Asymmetry from fat grafting under my eyes. What options do I have for revision of this adverse result?

Question

As part of a face lift in January, my plastic surgeon used fat grafting in my lower face and along my cheek bones. I am left with extreme asymmetry in my lower face and an unnatural, over done appearence of my cheek bones.

Jonathan Kulbersh, MD · Answer

Thank you for your question and photos, and I am sorry you did not see a satisfactory result from your facelift. Fat grafting is commonly performed with this procedure to volume in key areas and achieve the most natural facial contour. The problem with fat is that it requires a great deal of expertise and precision to perform correctly and even then, the results can be somewhat unpredictable. If fat is the issue in your lower jawline, there are ways to remove the fat and create a more symmetrical contour. I recommend scheduling a follow-up with your surgeon for a full assessment and discussion of your treatment options to correct this issue.

Anil R. Shah, MD · Answer

Asymmetry from fat grafting can be concerning to patients. There are a variety of techniques to correct this including addition (additional fat grafting and/or filler) and subtraction (kybella, lipocontour, direct removal).  Seek advice from a facial expert.  Best Dr. Anil Shah

Jag Chana, MD, FRCS(Plast) · Answer

It is a little difficult to assess this from the photographs provided. It would be useful to have better close up photographs. There looks to be some excess fat on the lower eyelids that should be amenable to correction. Usually fat is injected in the tear trough area at the lid-cheek junction with sometimes additional fat into the midcheek below. However, if there is persistent fat herniation which corresponds to true orbital fat this could be corrected. I would recommend you return to your surgeon for a further discussion

Andres Bustillo, MD, FACS · Answer

I would be ideal to have the  proper before and after pictures taken before your surgery to compare. I would suggest that you speak with your surgeon, review pictures and discuss a solution to your problem.

Michael P. Morrissette, DDS, FACS · Answer

You mentioned that you had facial fat grafting to your cheeks and lower face. The photos that you have provided show the typical pattern of orbital fat herniation that is seen when a patient is seen for a lower blepharoplasty consultation. I would recommend that you follow up with your surgeon to discuss whether this is the case.

Juan Carlos Fuentes, MD · Answer

I will recommend you to go back to your surgeon and discuss your concerns. You have more than 6 months from the surgery and by now most of the swelling should be gone. so if there is still some swelling on the lower eyelids may be from the fat injections, also if you think your cheeks are overdone, then maybe some liposuction on those areas can reduce the volume.

Zoran Potparic, MD · Answer

It is very hard to see on these photos the extent of "secondary deformity" that you claim to be result of fat grafting. Waiting at least 6 months or longer after fat grafts will give you better idea how much of grafts have actually survived. In our experience it is about 30% in the face? Once this period is over one may consider lipo-contouring of redundant areas with fine cannula or in some cases direct excision (shaving) using already existing face lift scars. Good luck.

Garrett Griffin, MD · Answer

Hi, I see what is bothering you and I'm sorry this happened.  It looks like the left side of your face was probably larger to start with (based on your eyebrow height and the size of your left eye), so if he put the same amount of fat on both sides, it may have accentuated that difference.  It also looks like you have a visible bump with a little redness on the left cheek, which might be a fat granuloma. To treat a fat granuloma, I usually try injecting steroid first, with surgical excision as a last resort.  I would treat the bump/redness on your left cheek first to see how much that helps with the asymmetry.  If after that is resolved you are still asymmetric, choose the side you like better. If you like the fuller left side better, put more fat or filler on the right to make it match. If you like the right side better, discuss microliposuction or a revision facelift to remove a little fat on the left face.  Again, I am sorry this has happened, hang in there.  Dr. G

Curtis Wong, MD · Answer

identify the problems and see your surgeon for options (there are always options) for what you can do.  But you must choose what side you like better and then your surgeon can provide you with options from which you can choose.  Hopefully your surgeon has a decent revision policy to minimize your costs for what comes next.

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

Hi, I have performed many facial shaping procedures using dermal fillers, facial implants (cheek, chin), liposuction and/or facelifts for over 30 years.  In my experience and despite its recent increase in popularity, fat transfer (fat injection) offers "far" less of a reliable and predictable volume for facial shaping than an off the shelf dermal filler or silastic facial implant.  For that reason, I do not use fat to shape the cheeks, chin, lips or jaw line.  Tissue physiology is quite simple.  Tissue requires a blood supply in and out as well as lymphatic connections to remain viable and alive.  Once fat is removed from the body all of these things have been disrupted.  Just because the removed fat is mixed with PRP or something else doesn't make the blood and lymphatics magically re-appear.  The fat at that point is not living tissue which means that it's prone to being dissolved by the body (most likely in an uneven and unpredictable manner).  Injecting fat back into the face does not create the required elements to make the fat living tissue once again.  So the argument that fat is alive and viable in the face once it's been removed and re-injected makes no sense to me as a physician and surgeon.
 The other issue that I have with fat transfer is the lack of precision.  Fat is thick by nature which means it's not the same consistency as an off the shelf dermal filler.  Fat injections use an increased volume injected in an attempt to compensate for the volume loss that "will" happen.  This means a lack of specific shape and volume that simply can not begin to compare with the specificity of using a silastic facial implant of a "known" shape and volume.  In that regard fat offers too much of an unknown to make it a reliable and predictable method for facial shaping.  There's a significant difference between a 3mm and 5mm thick cheek implant.  You can imagine the magnitude of difference there is between retaining 60% of 25cc's of fat versus 35%.  In my humble opinion, I just don’t see how fat could possibly be used to precisely shape facial features?
  Some of the fat will likely dissolve with time.  Liposuction of unwanted fat, fat lumps/clumps from fat injection in areas over the cheeks, mid face, lower face and neck can be done as a subcutaneous fat layer exists in these areas.  Energy based skin therapies (using RF and Ultrasound) can be used to dissolve the fat but smooth, consistent results are not guaranteed. I prefer using precise placement of a dermal filler or silastic facial implants (when appropriate) over fat to shape the cheeks, chin, lips and jaw line....often performed the same time as the facelift procedure as described below. I have performed many SMAS facelifts for over 30 years and have performed many minimally, invasive SMAS facelifts.  The reality is, there are many different ways to perform a facelift from incision length, incision placement, level of tissue dissection (skin only, SMAS, Deep Plane, Subperiosteal), different degrees of tissue undermining, how to lift and support (imbrication versus plication of the SMAS layer), how much excess skin to trim, is excess fat going to be reduced and finally will the overall shape of the face be made more feminine or masculine (while avoiding the over pulled, windswept appearance).  Price is determined by the reputation, location and experience of the Facelift Surgeon.
 In my humble opinion however, there are some basic requirements that must be met in order for a facelift to be "effective", yielding "aesthetic pleasing" and "naturally attractive" results.  These include: 
 1. Some type of incision either curved around the front (preferred) or straight in front of the ear.  This is how excess skin is removed which is not possible with an incision behind the ear alone.  If you have so little excess skin on the face that "none" needs to be removed you are not a candidate for a facelift in the first place.
2. The facelift must address correction and softening of the "jowls" using a long lasting and effective technique.  If you have "jowls” these are sagging facial tissues and the main indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.
3. Facial shaping must be combined to properly shape the cheeks, chin, jaw line and lips for feminizing or masculinizing the face as the case may be.
 Following my beauty principles, women look the most feminine, youthful and attractive with heart shaped faces.  Heart shaped faces have cheeks that are full and round in the front.  If the cheeks are either concave or flat in the front cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement can create full, round cheeks that will feminize the entire face.
 A weak chin creates an imbalance making the nose appear larger, the mid face top heavy and the lower face look short that de-emphasizes the lips and allows early formation of a double chin.  Chin augmentation using a chin implant will add projection to the chin creating harmony and balance to the lower face.  I have found placement of a silastic chin implant, through a small curved incision under the chin (also allows excess skin removal) to be very safe, quick and highly effective.
 If you have "jowls” these are sagging facial tissues and the main indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.
My most popular SMAS facelift is the minimally invasive, short incision SMAS facelift that has all the benefits of more invasive facelifts (traditional, mid-face, deep plane, cheek lift and subperiosteal facelifts) but with these added benefits:
very small incisions and no incisions extend or are placed within the hair.
minimal tissue dissection = less bruising and swelling = rapid recovery ( several days instead of weeks or months with the more invasive type facelifts mentioned)
can be performed in 90 minutes or less, with or without general anesthesia
proper SMAS Imbrication technique
no incisions within the hair = no hair loss
excess fat can be removed from the face and neck
excess skin removed from the face and neck
cheeks, chin and jaw line can be augmented with dermal fillers (I prefer Restylane Lyft) or facial implants
most patients fly back home to parts all over the world in as little as 3 days post-op
I combine facial shaping with every facelift procedure.  When jowls are present, these should be done in concert and not alone or separately in order to create a naturally, more attractive face.Hope this helps.

Asymmetry from fat grafting under my eyes. What options do I have for revision of this adverse result?

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