Hi Lookingforsolutions,It's easy to say either fat grafting is horrible, or fat grafting is great as long as its performed in "experienced hands" which implies that the surgeon making the statement is experienced.There are many factors to consider when approaching Fat grafting AKA Fat transfer. I will try to explain these factors which the plastic surgeons are taking into consideration when performing this procedure and why asking for a guarantee may be too much to ask for. Perhaps avoiding complications is possible, if very little fat is grafted, the smaller volume of fat transferred should reduce the risks that you are worried about, but then the results may be too subtle to be noticeable, which then begs the question why go through it at all.I think using fat has the potential to be great, since is it your own tissue and the transfer of fat cells are permanent once it gains a blood supply. Since it is alive and has a blood supply, if there is any infection is can be treated with antibiotics and it can clear infections as it does with normal tissue. It can't be rejected with an immune reaction called a foreign body granuloma or form a biofilm which is an infection on the surface of an foreign implant (pacemaker, breast implants, facial implants, joint replacements, etc). Having pointed out the Pro's, I am careful not to represent Fat Transfer as a Panacea or "cure all" solution. It is known that Fat survival after fat transfer is unpredictable. Surgeons know that fat survival can range from <30% to >50% depending on some strategies or techniques. They have tried different methods to increase fat survival percentages, by adding PRP (platelet enriched plasma), enrich stems cells and add it to the fat, wash the fat, spin the fat, only take the bottom 50% of centrifuged fat (stromal fraction) which has a higher fat surival percentage than the top 50%. The top fat transfer experts who harvest plenty of fat may even discard all of the top 50% of centrifuges fat and only use the better stromal fraction fat for injection to get a higher fat survival rate closer to 70-80%. Some surgeons may not be aware of this and may load the syringes and have stromal fraction (better fat) injected on one side and the worse fat on the other side and the fat survival between the two side may look quite different. A special centrifuge invented by a Korean plastic surgeon called Adivive uses a weighted mesh filter and higher centrifuge speeds to squeeze the fat harder and pop any "older fat cells" which cannot withstand the higher G forces. The reported fat survival rate using Adivive is closer to the 70-80% which is more like having all of the fat centrifuged closer to the stroma fraction type of fat. The Adivive users are cautioned not to inject this fat not the same way as regular fat transfer, otherwise the patient may get a big surprise of being overfilled, because the fat doesn't shrink down 50-70% after the first 6-9 months.There are two strategies for Fat Transfer performed by experienced surgeons who regularly perform fat transfer. The surgeons who do not want to perform as many touch up sessions and have the patient go through multiple recoveries may inject double or triple the amount of actual fat that they want to survive. These patients can look very bad, even "monstrous" according to some surgeons, initially after the procedure. As the swelling comes down and the fat that will not survive begins to get absorbed, it begins to look more and more normal. If they are going for this strategy of "One and Done" then the patient will look distorted initially and "overfilled" only to realize the real result later. If the surgeon is going for a single session of fat transfer and is not planning to do any touch up sessions, if the patient looks good immediately after the procedure, then too little fat was injected, since only a third of the fat may survive, assuming the surgeon at least purified the fat through centrifugation or a closed wash system like Puregraft by Cytori. If they did not bother to purify the fat at all and simply reinject the fat, the survival rate may be as low as 5-10% since the impurities of oils from damaged fat cells and blood in the fat causes inflammation which reduces the fat survival percentage. Most doctors who do believe in Fat Transfer already know this and will purify the fat.Other surgeons who regularly perform fat transfer may inject only the amount that looks good as during the initial injection, knowing it will not be enough, but then repeat the same fat grafting one or two more times. Patients are told that they may need a second or third session, typically at a discounted rate from the initial session. The same liposuctioning harvest would need to be repeated again and the purification of the fat would need to be repeated prior to injection. Since the goal is to be conservative, then it may be okay to look normal but fuller immediately after the procedure, but much of this initial fullness will go down by 2/3rd's because that is the typical percentage of fat survival. Since less fat is injected, the chance for lumps should be low. This strategy will likely require at least one additional fat transfer session to get the aesthetic result that the patient desires, if not 3 sessions total. If the fat survival in the first session was surprisingly high at 50%, then two sessions may be enough, but if it was average at 30% then three may be the number.By understanding the fat survival percentage, this makes more sense of the Surgeon's strategy for Fat Transfer. Aggressive surgeons will likely aim for a Single session, and conservative surgeons will inform the patient of multiple sessions to prevent overfilling with fat.If the surgeon wants 10 cc's of fat to survive, and doesn't know if the 3 or 5 cc's will survive, then they can wait for the fat to settle and repeat. If both sessions of injecting 10 cc's of fat had about 5 cc's survive then it is two sessions. If only 3 cc's survive each session then it would be 3 sessions. It is also possible that one session may be 3, or 4 or 5. It is unpredictable and that is the least of the issues. Let's say 10 cc's looks good and 11-12 looks a bit puffy and 13-14 cc's looks weird. If the surgeon predicts 30% survival and injects 30 cc's to get 10 cc's to survive, but the patients fat is great quality and has 50% survive, then that would mean 50% of 30 cc's survives or 15 cc's. Let's add to the "what if" scenario. What if the patient is under weight and the body is too thin when the fat was injected to the face, and the surgeon tries to fat graft so the patient's face has perfect or optimal volume, yet their body is not proportionally optimal volume and is too thin. What will happen to their face if this patient gains some weight and is a healthier weight on their body? Their fat cells on their face will gain volume as the fat cells on the body are gaining volume. Can this be disastrous? Yes, and I think there are examples which can be seen in our celebrities. If they lose weight they should look better, but if these patients have weights that fluctuate 10-15 lbs through a calendar year from the holiday eating then thin out again in the summer months, this can be a problem. As patients get older, there can be more medical problems and may be prescribed medications such as steroids to reduce inflammation from arthritis, asthma, lupus, etc or in conjunction with chemotherapy treatments. This can cause significant weight gain and one side effect of steroids can be moon face which is independent of fat grafting. What will facial fat grafting look like if they need to be placed on these medications to save their life or improve their quality of life? As you can see, there are many factors to consider for the surgeon as well as the patient's stability in their weight. Hopefully this helps create some transparency in the thought process when offering Fat Transfer as a procedure. I could go continue my thoughts on Fat transfer, but I will keep some thoughts and opinions regarding Fat Transfer versus Fillers for a future Fat Transfer question. I do not simply offer procedures because they are popular or trendy, but there is quite a bit of thought process behind it. During my consultations, I will often go over my own thought process to make the patient more comfortable with the "Game plan" but often times my patients have already read what I have posted online since 2007. Keep on researching and Good Luck on your Plastic Surgery Journey.Best,Dr. YangP.S. There is a new feature on Realself, which is the "Follow" button. It is similar to the "Like" button on Facebook. If you like my response or any of the doctor responses while you research on Realself, you should "Follow" them. You will get email updates, when the doctors you follow post any new answers to questions, post new photos, or have any new reviews.
