It’s not always simply a matter of choosing one or the other, say the experts. Generally, fat is best used for global facial volumization and fillers can help to finesse results.

Think of fat grafting as an opportunity to create a better template to work from, suggests Cameron D. Chesnut, M.D., F.A.A.D., a dermatologic surgeon in Spokane, Wash.

“I view it as [a] reset button, and that's their new point of aging and then they're going to… keep up to it from there. So for [a] nurse practitioner or PA or nurse injector, you're starting with a better template to work with moving forward. Your results are going to be better because that patient had an initial fat grafting or two... I know they're going to be happier,” says Dr. Chesnut.

Although many patients can expect to need to have a touch up with fat, fillers or both, Dr. Prada says he doesn’t use the phrase “touch up.” He explains it in terms of “building” to patients.

“You need to allow a certain foundation to solidify before you can add more and you build that wall up slowly with fat. If you just clump the fat into an area, that fat isn't touching viable tissue. It's going to go away. It's not going to survive,” says Dr. Prada. “I tell all of them that you just can't clump 20 cc's in the face. It's not like a filler. The filler will sit there. The fat — you’re going to lose two-thirds of that.”

He tells patients there’s a 50% chance they’ll come back to continue building viable fat.

“I'd rather add more [later] than put too much in, and so that's another thing that I always tell them,” says Dr. Prada.

Despite the likeliness of fat resorption, Frank Fechner, M.D., a facial plastic surgeon in Worcester, Mass., says he doesn’t usually do touchups with fat.

“Everything after [fat grafting] is going to be managed by fillers, and there's always going to be something else that patients want to have tweaked, early or later,” he says.

The panel overwhelming agrees on the need to wait at least 6 months for fat transfer touch up.

Fat grafting isn’t just about adding volume, says Dr. Chesnut. It also benefits the skin.

“There’s an unquestionable paracrine effect that happens,” he says.

And that, Dr. Chesnut says, is a result of stem cells.

“I get really nerdy on this and like to get into different types of fat — micro fat, milli fat, nano fat — and I really focus on the stromal vascular fraction, which means my harvests are generally a little higher even for small volumes because I’m trying to get that stem cell dense portion… [which] I feel makes my results a little bit better, but it also sets it apart from filler… we know from… transferring human fat to mice that they get more stimulation of angiogenesis in fat, so there’s an unquestionable improvement with that transfer.”

Dr. Chesnut says he usually sees those skin results in a 6-month timeframe. For Dr. Lam, it’s closer to one to two years.

“I do a fair number of [fat transfers] alone without resurfacing too… and it’s more than just volume. There’s a quality change to the skin,” says Dr. Chesnut.

Articles

Fillers and fat aren’t necessarily mutually exclusive, say experts. Fat is great for global volume, while fat offers finesse.

Fillers for Post-Fat Grafting Finesse

When a patient asks, should I have filler or fat, how do you advise? That was one of the key questions posed by L. Mike Nayak, M.D., St. Louis-based facial plastic surgeon, during the “Fat vs. Fillers: Change My Mind,” session in his virtual Medspa Mastery course that took place earlier this year.

The answer is based on many considerations, including age, number of treatment areas and what those areas are, according to panel member Christian A. Prada, M.D., F.A.C.S., a St. Louis-based plastic surgeon.

“These are all going to come into play in terms of deciding whether filler or fat’s going to be better…,” he says. “Patients can come in and they're interested in one thing or the other and I just tell them, ‘you're going to do much better with filler. Go that way. That's how I would treat my wife if she needed something, or [go] the other way [if that’s the better option].”

Johnathan Sykes, M.D., F.A.C.S., a facial plastic surgeon in Beverly Hills and Sacramento, Calif., says he educates patients on the differences and leaves the choice up to them.

“I tell them, honestly, about all the things, pro and con, of fat and filler. If it's a more globalization thing, I like fat. If it's a patient that's going into surgery, I like fat. And that's my bias. If it's a patient that wants more spot treatment or a structural treatment, like her cheeks are drawn, I like filler. …I answer all their questions and I let them make a decision,” he says.

For Samuel M. Lam, M.D., F.A.C.S., a facial plastic surgeon in Plano, Tex., he generally prefers fillers in terms of longevity, predictability and cost-effectiveness.

“My patients have durability with fillers, so I no longer make the argument that fat is more durable than fillers,” he says. “Honestly, I would love to put 20 syringes of fillers in, but it's cost prohibitive. So I do fat if their weight is stable. And that's one point about safety is… to avoid issues with weight gain. That's something that doesn't occur with fillers. [With] fillers you have to worry about granuloma.”

Dr. Prada says he generally recommendation filler for younger patients who don’t want the downtime or require much volume.

“They're going to do much better with a very quick, in and out treatment. They do not want to have a week or two of swelling on their face. They just want to have the lips look a little bit more plump. And I've always found when I put fat into the lip, [patients] can go through four-to-six weeks of having this Daffy Duck look that they don't like.”

When it comes to lips, not everyone thinks fat is a good idea.

“I think, as we know, areas that have more motion in the face seem to disrupt the attachments in the fat and you just don't get as much take,” says Dr. Prada. “I don't find that [fat] take in the lip is nearly as good as it is over the zygoma.”

And there are additional reasons for opting for filler vs. fat in the lips, according to Dr. Sykes.

“…We can be more precise with a filler than we can with fat,” he says. “[With] filler we can either dilute it, we can put very tiny amounts, we really can control that amount that gets there. If we put a small amount of fat near the surface [of the lip], it may gain a really good blood supply and become a lump. So I love filler for lips. The patient says to me, 'I want to fatten my lips because I want it to last forever,' I try and reeducate them.”

Dr. Lam concurs. Not only does he avoid putting fat in the lips, but he also discourages the use of fat in isolated areas.

“If someone comes in and [says], ‘Just fix this tear trough with fat,’ I'm going to say, do fillers. Of course, there's risk with fillers but that's my approach to it.”

Dr. Sykes agrees that fillers are a good choice for smaller areas and can offer a higher level of precision.

“If I’ve got a small area, I like the idea of using filler in that area, because it makes sort of sense of not going to the operating room not harvesting, from an area,” he says. “As far as the tear trough is concerned, I think we can be more precise with [a] fine 30-gauge needle than we can with that fine cannula, putting little lumps — even though they're micro lumps — of fat in that area.”

An expert panel shares how they choose between filler and fat for facial rejuvenation.  

Filler or Fat: How Do You Choose?

With the recent restrictions due to COVID-19, patients all over the world have been unable to regularly visit their medical and aesthetic offices. While some of these visits are for beauty augmentation, the majority are for self-care and maintenance. Although physical access to facials, chemical peels and lasers is still limited for many, technology allows physicians and health care providers to visit virtually to address aesthetic concerns and enhance skin health. Many of our patients have been asking us how to take advantage of this social downtime for their skin. While quality time with skincare physicians and/or aestheticians is integral to skincare, there are some other great options available while we continue to restrict and/or limit face-to-face contact.

Because our patients are focusing on correcting and improving their skin during this pause from social engagements, we have started to dive deeper into options for at-home peels. While we usually use in-office PCA Skin chemical peels administered by my aestheticians or myself, we have found some very effective alternatives that our patients can use twice a week at home. These are not only safe, but they can effectively enhance our in-office treatments.

The ClarityRx line has elegant formulations utilzing gold standard ingredients such as glycolic acid, salicylic acid and lactic acid, all mixed with water.

We have been seeing great results with their medicated Pick Me Up Booster Pads which incorporate alpha- and beta-hydroxy acids to increase cell turnover and clean pores. While not the same strength as what a patient would have in our office, these are very clean, efficacious formulations that provide a great alternative to having a professional chemical peel.

Retinoids can be used to create an at-home peel.

If the patient is on prescription tretinoin, I ask him or her to increase usage to twice a day for four to seven days until peeling is seen. For those patients who are exercising outside, I recommend one of the PCA Skin retinols as the retinol is stabilized with omnisome technology and are not degraded by sunlight.

Clients with retinoid sensitivity can still benefit ISDIN’s Melatonik which contains bakuchiol shown to be as effective as tretinoin without the irritation. Another excellent retinol alternative is ClarityRx’s Sleep It Off Mask. This product is applied on clean skin and has a warming sensation as it activates. This unique mask then converts into a moisturizer to be left on overnight.

Masks, too, have been a very popular addition to our patients’ skincare routines. We carry a variety of masks to specifically address each patient’s concerns, and with this new-found commitment-free time at home, many of our patients are alternating different masks to keep their skin refreshed and glowing. In fact, over the past three months, our monthly at-home mask sales have been seven times higher than average. Typical usage is two to three times per week. The mask is applied and left on anywhere between 15 and 30 minutes before rinsing off.

Dr. Suneel Chilukuri is a board-certified dermatologist in Houston, Tex., who specializes in cosmetic dermatology. He is an international trainer for numerous cosmetic dermatology products and procedures and a member of the Aesthetic Authority Editorial Advisory Board.

Dr. Suneel Chilukuri offers observations and opportunities for patient self-care and maintenance during the pandemic.

Skin Solutions During the Pandemic

 details fast and effective sunburn treatments, and a $3 Magic Shaving Powder that TikTok is obsessed with, 

 explains the difference between retinoid and retinol, and 

 talks aloe vera uses that have nothing to do with sunburn relief as well as skincare tips from Dr. Barbara Sturm.

The Fastest, Most Effective Ways to Treat a Sunburn

Retinoid vs. Retinol: When to Use Each and Why

Why You Don't Need More Than 5 Products in Your Skincare Routine, According to Dr. Barbara Sturm

8 Amazing Benefits And Uses For Aloe Vera

TikTok Is Obsessed With This $3 Magic Shaving Powder, But Is It Safe?

This week, consumer magazines talk retinoid vs. retinol, effective sunburn treatments and more. 

Retinoid vs. Retinol

This week in aesthetics, we compare stem cells and exosomes, a recent study shows an increase in PRP use for the periorbital region, Dr. Jeffrey Dover shares what he’s learned about COVID-19 since reopening, Dr. Joel Cohen talks about popular combination therapies, Dr. Zoe Draelos discusses facial appearance apps, Dr. Jason Pozner provides an inside look at the latest ultrasound technology and Dr. Vince Bertucci offers tips for improving the injectable consultation.

Stem cells largely remain an unproven therapy. Could stem cell-derived exosomes be the key to successful anti-aging treatments? 

PRP Use Increasingly Popular for Periorbital Region

PRP joins peels, lasers, neurotoxins and fillers as a go-to treatment for periorbital rejuvenation according to a recent study in the

Dr. Jeffrey Dover, Chairperson for the AesCert Guidance Supplement published by the AAFPRS, provides an update on the current state of safety in the aesthetic practice.

With many patients working from home during the pandemic, Dr. Cohen says more patients are open to combining treatments and extending their downtime. 

Dr. Zoe Draelos discusses the role of consumer-targeted facial appearance apps, how they work and how they can be manipulated.

Device guru Dr. Jason Pozner provides an inside look at the latest in ultrasound technology.

Dr. Vince Bertucci offers tips to improve the cosmetic injectable consultation

Dr. Jeffrey Dover shares what we’ve learned about COVID-19 since reopening the aesthetic practice.

In case you missed it, this week we talked about ways to improve the injectable consultation, AesCert Guidance and more. 

This Week in Aesthetics: June 29 – July 3 

Despite the growing interest at the turn of the century in pursuing stem cell research to treat physical degeneration, damage and disease, nearly two decades later, the general safety and efficacy of stem cell therapy for regenerative medicine remains largely unproven.

According to the U.S. FDA, the only approved stem cell applications are from bone marrow or blood in transplant procedures to treat patients with cancer and disorders of the blood and immune system.

The FDA warns of the potential dangers of unproven stem cell therapies, including administration site reactions, the failure of cells to work as expected and the possibility that cells may move from placement sites and change into inappropriate cell types or multiply.

 reported a case of macular degeneration that led to blindness in a patient after a stem cell injection into the eye.

Another patient grew a spinal tumor after receiving an injection of stem cells to the spinal cord, according to the FDA.

Foreign stem cells can also be rejected by the immune system.

Exosomes, on the other hand, are released from stem cells and are cell-free. Researchers from Oxford and Scripps now conclude that it’s the exosomes specifically that have the regenerative benefits.

 The tiny sacs, 30 nm to 150 nm across, transfer DNA, RNA or proteins from cell to cell, affecting the function of recipient cells.

Researchers have examined exosomes harvested from human skin cells for skin repair.

In a paper on the subject, researchers at North Carolina University saw the anti-aging potential of exosomes after testing 3D spheroid-grown exosomes compared with a retinoid, 2D spheroid-grown exosomes and bone marrow-derived mesenchymal stem cell (MSC) exosomes (which the authors note are currently used as a stem cell anti-aging treatment) to evaluate skin thickness and collagen production in mice.

They found that the 3D exosome-treated skin was 20% thicker than untreated skin, 5% thicker than MSC-treated skin, and had 20% more collagen than MSC-treated skin.

Unlike stem cells, exosomes can’t replicate or transform into malignant or harmful cells because they themselves aren’t cells. They also can’t be infected with viruses and are less likely to trigger an immunogenic response.

Their small size gives exosomes the advantage of being able to circulate more easily through the body and be administered without the use of needles. They’re able to penetrate the skin using pressure or jet injection methods.

For all these reasons, exosomes may turn out to be the holy grail initially envisioned with stem cell therapies. Stay tuned for more.

https://www.fda.gov/consumers/consumer-updates/fda-warns-about-stem-cell-therapies

Kuriyan AE, Albini TA, Townsend JH, et al. Vision Loss after Intravitreal Injection of Autologous "Stem Cells" for AMD. 

Stem cells: What they are and what they do. 

https://www.mayoclinic.org/tests-procedures/bone-marrow-transplant/in-depth/stem-cells/art-20048117

Nine Things To Know About Stem Cell Treatments. 

https://www.closerlookatstemcells.org/stem-cells-medicine/nine-things-to-know-about-stem-cell-treatments/

Ian Dixon, M.D. Exosomes vs Stem Cells: Exosomes as the Next Big Thing after Stem Cell Therapy. 

https://exopharm.com/the-next-big-thing-exosomes-versus-stem-cells/

Hu S, Li Z, Cores J, et al. Needle-Free Injection of Exosomes Derived from Human Dermal Fibroblast Spheroids Ameliorates Skin Photoaging. 

Tracey Peake. Suntanner, Heal Thyself: Exosome Therapy May Enable Better Repair of Sun, Age-Damaged Skin. 

https://news.ncsu.edu/2019/09/exosome-therapy-skin-repair/

Stem cells largely remain an unproven therapy. Could stem cell-derived exosomes be the key to successful anti-aging treatments? 