UNDERSTANDING THE NATURE OF A TRANSPLANT
Fat Grafting Evolution Photos
In January of this year, I sat for my hair transplant board examinations in Houston, Texas and am fortunate to be one of about 120 diplomates of the American Board of Hair Restoration Surgery in the entire world. It was a very rigorous examination, testing me on every aspect of surgical and medical hair restoration but also on hair loss diseases and basic science information related to hair. The thing that I want to focus on in this blog that I got out of that examination is understanding how a “free graft” transplant works. This knowledge is applicable both for my hair transplant patients and my fat grafting patients. I oftentimes joke that I am no longer a plastic surgeon but a transplant surgeon now. Okay, that was not that funny.
In Unger’s magnificent book, Hair Transplantation (4th Edition) he has a drawing of a hair follicle start to get fully connected to the surrounding blood supply somewhere around 6 months postoperatively. This is the time that a hair transplant begins to take root so to speak and start to show significant growth that continues upwards of 18 months to 2 years following a hair transplant procedure.
Now the main purpose of this blog is not to talk about hair restoration but to use it as a model for one to understand how I perceive the evolution of a fat transfer. Fat grafting, like hair transplantation, relies on placing a “free graft”, i.e., a graft placed into the surrounding tissue that must take hold for it to grow. Unlike a microvascular free flap that has the blood supply actually sewn together, these free grafts must have enough blood supply over time to become a live graft.
This is why I inform my fat grafting patients that there can be a dip in the result between the early swelling of 3 to 5 weeks and the “result” that begins to appear after 6 months when the blood supply begins to take hold. Like a hair transplant the result begins to manifest about 6 months out and improves up to 2 years post. That is also why I put together the fat grafting evolution series in my before and after gallery to help you better understand this principle. The photo shown is of my patient that I just uploaded last Friday showing her before, 1 week after, 3 months after (the dip), and 1 year following (the result but still improving).
I know many patients have a great fear that the fat transplant will not last. Simply put, that is what happens with other surgeons who do not know how to handle and inject the fat well. My fat not only lasts but improves over time. I think many surgeons at 3 months encounter one of two problems. Either their fat is gone because the fat graft did not hold well, or the fat is in the “dip” phase and they decide to go back and do a touch-up. If the fat is going to hold, the individual will look grossly overcorrected at 1 to 2 years post. This is why I always say to my patients put your seatbelt on at 3 months and patiently wait. If you dip hard (20% do), you should be fine. If not, let’s do a touch-up at a year on my nickle.
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