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The Skinny On Fat Versus Fillers

By Robert Kotler, MD, FACSOctober 19, 2011
From the WebMD Archives

Patients coming in for surgery to make them look younger often will ask about fat injections.

There has been a lot of attention in the press about fat injections as a way to fill the grooves and troughs around the face. The areas most commonly affected by aging are around the mouth and lips. There are the nasolabial creases, the pair of which looks like parentheses, extending from the side of the nose down to the corners of the mouth. Then, there are the marionette lines, also somewhat parenthetic and parallel, running from the corners of the lower lip to the chin.

Another area that frequently tends to shrink and flatten out is the cheek bone area, particularly toward the nose under the eye. Finally, the area that shows hollowness with increasing age is below the cheek bone in the mid-cheek area.

What are the options? Today, we have more than ever. First, there is fat grafting. It begins with liposuction from the abdomen or the buttocks. It is filtered, prepared, and then injected into the areas that show shrinkage.  In excellent and in experienced and highly specialized hands, fat injections can be successful. The alternative is to fill with man-made fillers. This would include Restylane, Juvederm, Radiesse, Artefill and Sculptra.

Now, Radiesse and Juvederm are very similar – each is composed of hyaluronic acid – a natural occurring substance in human bone cartilage and skin. The product is bio-engineered in the laboratory and is considered pure and free of any possible rejection phenomenon. Complications from these injections are very, very rare. One unique property of Juvederm and Restylane, being hyaluronic acid, is that in case of overinjection, they can be dissolved using an enzyme called hyaluronidase. 

While Restylane and Juvederm have a relatively short life within the tissues, typically 4-6 months or a bit longer, some of the other products are engineered to last longer. I have seen nice results from Sculptra injections done five years prior. 

So, what about this competition between fat injections and what I will group together as the “non-fat injections”? The non-fat injections, which are laboratory made, allow a major advantage in that when the injections take place, one can see the result. Now, Sculptra is somewhat of an exception because it takes several months for the body to make new collagen and capitalize on the presence of Sculptra. The other products render an immediate, visible improvement. That is a huge advantage because the patient gets to make a decision when he/she is happy with the amount of filling. Further, one can fill a moderate amount and see how it looks in a few weeks, and go back and “top off.”  There is no need to puncture the body to obtain this as there is with fat injections.

I happen to like the concept of “testing the waters” with the non-permanent hyaluronic products, Restylane and Juvederm, almost as a “demo”. Their immediate effect and shortened longevity also allows the patient to quickly decide if they are happy with the results. If they do not see the demonstrable improvement, and do not feel that it is a reasonable investment of their time and money, they can refrain from any further injections. There is economy of dollars there. 

Now, let’s look at fat injections. I want to cite the recent discussion that took place on the pages of an excellent cosmetic surgery magazine for surgeons, Cosmetic Surgery Times. The publication interviewed two veteran cosmetic surgeons who faced off on fat injections. In the fat injection corner was J. William Little, MD, and in the “non-fat” injection corner was Val Lambros, MD.

I do not know Dr. Little personally, but he enjoys an excellent reputation nationally and internationally. I do know Dr. Lambros, and I have always admired the work that he has done, including his very unique tracking of individual facial aging using medically-consistent photographs. He has been a very good student of the subject of where the face ages, how it ages, and how, to the eye, the signs of aging can be reversed.

 Dr. Lambros made a very strong case for the unpredictability of fat injections. Frankly, I sit in that camp, also. I have always seen the unpredictability as the major disadvantage of fat injections. It does not mean that you cannot have a spectacular result, but it would take a very experienced practitioner, and somewhat of a “good day.”  Remember, not all practitioners are experienced enough to have a long track of patient observations, and Dr. Lambros referred to that.  I have selected certain quotes from his commentary because I think they are very on point. 

“Injected fat can grow. This will be the longest long-term problem with fat.”  Dr. Lambros goes on to mention that, indeed, “the injected fat cannot be removed.  Then, you have the issue of symmetry. The surgeon may inject equal amounts into both cheeks, but maybe some of the fat will take on one side, and more will take on the other.  Another point made was that, in fact, due to a variety of anatomic factors, the fat takes better in younger people.  But, it is the older people that need the fat more because the hollowing of the face is a function of aging.” 

Further, Dr. Lambros agreed with my observation that it takes quite a bit of experience and, what he calls, “finesse” and “esthetic sensibilities.”  While these are laudable and important characteristics in the cosmetic surgeon, we have to admit that not all will have this. If so, that is a negative.

Young surgeons are always taken with technology. In fact, it is a little more exciting to harvest the fat, treat it, and inject it.  It is more mechanical, more surgical than the mere injection of a syringe filled with a non-fat filler, such as Restylane, Juvederm, Radiesse, Sculptra or Artefill. 

I sense that there will always be a difference in opinion because cosmetic surgery is an art. Each practitioner should develop facility with those techniques and procedures that he finds to be most successful, and with which he is most comfortable.

For the patient, the only thing that counts?  Results.

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