Fat transfer

Volume and laxity are different problems. A facelift repositions tissue that has descended. Fat transfer adds volume where tissue has thinned. The two can be complementary. They are not substitutes for one another.

On the face, fat transfer can be used in the lateral part of the eyebrow, the upper eyelid, the temples, the cheekbones, the nasolabial and labio-mandibular (marionette) lines, the jawline, the chin and the lips. The choice of site is not a menu. It follows the pattern of loss in that face, and the effect that a modest addition of volume would have on shape and on the skin above it.

The graft is living tissue. That is its advantage over a temporary filler, and also its limit. How much of it remains is not guaranteed in the same way that an implant remains. The conversation has to include that from the start.

Fat transfer is useful when the complaint is deflation rather than descent: temples that have hollowed, cheekbones that have lost their characteristic, an upper orbital rim that has flattened, a jawline or chin that has thinned, or a face that looks more drawn after weight loss even though the skin is still reasonably good.

It is also considered when volume loss is uneven — one zone, or one side of the face — because of a medical condition. Those cases need a more specific medical history, and sometimes a conversation with the physician already looking after that condition, before a grafting plan is made.

It is not the operation for skin that has to be lifted, for hyperactive platysma bands, or for a midface that needs a firmer skeletal platform. Those problems belong with a lift, a deep contouring neck lift, or a cheek implant. Fat can sit on top of those operations. It does not replace them.

People who smoke, who have a very low body-mass index, or who have a very active lifestyle need a particularly honest discussion about longevity. In those groups the graft may not last as long as it does in others. That is not a reason to refuse the operation automatically. It is a reason not to sell it as permanent volume.

Facial sculpting is usually better served by moderate change in several areas than by a striking change in one. Fat transfer is one of the building tools in that group. The reducing tools — buccal fat reduction, facial liposuction, anterior neck lift — sit on the other side of the same idea.

Hyaluronic acid fillers remain useful for a modest change, and for a reversible trial of a shape before anything more lasting is considered. They do not behave like living fat, and they do not have the same effect on the skin above them.

Cheek implants address underdevelopment of the bone. Fat can enhance the characteristic of the cheekbone; it does not replace missing skeletal projection. When the bone itself is the problem, the implant is the more direct answer. When the bone is adequate and the soft tissue has thinned over it, fat is often the better one.

Fat transfer is frequently combined with a deep plane or short-scar facelift, with a neck lift, or with procedures around the eyes. The lift manages laxity and vector. The graft manages the hollows that a lift does not fill. Around the eyes, fat can help the upper orbital rim and the transition from lid to cheek; it does not treat pigment, and it does not replace a blepharoplasty when the problem is skin excess or fat herniation.

3D capture and simulation are a useful way to look at where volume is missing, how much addition would change the three-quarter view, and whether the same face also needs a lift, an implant, or a reduction somewhere else. The simulation is a planning tool. It is not a photograph of the healed result. Graft take, swelling and the behaviour of the skin above the graft all differ from a rendered image.

The operation involves harvesting fatty tissue from the tummy, the flanks, the inner thighs or the inner knee. The donor site is chosen for the quality of the fat and for a discreet harvest, not to reshape that part of the body as the primary aim — though a small reduction there is an inevitable part of taking the graft.

The fat is then separated from infiltration fluid and fibrous tissue. That can be done by centrifuging or by filtering. The purified fat is injected with a blunt, fine cannula into the target areas of the face. The access points are very small — the size of an injection with a larger needle — and they do not leave marks on the skin.

The fat has to be distributed in very small amounts so that each parcel stays close to a blood supply and is helped to survive. Large boluses look simpler and take less time. They also fail more often. The time in the operation is spent on that distribution, not on the harvest.

Isolated facial fat transfer typically takes 45 minutes to an hour. It is done under general anaesthetic or local anaesthetic with intravenous sedation, as a day-case intervention. When it is combined with a facelift, a neck lift or eyelid surgery, the anaesthetic plan and the length of the day follow the larger operation.

The consultation has to cover medical history and the medicines actually taken. Blood thinners raise the bleeding risk and need specific management. Raised blood pressure does the same. Both have to be known and planned for, whether this is an isolated graft or part of a lift.

The risk that belongs on this page, rather than in a generic list, is variable longevity. Not every parcel of transferred fat survives. Some of the early volume is swelling and fluid; some of the later volume is the graft that has taken. A second, smaller session is sometimes the honest way to finish a plan. It is not a failure of the first one.

Other risks include bruising and swelling at the donor site and on the face, temporary firmness or small irregularities where the fat has been placed, under-correction, over-correction in a small area, and asymmetry that cannot be fully evened. Infection is uncommon. Pain is usually modest.

Smoking reduces graft take and delays healing at both the donor site and the face. That is part of the consent discussion, not an afterthought.

Expect swelling and bruising in the face and at the harvest site. The face can look more filled in the first days than it will once the fluid has gone. That early fullness is not the final volume.

A quiet first week helps. Sleeping propped up reduces facial swelling. The donor site is usually more uncomfortable than the face; a supportive garment over the harvest area is typical for the early period. Desk work is often possible within a week when the graft is isolated; combined operations follow the recovery of the larger procedure.

Strenuous exercise and anything that drives the blood pressure up should wait for about three weeks. Pressure, heat and massage over the grafted areas in the early period are unhelpful. The graft is establishing a blood supply; it should be left alone.

What remains at three months is a better guide than what is visible at ten days. Further, slower settling continues after that.

The fee is set after the consultation, once it is clear whether this is an isolated 45-minute to one-hour day-case graft or part of a wider plan with a facelift, neck lift, blepharoplasty or skeletal work. A number given before that plan exists is not the fee. Combined procedures typically cost less than the same operations done separately, because the anaesthetic and facility time are shared.