I had a consultation last week when a woman said two of her friends had a fat grafting (performed elsewhere) where the fat graft went away after two years. This comment made absolutely no sense to me. I use the analogy of a skin graft or a hair graft. Once a graft grows after a few months, it cannot go away. The process by which a graft acquires blood supply occurs in stages. The first few days there is what is known as imbibition, followed by early in-growth of tissues known as primary then secondary inosculation. These early stages are finished when formal neovascularization (new blood supply) is fully established by 6 months or so.

Now there are two confusing elements that occur in the initial few weeks to months that can be interpreted as fat grafting going away. The first is, simply put, swelling. When there is swelling, people can associate the swelling that is there and that can linger even past a month to be actual volume, when it is not. The second element is that not all fat grafting survives. What percent? It’s hard to tell but I have been doing fat over 20 years and have seen it absolutely survive in remarkable ways. I use the analogy of planting flowers. If I plant 10 flowers, 7 may grow, but not zero. With the right sunlight, water, and fertilizer (which would be analogous to gentle harvesting, excellent processing using Pure Graft, and accurate microdroplet injection), there should be good survival even in smokers or others who should not have fat survive well but they do. The problem is when someone goes through the perfection phase at 2 to 3 months, they think that is the result, when it is isn’t.

I divide fat grafting into three phases. Phase 1 occurs in the first few weeks and is simply “swelling” and that is not representative of the result. Phase 2 occurs a month or two afterward when the fat has not fully taken and the skin is still slightly stretched out to perfection and I liken this phase to “unrealistic perfection” phase. Then several months later, there can be disappointment. However, when someone comes in to take a photograph it should be quite clear that the result is still tangibly better, especially when you think about the right-brain improvement that I can achieve, which means that I may not have eliminated a tear trough or covered bone perfectly but something looks tremendously better with the face.

Look at the accompanying video and photo of a woman who is shown at 1 year and 2 years after fat grafting. She asked me if the fat survived when I saw her at 2 years post-fat grafting. She had forgotten what she looked like until I showed her the photos, which is something very commonly encountered because we get amnesia of what we used to look like until I do comparative, standardized photographs. In summary, once we pass 6 months, the fat grafting result is permanent. I have had to cut out fat grafting from overdone lips performed elsewhere and what I see 10 years later in these lips is fat tissue, not scar tissue, but pure fat. Accordingly, fat survives but again not perfectly.

If fat is permanent, then when do you need another round of fat grafting. The answer really depends on lifestyle, ethnicity, and sun exposure, with the latter being the worst offender. If someone has a bad diet and poor lifestyle and is very fair skinned, I have had to go back to touch up a fat graft as soon as 5 years. However, in most cases, I do not need to go back until 10-20 years later because the patient still looks good despite some minor, ongoing aging. A common question I get asked is should I touch up a fat graft after a few months to get a better result. My answer is always a resounding no because another round does not lead to perfection. It just wastes money, adds recovery time, and does not necessarily make the result that much better because you can’t get perfection anyway.

I always use the analogy that if you have an identical twin sister and both of you have the same lifestyle (diet, stress, exercise, sun exposure), you will always look 10-20 years younger than your sister if you are the one who had a fat graft. However, having a fat graft does not stop aging.

Another analogy that can be helpful to understand the permanence of fat grafting is think of a glass of water with a tiny hole on the bottom. This is your face and the water represents the fat level in your face. The tiny hole on the bottom represents aging with ongoing volume loss. The hole can be bigger with bad lifestyle. Nevertheless, the fat (or water) that has been filled up will always be there. If you think of two glasses of water, each with the same hole on the bottom, but one glass is filled up and the other one is not, over time, the one that was filled up may see the water level go down but relative to the other glass of water still looks fuller. That is the idea. Essentially, you are losing more of your natural fat, not the transplanted fat.

I saw a lady last year for whom I did a fat graft at 55 years of age and she returned at 70 years and said she wanted more fat grafting now because she loved it so much. I told her she had two options only: a facelift or a facelift with a fat graft. The reason is that even though her face had aged over the intervening 15 years, her neck (because there was no intervention in the past) had aged considerably more. Accordingly, if I had done a fat graft for her again, her face would have been even younger compared with her neck and that would have looked unnatural.

If you ever have questions about fat grafting, please let me know. I literally wrote the book on it. In 2006, Complementary Fat Grafting (Lippincott, Williams, & Wilkins) was the most popular textbook in the world on fat grafting. I love fat grafting, along with all my other rejuvenative procedures like deep-plane facelifting, blepharoplasty, hair transplant, etc. I would welcome the opportunity to speak to you about fat grafting as one of the options to help rejuvenate the face, and no you won’t look “fat” when I do it. Trust me I hate the overfilled look more than you do!