Facial Fat Grafting: Keep It Simple

The fat-grafting revolution perhaps rests less on advanced technology than the adoption of simple strategies. While newer equipment can streamline fat processing, getting started in facial fat grafting requires little more than syringes, cannulas, saline, and gauze. Technical consensus remains elusive, but experts expect this market to continue growing.

“Most plastic surgeons would agree that fat grafting is undergoing a revolution right now, and it’s been increasing in popularity,” says M. Bradley Calobrace, MD, founder of CaloAesthetics Plastic Surgery and a clinical professor of plastic surgery at the University of Louisville and the University of Kentucky. Dr. Calobrace focused on the topic of fat grafting and offered first-hand experiences and pearls in a recent presentation at the 2023 Beauty Through Science (BTS) conference in New York.

Market and Costs

Between 2023 and 2030, the global facial fat-grafting market is expected to grow from $2.1 billion to $4.9 billion,1 according to SkyQuest Technology Group. The pioneering work of Sidney R. Coleman, MD, made facial fat grafting a widely discussed topic.^2,3 Due to the complexity and laboriousness of Dr. Coleman’s technique, however, Dr. Calobrace explained that fat grafting never caught on until recently, when surgeons began to appreciate the need to restore volume—and not just tighten sagging skin—aiming to achieve the most youthful aesthetic outcome.

Currently, fat grafting is a near-essential tool to agument surgical results of the face, breast, and buttocks. To collect fat for facial grafting, most surgeons insert a syringe through a small cannula and apply gentle pressure. One can then place the fat on nonadherent gauze (to drain oils) or use saline rinse before loading syringes for injection. Harvesting and processing fat this way takes 5 to 10 minutes, Dr. Calobrace said. “The less you process the fat, the better,” he added, noting that minimizing trauma improves fat cell survival. “In the past, we would expect to get maybe 30% to 50% of the fat to survive,” he said. “Today, we can expect 50% to 70% fat survival in the face.”

Dr. Calobrace says that if he injects 30 cc of fat, within 3 to 4 months, approximately 15 cc remains, at a cost of $2,000 to $3,000 for results that last potentially a lifetime. A comparable amount of hyaluronic acid filler, he says, would cost $10,000 and last 1 year.

Extracellular Matrix: An Alternative to Fat Grafting?

An off-the-shelf injectable matrix encourages growth of new fat cells, restoring lost facial volume and improving skin quality with predictable results that last longer than fillers. The only potential downside, says a physician who spoke at the 2023 Beauty Through Science (BTS) conference, is that some patients might reject the product’s donor-derived composition.

Shino Bay Aguilera, DO, a Fort Lauderdale-based dermatologist, said in a recent presentation at BTS meeting that he has seen some of the challenges with fat grafting, such as patients who “paid a lot of money, went through the downtime, looked weird for 3 months, then looked great. Then, a year later, it all went away.”

Conversely, he says, Renuva, an adipose-derived extracellular matrix allograft, requires neither surgical fat harvesting nor overstuffing.

“I know that whatever I get from the injection from the syringe, the patient gets to keep, he said.^¹

Processing removes any living cells but leaves the same proteins, collagen, and growth factors found in autologous fat to nurture creation of new fat cells.^2,3 Dr. Aguilera noted that in a 6-month study of 10 patients with atrophic temples, temple fullness increased 75% from baseline.^⁴ The average patient requires 3 to 6 cc of the adipose allograft matrix solution. Patient pricing starts at $1,082 for 1.5 cc, according to Renuva’s manufacturer MTF Biologics.

“There is very little to no downtime other than bruising, and results typically last 5 to 10 years depending on the patient’s metabolism and lifestyle.”

Results begin appearing in about 6 weeks, he says. Eight weeks post-injection, Dr. Aguilera assesses whether patients need additional treatment. Not only do patients regain lost facial fat volume, he says, but the treatment also improves skin quality more significantly than fat grafts do.

“You can treat areas like the neck with hyperdiluted Renuva, and the skin looks incredible,” he said. “I can improve skin quality while replacing the volume that was lost.”

Ideal candidates include healthy patients with significant age-related facial volume loss, as patients in a catabolic state cannot respond satisfactorily.

Dr. Aguilera says comparing fat grafts to Renuva is comparing apples to oranges. However, he noted that a durable treatment that costs the same or potentially less than fat grafts, without surgery and the need for overcorrection, may be more appealing to consumers.

Disclosures: Dr. Aguilera is a speaker and trainer for Galderma, Allergan, BENEV, Toskani, and Prollenium.

1. Aguilera, SB. Don’t fake younger. Beauty Through Science USA; December 3, 2023; New York.

2. Kokai LE, Schilling BK, Chnari E, et al. Injectable allograft adipose matrix supports adipogenic tissue remodeling in the nude mouse and human. Plast Reconstr Surg. 2019;143(2):299e-309e. doi:10.1097/PRS.0000000000005269

3. Giatsidis G, Succar J, Haddad A, et al. Preclinical optimization of a shelf-ready, injectable, human-derived, decellularized allograft adipose matrix. Tissue Eng Part A. 2019;25(3-4):271-287. doi:10.1089/ten.TEA.2018.0052

4. Gold MH, Kinney BM, Kaminer MS, Rohrich RJ, D’Amico RA. A multi-center, open-label, pilot study of allograft adipose matrix for the correction of atrophic temples. J Cosmet Dermatol. 2020;19(5):1044-1056. doi:10.1111/jocd.13363

Going Micro and Nano

Microfat injections involve passing structural fat or macrofat (like that used for the cheeks, temples, and jawline) through a sieve to break down particles for smoother superficial injections in delicate areas such as the lower eyelids and perioral region.4

When injecting lower lids or lips, breaking down fat cells themselves produces nanofat.5 Stem cells and other regenerative cells in nanofat improve skin texture, contour, and vitality without boosting volume, Dr. Calobrace noted. For many surgical patients, he said that he applies nanofat over the lips, marionette lines, and wrinkles before “driving” it into the skin with microneedling or microcoring. Another evolving technique for enhancing nutrients within fat is augmenting it with platelet-rich plasma (PRP).

Systems that can streamline microfat and nanofat processing include the disposable Lipocube Nano, as well as reusable kits such as those made by Tulip Medical.

No Perfect Solution

Granted, every device or disposable increases cost to patients, and Dr. Calobrace pointed out that there is always a balance between how many special devices and/or costs they want to incur and to keep treatment affordable.

Moreover, fat-grafting techniques and results remain provider-dependent.

“There’s never been any agreement about how you collect, process, and place it,” he said. “No single way works perfectly in everybody’s hands, he says, “or we would all be doing it the same way.”

When using autologous tissue, Dr. Calobrace said that results are only as good as the patient’s overall health.

“Younger fat probably is more viable, with better stem cells and more ‘magic’ than other fat,” he added.

Ultimately, performing rigorous studies in all fat-grafting indications will help doctors make better decisions about which systems work and how long results last. As an example, he points to a 14-site prospective study of the Viality device for fat grafting in the breast, for example, showing that at 1-year post-procedure, more than 80% of grafts survived.6

Dr. Calobrace is enthusiastic and optimistic about the future.

“Fat grafting in the face and all areas of the body is here to stay, expanding, and evolving. What we are doing today is only a small fraction of what we’ll be doing in the future.”
—by John Jesitus

Disclosures

Dr. Calobrace was principal investigator (unpaid) for Sientra (Viality) but received no payment except to reimburse patients. He reports no other relevant financial relationships.

1. SkyQuest Technology Group. Global facial fat transfer market size, share, growth analysis by donor site (thigh, abdomen), end-use (hospital, clinics & surgery centers) – industry forecast 2023-2030. https://www.skyquestt.com/report/facial-fat-transfer-market. October 2023. Accessed January 19, 2024.

2. Coleman SR. The technique of periorbital lipoinfiltration. Oper Techn Plast Surg. 1994;1:120-126.

3. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg. 1995;19(5):421-425. doi:10.1007/BF00453875

4. Lindenblatt N, van Hulle A, Verpaele AM, Tonnard PL. The role of microfat grafting in facial contouring. Aesthet Surg J. 2015;35(7):763-771. doi:10.1093/asj/sjv083

5. Tonnard P, Verpaele A, Carvas M. Fat grafting for facial rejuvenation with nanofat grafts. Clin Plast Surg. 2020;47(1):53-62. doi:10.1016/j.cps.2019.08.006

6. Shridharani S, Medina M, Calobrace MB, Dajles D, Saul S. Preliminary results from multi-center volume retention study of Viality. Presented at: American Society of Plastic Surgery Annual Meeting; October 28, 2023; Austin, TX.