Eliza Cabana

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?

Most practices have reopened and have put processes in place, including some combination of AesCert, professional association and local and federal guidance, but what have we learned?

We have learned a lot since just following the COVID crisis. We've learned, for example, that surfaces are not as important as aerosol. That this is an aerosolized virus that can spread from super spreaders, but you never know who they are. The 

 just published a big paper on super spreaders. We don't know what they are. We just know they can give it to 20 people, while the other nine in the room give the virus to nobody. But we don't know why. But there are these large boluses of virus, which can be aerosolized. So while surfaces might be important, small closed spaces for prolonged periods of time without masks is the worst. 

You don't want to be with someone without a mask for prolonged periods of time when they're close to you and it's probably 10 or 15 minutes. Someone's positive, but you don't know they're positive till a week later. So I think what we do is have to assume everybody's positive, socially isolate, and I think by keeping these rooms clean, high circulation of air, wiping down surfaces, masks. We wear N95s 12 hours of the day. The minute I arrive, to the minute I leave, it doesn't come off. For lunch, I'm in a private room all by myself. Now, I get hypoxic, and I'm hot and it's uncomfortable, but I'd rather be that than in the ICU.

We've already had one of our head nurse’s mother-in-law died of COVID. She's a registered nurse with one of the big hospitals in town. Sixty-two and perfectly healthy. 

I've had 10 colleagues’ parents die of COVID in nursing homes in Canada, Britain and in America. It's not to be taken lightly. It's a serious disease and lots of sequelae, and it's going to be around now, we've also learned, for a couple of years. At least it's not going away this fall. It’s not going away next winter. The vaccine will not be ready for primetime in December.

Unfortunately, our leadership has been lacking tremendously on a governmental level, so we have to do it on a grassroots level, locally and physician-to-physician, colleague to colleague, and set the standards. Because we actually know public health. 

We know, protect the cough, protect the spread; wear gloves, clean and do all these things. And when you do that it actually works. It's been shown.

Videos

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

COVID-19: What We’ve Learned

Jeffrey Dover, M.D., Chairperson for the AesCert Guidance Supplement, and the entire panel of national physician experts who collaborated on the project, achieved something previously unheard of.

“In two weeks, we wrote this 26-page manuscript. Four days later it was accepted for publication, and then a month later was actually in print,” says Dr. Dover, Co-Director of SkinCare Physicians in Chestnut Hill, Mass., Associate Professor of Clinical Dermatology at Yale University School of Medicine.

If that isn’t impressive enough, Dr. Dover says theirs were the first guidelines published, even before the professional societies developed their own.

“You can do it nimbly when you have a small group of people who are not associated with a big organization. But we use their expertise,” he says.

Case in point, second author, Mary Lynn Moran, M.D., is the current president of the AAFPRS.

“We put together a panel of national experts: The head of infectious disease at two of the Harvard teaching hospitals; the head of infectious disease at Stanford; the head of medicine at UCSF in San Francisco; facial plastic surgeons and plastic surgeons across the country; and public health experts at Harvard,” says Dr. Dover.

The guidelines, he says, have been well received, not just in the U.S. and Canada, but from all over the world.

“It’s truly for everybody in every specialty: dermatology, plastic surgery, facial plastics, oculoplastics, non-core — for anybody in aesthetic medicine, and even aestheticians,” says Dr. Dover.

When asked whether he was following the guidelines, Dr. Dover’s response was “to a T.”

“We're following the template exactly for reopening and of course since the publication in early May, and online in April, we have reopened. And we're using this as our guideline, but we then modified it for our staff.”

“There's very little to add,” he says, reinforcing how comprehensive the AesCert guidelines are.

Importantly, and perhaps not as widely known, the guidance was also developed for the patient community. The aescert.org site also provides guidance for patients in terms of what they can expect when they visit a practice that follows the guidelines.

“We have practices who are using the AesCert emblem on their website and in their offices to say, ‘We’re following these strict guidelines,’” says Dr. Dover.

This, he says, provides the trust and credibility patients need and are actively seeking.

“I make it very clear. I say, ‘See the way I'm dressed? This is for your protection.’ You notice there's no nurse in the room. You notice there's no waiting room. You walked right in [and] sat down. It's just two of us. There's zero exposure. You cannot be in a safer place. We're following these special guidelines, and we are generating tremendous trust.”

Today, many practices have processes and protocols in place and are currently providing elective treatments. What have we learned since the guidelines were first issued?

According to Dr. Dover, we’ve learned a lot.

“We learned, for example, that surfaces are not as important as aerosol. That this is an aerosolized virus that can spread from super spreaders, but you never know who they are… so while surfaces might be important, small, closed spaces for a prolonged period of time (10 to 15 minutes) without masks is the worst,” he says.

If someone’s positive, you won’t know it until a week later, he points out. “So, I think... we have to assume everybody's positive and socially isolate.”

Dr. Dover believes the current approach is going to be something physicians and patients must learn to live with.

“It's a serious disease and there’s lots of sequelae, and it's going to be around… for a couple of years at least,” says Dr. Dover. “It's not going away this fall. It’s not going away next winter. The vaccine will not be ready for primetime in December, and unfortunately our leadership has been lacking tremendously on a governmental level. So we have to do it on a grassroots level locally and physician-to-physician and colleague to colleague and set the standards. Because we know public health. We know, protect the cough, protect the spread; wear gloves, clean and do all these things. And when you do that it actually works.”

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. 

Author | Eliza Cabana

Articles