Fat Grafting to Tear Troughs

Q: Hi Dr. Yang,

I am 33 and have lost a LOT of volume in my upper cheeks and especially tear trough region. I have always hard “dark circles” to a certain extent but now the crescent shaped groove has formed, is really pronounced and my cheeks seem flat. I have been researching fat transfer, but I can’t find enough information on any Dr.’s in California or on the west coast. I liked Dr. Donofrio’s method of several visits, but she is in Connecticutt and that would be too hard to manage traveling to the east coast. Can you make any recommendations of fat transfer providers in the LA area?

A: Hi spring2011,

There should be plenty of fat transfer providers in the LA area. I don’t know any of them well enough to recommend them.

The method of liposuctioning then reinjecting the fat in multiple sessions requires freezing the fat in a freezer and defrosting it later for reinjection. This method sounds good, but does have some problems. First of all, freezing human tissue requires tissue bank protocols similar to what they do in hospitals and research institutions to prevent mixing up of different patient’s fat. Most of these procedures are performed in private offices and there may not be any oversight in how these fat harvest are handles and documented. God forbid, you get injected with someone else’s fat, who may or may not have a communicable disease. It would be just as bad as a nurse getting stuck with a needle from a patient they are drawing blood from. Instead, whole fat particle are reinjected into the body. If it is someone else’s fat, none of it will survive. Your body would recognize that the fat is not your own, and it would intentionally kill that fat using your immune system as if it were an virus, bacteria, or fungus.

Assuming you got your own fat back the second and third time. The fat survival rate after purification of the liposuctioned fat is only 30%. So if the surgeon injects 10 cc’s of fat, typically only 3 cc’s will survive. This is the reason for the multiple sessions. If the patient appears to need 3 cc’s of fat, if the surgeon injects 3 cc’s of fat, only 1 cc may survive. Therefore, the surgeon then needs to repeat the sessions another 2 times to get the needed volume, that the patient wants for a nice result. When small volumes of fat are injected, the bruising from fat transfer is usually not as bad.

However, what happens if the surgeon doesn’t freeze the fat and attempts to anticipate the 70% fat absorption, and injects much more fat. Take a look at this website (http://www.lipostructure.com/fat_grafts.html ). Although the procedure is considered non-invasive, since there are no incisions, if the surgeon is careful with their injections and injects small particles of the fat in multiple layers, there is typically a tremendous amount of bruising. Since there is no incisions, if there is bleeding which will cause bruising, the surgeon has no way of stopping the bleeding since there are no incisions. Some surgeons have begun offering a laser treatment 48 hours after fat grafting to help make the bruising go away faster.

Now that you know that the typical fat transfer survival rate is low, guess what will likely happen if you then freeze this delicate fat and defrost it. When the fat is reinjected in the same session as it was harvested. The fat is still alive, and the goal is to get the fat immediately back into the same person’s tissues, so those small particles of fat can immediately reconnect to a blood supply. Fat grafting in the past did not work well at all. Most of the time all of the fat that was injected would die and get absorbed by the body. The careful handling of the fat, by not using high powered liposuction vacuums, and only using enough vacuum from a syringe, as well as purifying the fat by minimizing exposure to air, and removing oils and blood from the fat has helped surgeons to increase the survival rate to 30%.

Now imagine being so careful with this precious fat, then throwing it in the freezer. When the water inside the fat cells freeze, the chance of getting even 30% survival decreases dramatically. How many fat transfer experts are using Dr. D’s freezing and multiple session injection technique, if it is working so well? I can’t think of anyone. The father of Fat Transfer, Dr. Coleman, warns surgeons of using the freezing technique, as well as the possibility of calcifications since the injector is essentially reinjecting dead fat.

Overinjection technique for fat transfer is also a problem. Some surgeons realize that only a third of the fat will survive, so they may “fat transfer” double or three times the amount of fat that they want to survive. The problem is that occasionally the survival rate may be slightly higher than the surgeon anticipated, and then the patient is overly fat grafted. Let’s say 2-3 cc’s of fat looks good, but 4-5 cc’s looks bad. If the surgeon is trying for 2-3 cc’s and inject 6-10 cc’s. What if more than 30% survives? let’s say 40-50% somehow survived, out of sheer dumb luck. Now how does the surgeon get rid of that extra fat? It is essentially permanent.

There is a lot of PR and press regarding stem cell fat grafts. Supposedly the stem cells can help increase the fat survival rate better than the 30%. I would be more worried about too much fat surviving. If more is needed you can always at more, but if too much survives, it will look puffy, and not flattering.

With Murphy’s law, if you love the results, the fat in many cases doesn’t survive. When you hate the results, somehow the fat lasts forever. This is the reason that hyaluronic acid injections (Restylane and Juvederm) is still very popular. The recovery is minimal, but it does last longer than for other areas. Typically for tear troughs it can last up to 9 months to a 1-1/2 years. Even at 2 years, sometimes there is still some left over, and the touch up may not need as much as the first injection.

Depending on the volume needed for the results desired, either fat transfer or hyaluronic acid filling may be the obvious choice. I offer a saline/filler simulation, where I inject saline mixed with lidocaine (a numbing medication like Novocaine). If the patient only needs 1/2 cc of volumeper side, then they could use a single syringe Restylane (1.0cc) to get the results they want. Typically for deeper tear troughs with hollowing of the outside part of the lower eyelids, which appears as bags, the patient may need 1cc of volume per side. Rarely do patients need 2-3 syringes of restylane per side, but if that were the case, it wouldn’t make sense to buy 6 syringes of Restylane for a single session, and maybe fat transfer is the more obvious choice. If the patient only needs a single syringe to get the results desired, then spending 3-6 thousand dollars (depending on the surgeon, I’ve heard $15K for tear troughs only too) for something that a $6-700 syringe can do with minimal down time.

The filler simulation lasts 3-4 hours before it dissipates. The main problem is that the actual procedure with Restylane is essentially the same, so small amounts of bruising can occur. If this happens, then the patient should wait at least 1-3 weeks to be absolutely certain that all swelling and bruising is completely gone, before using the actual Restylane. Since Restylane can be dissolved using hyaluronidase if the patient really doesn’t like it, some patients just go for the real thing and ask to check the results as the injection proceeds, to make sure it is not overinjected based on their own goals.

Sorry I’m not able to make any recommendations, but I thought you should be properly informed while performing your research for the right procedure and surgeon for your tear troughs. A dermatologist who only does fillers may push you to have fillers, while a surgeon may only want you to have the surgical procedure. The reality is there is no right way to do it, and the patient needs to be fully informed and pick the procedure based on their own financial situation as well as the risks they are willing to take with their face. Temporary fillers are low risk if you don’t like it since it will go away; procedures which are considered permanent are higher risk. Another option is to try the filler first, then when it completely gets absorbed 1 year later (or longer) then switch to fat transfer, knowing how much volume you used with the filler.


Dr. Yang