When people think of surgical volume enhancement, they usually consider two types of volumizing procedures: fat grafting and facial implants. Each procedure has its own distinct advantages and disadvantages, and I use each type differently based on the benefits of each one. I will also discuss how I use fillers as alternatives or adjuncts to these surgical volumizing procedures.

Fat grafting, also known as fat transfer, describes a method in which fat that is harvested from the body, typically belly and/or thighs, is transplanted into areas that are deficient in the face like cheeks, chin, eyes, etc. Fat is harvested by a method like liposuction. However, the technique is gentler using hand harvesting rather than a high-powered machine to ensure fat graft survivability. Then the fat is processed to remove unwanted impurities like blood, broken fat cells, and local anesthesia. I have used centrifugation in the past but now prefer to use a process called PureGraft that has yielded much purer fat, which has correlated with improved survival and longevity. Fat is then delicately re-injected into the face into the various areas of deficiency. I talked about my method in my textbook Complementary Fat Grafting (Lippincott, Williams & Wilkins, 2006) but a lot has changed and evolved since that time both in terms of technology (mainly in fat processing) and artistry (I no longer inject the anterior cheek since I believe this leads to a distorted, unnatural result in the face).

Fat grafting has had some negative press, which in my opinion is unwarranted, related to technical errors or poor artistic judgment. For example, the area around the eyes (periorbital area) has been thought to be unsafe due to the risk of lumpiness, but I have performed this procedure safely for 20 years now almost every week and have rarely encountered minor contour issues that almost always resolve or is easily corrected. Also, the other contention is that fat grafting does not survive, and this is simply untrue as well. I have seen my patients many years after a fat transfer and the results hold quite well. That being said, there are two distinct disadvantages of fat grafting. First is that even though survival is in my opinion consistent there is some level of variability of a result, so I always try to explain to patients that the improvement should be “right brain” meaning that you should see that you look a lot better but it may not be perfect, that is “left brain.” Second, is that fat is dependent on one’s weight profile. If someone loses a lot of weight, then the fat will look less impressive. However, if someone gains a lot of weight, the fat could look fuller than desired.

Solid implants, on the other hand, are inherently different from fillers and can encompass a full range of implant types that span the entire face. Classically, the two types of implants that are the most popular are cheek and chin implants. The types of implant materials are also wide and varied that include silicone, Gore-Tex (also known as expanded polytetrafluoroethylene [ePTFE]), and Med-Por. I exclusively use silicone implants because they meet all the criteria that I want in an implant. Silicone is bioinert, very stable due to encapsulation of the implant, and easily removable. Gore-Tex, on the other hand, has some inherently problematic issues, and I have stopped using it. The first problem is that over time it compresses a little bit, so you lose some of the initial projection. Second problem is that it is much harder to remove and can cause some tissue damage to the surrounding tissues given the adherent nature to the neighboring soft tissue. I have never used Med-Por and never plan to do so. It has a higher chance of infection and can be near impossible to remove due to high levels of tissue ingrowth. That combination is truly problematic and if someone has Med-Por placed by another surgeon I will not elect to remove it but will refer that patient elsewhere due to the technical difficulty of removing such implants.

I like the principle of “like replaces like” in my decision-making process to explain what type of implant I prefer to use. With aging, even though there can be some loss of bone tissue, most of the loss comes with soft-tissue loss like loss of fat in the face. Therefore, when I want to restore volume to the periorbital region (around the eyes), cheeks, and around the mouth, fat grafting is my go-to solution. By contrast, if someone is born with a weaker chin, then a surgical implant wins in my opinion. A solid implant allows for a very predictable outcome in terms of projection since fat can absorb somewhat. In addition, adding a lot of fat into the chin just makes the chin appear fat rather than like bone, which should be the goal. I am good with replacing some soft-tissue loss around the mouth with fat but to achieve a predictable, natural, and aesthetically pleasing result in the chin, I truly prefer a chin implant if someone is really requiring that result.

In principle, I do not like cheek implants for many reasons. First, it is very hard to get two cheek implants perfectly symmetric. Second, these implants have about a 10-20% risk of infection. They also can tend to shift and migrate even when firmly anchored. However, the big reason I do not like cheek implants is that they do not solve the problem. As we get older, as mentioned, we lose the fat envelope around the bone tissue. If we stick a bony-appearing implant under this absent soft tissue, we only see a bonier appearance, which can make someone appear older rather than younger. For all of these reasons, I am not a big fan of cheek implants.

What about fat in the cheeks then? Well, I only perform fat grafting in the lateral cheek, that is, under the outer zygomatic bone and the reason is that the anterior cheek, which is a darling location for most fat grafters and filler injectors, really looks weird when someone smiles. It looks like the “pillow face” we are all trying to avoid. Unfortunately, for my patients who had my fat transfer 15 years ago, I have had to do some microliposuction to correct anterior cheek filling, which I no longer like. I truly want to avoid the “pillow face” that has become synonymous with bad work and makes people look unnatural, and frankly frightening. Essentially you should not worry because I do not overfill the lips and cheeks with fat and/or fillers.

Are fat and fillers the same thing? In short, no. Fillers have gotten a bad rap that they disappear after a few months. In my opinion, this is not the case. There is a component of fillers that stays years if not forever. However, fillers suffer from several major drawbacks. First, fillers can be quite expensive because they are charged per syringe, and a face can require many syringes to fill it; whereas fat is “free”, that is, it is not charged per syringe. Second, fillers are not great around the eyes like the tear trough because I have seen that these products migrate over time in this area, which is not good, even years later when these “temporary” hyaluronic acid products should have already dissipated. In short, they do not go away. Fillers, however, are great for lines and folds, especially dynamic wrinkles of the lower face, where fat simply cannot address those areas. Fillers are built slowly over time so that a more precise result can be achieved than fat. Fat provides a more global foundation where the face simply looks significantly younger. In short, I love both fat and fillers but use them quite differently.

Implants, fat, and fillers all provide volume in different ways, each with distinct pros, cons, and limitations. Despite any of these differences, the key is to apply them with judgment, technical skill, and artistry. For me, what makes or breaks a result is a true artistic eye that allows one to make a face beautifully and naturally volumized and to simultaneously avoid an overfilled, pillow face appearance. Not only do I practice facial plastic surgery every day but I also paint every day. On weekends, I paint and go to museums to enjoy art. At heart, I am an unrepentant artist who loves design and art. I do not have it within me to paint a bad picture so to speak. My pride and joy are to do life-giving, beautiful, natural work.