suggests a problem with surgical planning, a problem with surgical technique, or a possible postoperative complication. I have met with a number of patients who have undergone staged fat grafting procedures in other practices using previously harvested, frozen autologous fat. Many of these patients have experienced, among other things, hardness in the grafted areas postoperatively as well as no significant long-term persistence of grafted fat. It is widely accepted in the plastic surgery community that only autologous fat that has been freshly harvested should be used for grafting.
Hardness can also result from over-grafting and/or an inappropriate grafting technique. While in some cases it is desirable to add a large amount of fat in a certain area, adding too much fat may prevent new blood vessels from growing into the recipient site. An over-grafted area feels very firm immediately postop, and often turns hard as the grafted fat fails to develop a new blood supply. Failure to evenly disperse grafted fat throughout the recipient site will also impair the establishment of a new circulation. ‘Fat necrosis’ is the medical term for the phenomenon of fatty tissue turning very hard due to an insufficient blood supply. In some cases fat necrosis will soften over time (usually months), but it may also may remain hard indefinitely.
Hardness could also result from a persistent, organized hematoma in a grafted site. The only way to diagnose the cause of hardness, and to make treatment recommendations, is by physical examination. Heat and anti-inflammatory medications may be helpful in some cases; massage can be used in some instances but should be carefully directed by the physician.
Severe hardness following fat grafting certainly deserves a careful evaluation by your doctor, and some appropriate treatment recommendations based on that evaluation. Firm areas usually soften with time; the fate of hard areas really depends on the diagnosis. Whether or not fat will persist when the hardness resolves will take several months to determine.