The concept of transferring fat from one area of the body to another is not a new one, however it is only in the last decade that surgical techniques have developed sufficiently to allow for relatively predictable results. There are a huge number of applications for this technique, such as improvement of facial and body contours, rejuvenation of hands, improvement of the appearance of scars, and enhancement of the breasts.

The advent of effective techniques for fat transfer is one of the most exciting developments in the field of plastic surgery in recent years. This explosion in popularity coincided with my years in training as a plastic surgeon, meaning that I have ‘grown up’ with the technique. During the course of my fellowship training, particularly during the time spent with Dr. Jeroen Stevens in Holland as the Dutch Association for Facial Plastic Reconstructive and Aesthetic Surgery fellow, I gained extensive experience in the nuances of the technique; in particular methods to improve graft survival and novel applications for the technique.

Fat injections to the face may be performed in isolation, or in conjunction with other rejuvenation procedures, in particular facelifts, lower eyelid lifts (blepharopasty), or facial liposuction. It is an exciting alternative to synthetic fillers: as it is from your own body, it is 100% biocompatible, there is usually an ample supply, and it offers the possibility of permanent results. There is increasing evidence that it acts to prompt rejuvenation of the tissues around it, such as collagen, rather than sitting there in an inert manner. As well as being used in conjuction with surgical techniques, it is also very useful when combined with other non-surgical treatments such as botulinum toxin injections or resurfacing procedures. There are a wide variety of applications for fat used on its own, which include:

• Treatment of hollowing and prominent veins in the temples
• Cheekbone enhancement
• Midface volume restoration
• Reduction in nasolabial folds (lines running from nose to mouth corners)
• Lip enhancement
• Reduction in perioral lines (“smokers’ lines” around the mouth)
• Chin enhancement
• Jawline enhancement
• Skin texture improvement
• Improvement of asymmetry
• Improvement in the appearance of scars

The surgery is may be performed under local or general anaesthetic, depending on the extent of the planned procedure. Fat is removed/ harvested from the donor site – usually the outer thighs, using very gentle suction. This is different from the more powerful suction used in traditional liposuction, as the aim is to avoid damaging the fat cells as much as possible. Other donor areas may be used, and this can be discussed at the pre-operative consultation. For more information on the donor site, see the liposuction section. The fat is then prepared for injection into the face (recipient area). These injections are done via tiny holes made with a needle which usually heal well of their own accord, without the need for stitches.

The success of the procedure depends on the injected fat cells being placed beside tissue with a blood supply, which they can then connect to in order to survive. In practice, this means that multiple tiny tunnels are made with the injection needle, with the fat cells evenly spread throughout the tissue. Simply injecting a large blob of fat into a single area will inevitably lead to failure. A useful comparison (at least to my mind!) is to compare carefully spreading a load of seed evenly over a prepared field, compared to dumping the entire lot in the middle of the field and expecting a bumper crop. In practice, this means that there is a limit to the amount of fat that can be injected at each procedure, and that optimal results may require a second, and often subsequent procedures. While I am happy to over-correct in less conspicuous areas of the body, I do so to a lesser degree in the face, as it has been my experience that people prefer to undergo a second top-up procedure rather than spending a number of months with an over-filled face. As a general rule, a little over half of the transferred volume is expected to survive in the long term, even with best technique, so a top-up procedure is reasonably likely, and you should consider this before making the decision to proceed.

Swelling and bruising in the immediate aftermath of the procedure are normal and expected. The bruising will tend to track down into the neck in the days following surgery. Camouflage make-up may be used from the day after surgery, provided it is applied gently, and the injection sites themselves are avoided. The amount of swelling seen varies considerably between patients, and even within the same patient: one side may swell more than the other, and certain areas like the lips tend to swell more. Sleeping in as close to a seated position as possible can help minimise the swelling, which does tend to be worse in the morning.

Except in the case of an asymmetry-correcting procedure, great care is taken to place the same amount of fat in the same places in either side of the face. Despite this, some asymmetry may occur after this procedure. In the first days to weeks, uneven swelling between the two sides is the usual cause – factors such as the side on which you sleep can influence this. Asymmetry that becomes apparent in the months following the procedure may be the result of differing survival rates of the fat grafts, and a second procedure may be necessary to correct this. It may also be the case that the fat grafts serve to highlight a pre-existing asymmetry, that you may not have been aware of before scrutinising your post-operative appearance. This is where the pre-operative photographs we take are very useful. Some patients will be aware of the presence of the fat, particularly initially, but this awareness usually disappears with time. Occasionally, some lumpiness may be felt in the injected area, and this is particularly the case around the mouth. Conservative measures usually result in an improvement of this. As stated above, not all of the injected fat is expected to survive. Usually the fat that doesn’t survive is taken up and processed by your immune system’s cells, however on rare occasions, it may form a small “oil cyst” under the skin. If this is bothersome, a minor surgical procedure may be necessary to remove it.

Serious complications from this procedure are exceptionally rare, and can be reduced through the use of specific techniques. Nerve or blood vessel injury can occur. The chances of a permanent nerve injury are minute, but the skin in the treated area may be somewhat numb following the procedure. This will settle in the great majority of cases. If a blood vessel is punctured, some bleeding under the skin may occur, and this is easily managed by the application of pressure. The use of blunt injection cannulas rather than sharp needles reduces the chance of these problems occurring. One very rare but vary serious complication that has been described with synthetic fillers is injection into an artery that supplied the eye, which resulted in loss of vision in that eye. Theoretically, this same complication could occur with fat injected around the eye area. Because of this, I use only blunt injection cannulas in this area, and inject with a specific technique: both of these are designed to minimise the chances of an intravascular injection.