Q: I am a 25 years old female, 4 years ago I had fat grafting to my face to fill the area under my cheekbone, 2 years later some of the transferred fat moved from the injected area to my jawline ((I Had a wide jawline to begin with)) + I gained around 13 lbs Now my jawline is wide and I dont know what is the best method for me? the BOTOX ?? the Jawline Liposuction?? or should I consider losing more weight?
A: Jawline liposuction is not a good idea, but there are other potential options.
Although it is possible that the weight on your jawline is purely related to weight gain, the only way to find out is to try to return to closer to your original weight. Weight gain on the body does translate to some weight gain on the face. If you don’t believe me, simply watch a single episode of the Biggest Loser on NBC. Of course it is extreme in their cases, but it clearly shows the correlation.
It is difficult to say what exactly, occurred 2 years ago since your description of what happened is limited. If you noticed the fat shifted downwards 2 years ago after your fat transfer procedure 4 years ago, and subsequently gained 13 lbs over the past 2 years, then I believe you when you say that the fat grafts may have shift downwards. Fat grafting using the Fat transfer method is believed to be a type of permanent filler which will not shift or move over time as it was observed when Silicone injections were popular in the 80′s. The silicone injections were particularly popular in Asia, and I have seen people, not my patients, in everyday life who appear to have had silicone injections in the past for nasal bridge augmentation. The silicone looks great initially and maybe for many years, but over time it can shift and slide down, similar to melting wax. Since the liposuctioned fat is reinjected as small micro droplets, which subsequently grow into the surrounding tissues, it is highly unlikely to shift and slide. One other possibility that I just thought of is that the fat was blended from the hollow over the jawline for a smoother transition, and you are just now noticing the fat that was blended over the jawline, increasing in size.
Most people who have fat transferred to the hollows below their cheeks have something called buccal fat atrophy (hollowing under the cheek bones.) Buccal fat is a walnut sized +/- pocket of fat on the inside of our cheeks just along and in front of our masseter muscles which are used for chewing and related to your question about botox to this area. As we go from our youthful, child-like appearance in our teen years to our 20′s and 30′s, this area of buccal fat becomes metabolized. It is commonly known that people lose their “baby fat,” and buccal fat is one component of losing that baby fat.
I have been approached with the question many times whether fat transfer can “reverse” the buccal hollowing and in my opinion it can appear to “reverse” the problem, but it is is not actually putting the “baby fat” back into its original location. Liposuctioned fat from fat transfer cannot be used to inject into a “lump” or a pocket, since the whole concept of fat transfer is that the micro-particles of fat are essentially seeded evenly throughout many different layers of soft tissue under the skin. If the liposuctioned fat were injected into a pocket, similar to filling a sausage, the entire fat graft will likely become absorbed, as well as the possibility of lumping.
Fat transfer to the hollows under the cheek, injects the fat under the skin and interwoven into the SMAS layer of the cheek. But it is not anatomically in the same location as the actual buccal fat compartment. Imagine a walnut with a thin layer of skin over it. When you smile the thinner layer of skin slides over the walnut. However, if I chopped the walnut in half, and the volume in the cheek is now in half, and you are left with a hollow. If I fill the hollow by adding thickness to the layer of skin similar in size to the half of the walnut that was lost, it simply is not the same thing as regaining the whole volume of the walnut and letting the skin stay thinner. Is there actually a procedure to “refill” the buccal fat pocket? No, there isn’t. As the buccal fat pocket shrinks over time, it becomes harder and harder to locate the pocket. If a person has had a buccal fat removal, or significant reduction, the scar tissue from the procedure as well as the lack of a “walnut” of fat bulging, makes it more difficult to find the pocket again.
I understand the desire to use permanent fillers, so that there won’t be a long term upkeep issue of repetitive fillers, but faces change over time with natural aging. Since fat can gain and lose volume as the patient gains and loses weight, how can we predict whether the fat injected at age 21 will be in the right place when the person is 25, 35, 50 or 70? Since there is no actual way to replace or refill the buccal fat pocket, in my practice, I use temporary fillers which will hopefully dissolve gradually before it has a chance to shift. Also, as the person’s face changes with time and the “ideal look” can also change, and since the fillers are temporary, it can eventually go away, or if Hyaluronic Acid fillers like Juvederm/Restylane/Perlane are used, they can potentially be dissolved.
Will botox to the masseter muscle work? It may help somewhat. Although the fat is not reduced, losing some muscle volume can make up for the extra volume of fat along the jawline, especially if you are saying that you had a wide jawline to begin with. 4 years ago, Botox to the masseter was not as well known, so your prior surgeon may not have known to use it as a potential treatment option for you.
Finally to your question about jawline liposuction. Liposuction to the face itself is in general not a good idea. The skin is relatively thin, and the chance of ridges and irregularities is high with traditional liposuction. If the surgeon who performed the facial fat transfer knows exactly where the fat was transferred, microliposuction can be attempted to try to reduce fat in those areas. Steroid injections can be used to inject lumps of fat/scar tissue to soften them and reduce them, but it is not a good option for generalized fat reduction. I have attempted to microliposuction transfered fat under the skin, and I could not get much fat out. Instead, other soft tissue like collagen and a small amount of blood came out.
I predict that with the popularity of fat transfer, and the marketing of it as a non-surgical facelift, stem-cell facelift, or permanent filler so the patient will not need repeated injections of temporary fillers, will lead to more and more patients looking to “reverse” or take out the fat transfer injections.
I don’t know of any standard methods to suck the fat out, so I think the direction that reduction of previously injected fat will go towards not invasive procedures that transfer, heat, ultrasound, laser, or radiofrequency energy under the skin and can “melt” the fat without actually sucking it out with liposuction.
Is anyone doing this at the time? Not that I know of, and in my practice I don’t own any of these devices … yet. There are the “skin tightening” technologies which target the area under the skin and send energy to this layer to cause injury which is supposedly result in tightening of the deeper layers and ultimately the skin. It is commonly known that initial usage of the the technology Thermage, cause fat melting on the face. Newer settings and tips have reduced this problem. Laser liposuction, is not really liposuction, but actually a “laser on a stick” the laser on the tip of the metal probe melts fat when it is turned on. Potentially if the probe were placed on a very low setting, a very thin layer of fat could be potentially melted evenly without ridges. I don’t have experience with the laser liposuction, so seek a consultation with a board certified plastic or facial plastic surgeon using the technology.
Lastly, the Ulthera seems to be the latest thing in the news in the long line of non-surgical skin tightening, which uses ultrasound energy to heat and target the deeper layers of soft tissue under the skin. For the prior technologies, simply take out the word ultrasound, and use radiofrequency for Thermage, infrared for Titan, Bipolar/radiofrequency for Refirme, etc, etc. I have not had the opportunity to use the Ulthera machine, but I wonder if it has an screen to show the layers of the soft tissue similar to an ultrasound machine for looking at babies for pregnant women, maybe it can show the area where the fat is thickened, and try to actually melt the fat instead of tightening the skin. Melting fat for skin-tightening technology is a big no-no, which is different from the laser liposuction which is all about melting fat.
If the weight loss doesn’t help, and there are no great permanent options after many consultations, maybe trying the Botox to the masseter to see if it will give some cosmetic improvement while waiting for more time and insight into the new technologies to see if they really work as promised as well as more people who potentially are also trying to rid themselves of the transferred fat start discussing their successful as well as unsuccessful treatments.
I hope I was able to add some insight into the difficult issues you are having. Good luck with everything.