Fat injection

This article covers the volume aims of fat injection in the face and body, how it differs from ready-made fillers, how much of the transferred fat can remain, and the possibility of a second session. The healing, care and risks of the donor area from which the fat is taken and the recipient area into which it is placed are described separately. Breast imaging and the rare but serious vascular complications are also within its scope.

What is fat injection?

Fat injection is the transfer of a person's own fat tissue from one area to another where volume is to be added. It is also called autologous fat grafting or lipofilling.¹ The place the fat is taken from is the donor area and the place it is put into is the recipient area; the operation concerns both.²

The transferred fat is not a ready-made filler material but the person's own tissue. Part of the tissue that can gain a blood supply in its new place may remain, while part may be reabsorbed over time.² It is not assumed that all of the volume injected at the start will remain. Retention rates have been reported to vary over a wide range across studies.³

The aim is to reduce a lack of volume or a particular surface irregularity.¹ Adding volume is not the same aim as surgically repositioning loosened tissue.⁴ Its relationship with face and midface lifting is therefore explained below, as separate operations that can be carried out together.

Who is it suitable for?

Assessment can be made in people who have a lack of volume, who have an area from which fat can be taken, and whose expectations of the achievable change are realistic.²¹ Not every line in the face or every difference in breast shape is a problem explained by adding fat alone; planning first establishes which tissue and which aim are in question.

Hollowing at the temple and a shortage of volume in a particular area of the face are among the situations in which the procedure is assessed.⁵⁴ That an area ought to be fuller is not decided by age alone or by another person's appearance. Expectations are assessed through the person's existing structure and the feature they want changed.

The state of the recipient tissue, previous operations and factors such as radiotherapy can affect the plan.⁶ Where there is not enough donor area, or the recipient area cannot suitably accept the intended volume, the extent of the procedure is reassessed.²⁶ Taking fat does not mean an extensive body contouring operation will be performed in the same session; obtaining the fat and reshaping the donor area are set as separate aims.⁷

What does the examination assess?

The recipient area: The site of the volume difference, the match between the two sides, tissue thickness, previous procedures and existing scars are assessed. It is not assumed that the same amount of fat will produce the same appearance in different tissues; the characteristics of the recipient tissue matter in assessing the graft.⁶

The donor area: The places from which fat can be taken and any existing irregularities in those areas are examined. Regions such as the abdomen, the waist or the thigh can be used as a source of fat; the choice is assessed together with the tissue available and the aim of the operation.⁸ Previous liposuction in the donor area, and previous surgery or healing problems, are reported at the examination.

Previous procedures: If you have had fillers, fat injection, or facial or breast surgery, the date, the area and any operative records are made available for assessment. Adding volume is not planned as a correction that removes all the effects of an earlier procedure.

Breast assessment: Where a procedure on the breast is considered, any existing lump, previous biopsies and operations, and personal and family history of breast cancer are assessed. The need for imaging is determined by age, by risk and by the examination findings.⁶ Fat injection does not take the place of breast cancer follow-up.⁶

The examination assesses not only the appearance of the recipient area but also the healing burden of the donor area.² Plans for work, travel, hospital stay and everyday movement are prepared with both areas in mind. Where the feature the person most wants changed and the volume change this operation can provide are not the same thing, the aim is reassessed.

How is the operation planned?

Where is the fat taken from and how is it prepared?

Fat is taken through small skin entry points with a cannula, prepared for transfer, and delivered to the recipient area through small entry points.¹ Collecting the fat, separating it from components such as blood and free oil, and placing it are distinct steps; preparation methods vary between publications.⁸ Using the name of a method does not by itself indicate the same retention rate or a result without complications.³

The amount of fat taken and the amount transferred do not have to be the same; the components removed during preparation and the requirement of the recipient tissue are taken into account.⁸ The volume to be injected is planned according to the areas identified at examination, not to a single template. No single cannula size, injection plane or volume is recommended here for everyone.

What is aimed for in which areas of the face?

Around the temple, the cheekbone and the zygomatic arch, the aim is to assess the soft tissue volume over the bone and the transition to neighbouring areas.⁵⁸ The aim is not to enlarge the bone itself but to add volume to the soft tissue over it.⁴ Soft tissue fullness at the chin, volume in the lip, hollowing around the eyelid and the volume-related transition at the nasolabial fold are separate aims.⁴ The name of an area does not show that giving fat there is suitable in every person.

Adding volume around the eyelid is not the same operation as removing excess skin or correcting the position of the lid.⁹¹⁰ In areas with thin tissue, irregularity and fat deposits that become prominent also have to be assessed.¹¹ Adding volume at the temple likewise carries no promise that the brow will be lifted.

What is aimed for in the breast and other body areas?

In the breast, the aim may be to increase volume, to reduce a difference in fullness between the two sides, or to correct a contour deficit remaining after previous surgery.⁶ Adding fat injection in breast augmentation, breast lift, tuberous breast and breast asymmetry correction is a separate decision. Excess skin, tissue position and structural constriction are not assessed through the volume to be added alone.

Fat transfer has been studied on the back of the hand to reduce the prominence of bone and tendons caused by volume loss.¹² The aim here is not to remove all signs of ageing in the hand. The review covering this area reports that methods and volume measurements differ between studies.¹²

Fat transfer to the buttock is also a body procedure that can be carried out for volume and contour.¹ The safety assessment of this area is, however, separate. The American Society of Plastic Surgeons and the organisations issuing the joint advisory support delivering the fat in the subcutaneous plane above the muscle fascia, and monitoring the position of the cannula with real-time ultrasound.¹³ The extent and care requirements of a buttock procedure are not taken as the same as a small facial volume correction; the timetable here is not a standard that can be applied automatically to every area.

How does it differ from a ready-made filler?

Hyaluronic acid filler is a ready-made substance; a fat graft requires tissue to be taken from the person's own body. Fat injection therefore involves the healing of a donor area alongside the recipient area.¹¹ This difference affects the burden of the procedure and its care.

With hyaluronic acid fillers, hyaluronidase can be used to reduce unwanted volume. A fat graft cannot be dissolved and taken back in the same way with hyaluronidase.¹¹¹⁴ That part of the fat is reabsorbed on its own does not mean it can be reversed in the place and in the amount wanted. Where excess fullness or irregularity remains, separate assessment is needed.¹¹

The effect of the part of the fat that takes can last longer; this does not, however, mean that all of the injected volume remains unchanged.¹¹ The word "filler" covers different substances; the possibility of dissolving that is described for hyaluronic acid is not generalised to every ready-made filler.¹¹ Vascular complications have been reported with both approaches.¹¹ Using a person's own tissue does not make the procedure free of risk.¹⁴

Is it the same as the neighbouring operations?

Face lift and midface lift address the position of tissue, whereas fat injection addresses missing volume; they are separate decisions. Adding fat is not assessed as an equivalent alternative to a lift where one is needed.⁴ Where they are considered in the same session, the aim of each operation and its contribution to recovery are explained separately.

In lower eyelid surgery, repositioning the lid's own fat is not the same operation as transferring fat taken from another area as a graft.¹⁰⁹ In chin surgery, the position of the bone or the decision about an implant, and adding volume to the soft tissue, are likewise separate aims.¹⁵⁴

In cheek reduction, tissue is removed from the buccal fat pad; in fat injection, volume is added.¹⁶² Where adding volume is considered after a bichectomy, this should carry no promise of restoring the removed fat pad to its former state. These operations should not be thought of as automatic counterparts of one another, or as steps to be applied together in everyone.

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.¹⁷ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹⁸ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹⁹ Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.²⁰ The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Tests and anaesthetic assessment: The tests required are determined by general health and by the anaesthetic assessment.²¹ Any previous problem with anaesthesia or drug allergy should be declared. The instructions given about fasting and about how to take medication on the day of surgery are followed.

Home and transport: Someone is arranged to accompany you home on discharge.²¹ The timing of check-ups, the help you may need in the first days and the plan for time off work are organised beforehand. Follow the surgical team's guidance on preparing the operation area; do not shave or prepare the incision area at home on your own initiative.

The donor area beforehand: The areas from which fat may be taken are decided at the examination and explained before surgery.⁷ Previous liposuction, surgery or healing problems in those areas are reported. The compression dressing to be used and the plan for the donor area are explained beforehand.

What is recovery like?

The operation is carried out under general anaesthesia. 1-1.5 hours are planned for the operation and 1 night for the hospital stay. 1 week is expected for stitch removal; the entry points are assessed at the check-up. The first check-up is within the first week. These periods are a general framework; where an additional operation is carried out, its extent is also taken into account.

The donor area: 1-2 weeks are expected for early healing where the fat was taken. The cannula entry points and the compression dressing are checked. Early healing of this area does not mean the swelling and surface appearance have reached their final state. There can be bruising and discomfort in the area the fat was taken from.⁷

The recipient area: 1 week is expected for marked oedema to subside and 7-10 days for bruising to settle. Residual slight swelling can last 2-3 months. The result becomes more soundly assessable within 2-3 months; slight swelling may be present over the same period. The fullness seen in the first days is not identical to the volume of fat that will remain.¹

The timetable does not mean that every finding will end on the same day. Although check-ups on the two areas can be done at the same visit, they are assessed separately. A newly developing or steadily increasing finding is not treated as unimportant merely because it falls within the expected healing period.

What to pay attention to after surgery

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

Dressing of the donor area: Tapes are applied to the cannula entry points and a compression dressing to the area the fat was taken from. Changing the dressing, the amount of compression and how long it continues are carried out according to the plan given. The compression dressing belonging to the donor area is not applied to the recipient area.

Protecting the recipient area: Pressure on the area the fat was placed into is avoided for at least 3-4 weeks. Pressure on this area from tight clothing, from lying position or from items used daily is assessed in the care plan. A different approach to compression for the donor and recipient areas is also described in the care of breast fat grafts.⁶ The advice on scar care does not mean the area the fat was given into may be massaged on your own initiative.

Sleeping: Rest with the head elevated. Your surgeon decides how long that position and the avoidance of physical strain are continued. A sleeping position that puts no pressure on the incision is preferred. Returning to sleeping on the side or front is assessed according to the state of the incision and the swelling.

Lying position is arranged with both the area the fat was placed into and the area it was taken from in mind. Elevating the head does not, for example, take the place of the instruction to protect a recipient area in the breast from pressure. When the lying position is changed, the dressing of both areas and the plan for avoiding pressure are taken into account.

Cold application: Cold is applied to the operated area without pressing on it. The form and duration of the application are determined by your surgeon's instructions.

Which area cold is applied to, and its relation to the dressing, are explained on discharge. The general care sentence is not permission to apply force to the recipient area. The compression dressing of the donor area and the protection of the recipient area are maintained separately.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Movement: Strain such as bending the head down, straining and heavy lifting is limited in the early period. Movements that stretch or rub the incision area are avoided. Even if you feel well, do not return to strenuous activity suddenly. Activity and rest through the day are organised according to the plan given on discharge.

Pain: Tenderness and bruising can be marked where the fat was taken from.⁷ Pain treatment is used according to the instructions given. Pain that steadily increases in the donor or recipient area, particularly when accompanied by new swelling or a change in colour, calls for assessment. No new medicine is added on your own initiative.

Returning to work and sport: 1 week is set aside for returning to work. In physically demanding jobs the state of the donor and recipient areas is assessed separately. A return to sport is planned in stages within 2-4 weeks. 2-4 weeks are likewise expected for a full return to daily life. These periods do not lift the instruction to avoid pressure on the recipient area for at least 3-4 weeks; movements that load or strike that area are assessed separately.

Driving: A return can be assessed after 1-3 days. The effects of the anaesthetic on attention and reflexes must have passed, and there must be no use of a medicine causing drowsiness and no visual problem. Sitting, the seat belt and the manoeuvres required must not strain the operated areas. Where comfortable and safe control cannot be achieved, driving is not undertaken even if the timetable has run its course. Someone accompanies you home on discharge.²¹

Sexual activity: A return can be assessed once everyday movements no longer cause marked pain and you feel comfortable. Pressure on the donor and recipient areas, movements that stretch the incision line, and marked straining are avoided. Rather than a fixed day, the course of healing and the surgeon's advice are taken as the guide.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

Findings that are normal: Swelling, bruising and tenderness can occur in the areas the fat was taken from and given into; a temporary change in sensation can also be seen where the fat was taken.¹ The appearance can change as the swelling subsides. New firmness, a marked change in colour, increasing pain or spreading redness should not, on the other hand, be accepted as ordinary healing.¹²²

How do the scars change?

Although the entry points for taking and giving fat are small, a scar can remain on the skin; a small entry does not mean a result without a scar.¹ The healing of the incision and the assessment of the volume of transferred fat are separate processes. An entry scar in the donor area is not the same problem as firmness or irregularity in the recipient area.²²²³

Silicone gel and massage are advised for the entry scars in the skin. When they are started and how they are applied are determined by your surgeon after the wound has closed. This advice is directed at the entry scar; it does not mean applying widespread massage over the fat in the recipient area. It is assessed together with the instruction to protect the recipient area from pressure for at least 3-4 weeks.

Crusts are not picked off; the care plan given is followed for changing tapes and for applying products over the scar. Where there is an open wound, discharge or increasing tenderness, no attempt is made to correct it by massage. The course of the scar is assessed through the check-up findings.

Risks and complications

Risk assessment covers the areas the fat is taken from and given into together.¹ The problems reported in facial procedures include irregularities of shape and rare but serious vascular events.¹¹ A collection of reported severe complications does not show that all operations end with these problems at the same rate.¹⁴

Problems in the donor area

Bruising, tenderness, swelling and temporary or permanent changes in sensation can occur where the fat was taken.⁷²² Waviness, hollowing or asymmetry can remain at the surface; these are problems separate from the retention rate in the recipient area.²² Transferring fat to another area does not guarantee that a smooth contour will result where it was taken from.⁷

Injury to vessels, nerves or deeper structures along the path of the cannula is also among the risks of the liposuction step.²² New or progressing findings call for assessment by a doctor. Where pain or a change in colour increases under a compression dressing, the check-up appointment is not waited for.

Changes in shape and tissue in the recipient area

Insufficient volume, excess fullness, a difference between the two sides or surface irregularity can remain.⁸¹¹ The loss of viability of part of the fat is called fat necrosis; cysts and palpable firmness can develop.²³ Calcification, that is a deposit of calcium, can be seen on imaging, particularly in breast procedures.²³

In areas such as around the eyelid, fat deposits or nodules that become prominent may call for further assessment.¹¹ A difference related to early swelling is distinguished from irregularity remaining after healing. Adding new fat, or trying to correct the area by massage, before the cause of the problem is established is not regarded as appropriate.

Bleeding and infection

Bleeding and haematoma, that is a collection of blood, infection and wound healing problems can develop in the donor or recipient area.¹²² Rapidly increasing swelling, spreading redness, discharge, fever or the wound opening call for assessment by a doctor.¹ The treatment needed is determined by the findings; there is no single plan of medication or intervention for everyone.

How are breast imaging and follow-up affected?

After fat injection, fat necrosis, oil cysts and calcifications can be seen on mammography or other imaging.⁶ Most of these findings can be assessed as benign changes; a suspicious mass or image is not, however, treated as unimportant merely because fat injection has been carried out, and is investigated with a biopsy where needed.⁶

The radiologist is told that fat injection was carried out, when, and which breast was treated. Previous images are made available for comparison. Follow-up continues according to age, personal risk and any history of cancer treatment; not every patient is given the same additional interval of MRI or mammography.⁶

In the review assessing fat transfer to the native breast, the incidence of fat necrosis per participant was reported as 4.66 per cent and the rate of subsequent biopsies as 5.55 per cent; variation between studies was high for both outcomes.²⁴ The rates of fat necrosis seen on imaging and of problems felt by hand are not the same measure. If new firmness develops while ordinary follow-up continues, assessment is requested without waiting for the next screening date.⁶

Fat embolism and events affecting vision

Fat passing into a vessel and blocking the circulation can lead to a fat embolism. After facial injections, events affecting the blood supply to the eye or the brain, permanent loss of vision and cerebral embolism have been reported.¹⁴ These are rare but severe complications; using a person's own fat does not remove this risk.¹⁴

One systematic review collected 61 reported cases of arterial embolism.¹⁴ Death following the embolism was reported in 6 of these 61 cases.¹⁴ This number is not the result of a group in which everyone having fat injection was followed. Because the total number of procedures and the extent of under-reporting are unknown, an individual risk percentage cannot be calculated from it.¹⁴

Fat embolism affecting the lungs, and deaths, have also been reported with buttock procedures; the safety measures for this area are therefore addressed separately.¹³ A sudden change in vision or speech, loss of strength, altered consciousness or shortness of breath are not findings that wait for a routine check-up.¹⁴¹

Anaesthetic and general surgical risks

Risks relating to anaesthesia, the heart and breathing are assessed together with the person's health history and the extent of the operation.²² Where an additional operation is carried out, its care and risks are included in the plan. Fat embolism and the venous clot described below are not the same mechanism.¹⁴²²

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

The approach to preventing clots is decided according to the person's risk and the operation planned. The measures to be used are explained in the discharge and care plan. No blood thinner is started without being prescribed, and existing treatment is not altered on the person's own decision.

How much of the fat remains, and is a second session needed?

The retention rate describes the relation between the volume preserved at follow-up and the volume injected; it is not a percentage of satisfaction, nor a measure that all the fat cells have remained alive.²⁵ That the appearance becomes assessable at 2-3 months does not constitute a guarantee that the fat will not change afterwards.¹¹ Different studies have measured at different times and by different methods.³

In facial procedures, a meta-analysis covering 27 studies and 1,011 people found that retention varied between 26 per cent and 83 per cent across studies, with a pooled mean of 47 per cent reported; the 95 per cent confidence interval is 41-53.³ Follow-up ranged from 3 to 24 months. This wide range is not merely measurement uncertainty: the same review states that the method by which volume was measured significantly influenced the reported retention rate, and that a trend towards better retention was found for repeat grafting procedures.³ For that reason no single percentage, neither the lower nor the upper end of the range, can be used as the expected result for an individual.³

There are differences between areas as well. In a study focusing only on the temple, which measured 142 procedures in 96 people with three-dimensional laser scanning, mean retention was reported as 65.7 per cent (standard deviation 12.6).⁵ In the same study mean follow-up was 16.3 months and a mean of 1.5 procedures per person was carried out; this figure is therefore not the equivalent of a single session and cannot be transferred to other areas of the face.⁵

In another review assessing fat transfer to the native breast, covering 47 studies and 4,425 participants, fat graft uptake per breast was reported as 53.26 per cent; the 95 per cent confidence interval is 46.32-60.20.²⁴ In this research, which covers primary breast augmentation and procedures for symmetry in the opposite breast after reconstruction, variation between studies is very high. This result is not a common rate for the face, the hand or the whole body.²⁴

Additional sessions of fat injection may be needed to reach the fullness wanted after volume is reabsorbed.² In the review of fat transfer to the native breast cited above, the need for additional transfer was reported as 11.83 per cent; this rate is specific to the breast and is not transferred to facial procedures.²⁴ A second session can be assessed after healing, because of the person's expectation of the remaining volume or because of asymmetry. This possibility is explained as part of the initial plan; it does not by itself mean that the first procedure failed. Equally, the possibility of a further session is not dismissed by saying only that it "may not be needed".

The decision about a further session does not look only at the volume remaining in the recipient area; the area from which fat would again be taken and the state of the previous entry points are also assessed. A new transfer carries the burden of another operation and further care.² Repeating the procedure in the same person likewise does not guarantee the same retention rate as before.³

What can be expected from the result?

The aim is to reduce a lack of volume or a contour difference determined according to the person's structure.¹ Erasing every line, full symmetry, or the retention of all the injected fat is not promised. Fat tissue that remains can provide longer-lasting volume; weight loss can affect the result.¹¹

In assessing the result, the volume in the recipient area, the match between the two sides, whether firmness or irregularity is present, and the surface appearance of the donor area are examined together.⁷ The area the fat was given into looking good does not make a check of the area it was taken from unnecessary.

The suitable aim for fat injection is a lack of volume. Where a lift, skin removal, a change in bone position or eyelid support is needed, these are assessed separately.⁴¹⁰¹⁵ Not having the procedure, or adopting a more limited aim, may also be possible at the end of the assessment.

When should you contact a doctor?

Do not wait for the scheduled check-up in the following situations.

• Rapidly increasing swelling and tightness in the donor or recipient area.¹
• Pain that increases instead of decreasing, or becomes marked despite the treatment given.¹
• Fever, spreading redness, discharge, the wound opening or bleeding that does not stop.¹²²
• New marked pallor or darkening of the skin, or a change in colour together with severe pain.¹¹
• New firmness in the breast or a mass that steadily becomes more prominent.⁶

With a sudden change in vision, loss of vision, severe eye pain, disturbance of speech, loss of strength on one side, altered consciousness or sudden shortness of breath, urgent assessment should not be delayed.¹⁴¹ Emergency help is not held back while trying to reach your doctor; the emergency number is called. Where there are visual or neurological symptoms, driving is not undertaken.

One-sided leg pain and swelling, sudden shortness of breath or chest pain are also emergencies. It matters to state at presentation which of the donor and recipient areas the problem is in; time is not lost trying to work out the cause at home.

About the numbers in this article

The fact box, the timing of check-ups, the periods for returning to work and to activities, and the instruction on avoiding pressure are the care framework given by the surgeon. Individual healing and any additional procedures are taken into account in assessing this plan. The 1-2 week early healing of the donor area and the 2-3 month volume assessment of the recipient area are different stages.

The retention percentages in the research are not percentages of satisfaction or of complications. The facial and breast results come from different groups; they do not directly show the possible outcome in the same person.³²⁴ The method of volume measurement and the timing of follow-up can also affect the result.²⁵

Because the number of reported cases of fat embolism does not include a denominator covering all operations, it has not been converted into a frequency.¹⁴ Nor does the absence of a severe problem in one series mean that such a problem will never occur.

References

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