Fat Grafting: A Growing Problem?

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In the late nineteenth and early twentieth centuries, the facial indentations, flatness, and hollows seen with age were treated with injections of paraffin and petroleum jelly.1 These products must have had some benefit, considering how long the treatment was offered, but the complications of hydrocarbons in soft tissues were many and severe, leading to their clinical demise. The past few decades have seen injected fat and greatly improved fillers transform the rehabilitation of the aging face; the use of fillers has grown exponentially, and fat grafting has become common.2,3
When there is a global shift in treatment paradigms, the benefits shine brightly, and new procedures are universally and quickly adopted. As in other parts of life, it may be years or even decades before all the consequences of treatment become apparent. One might think of the nasal tip graft. Introduced by Sheen in 1975,4 the tip graft added volume and definition to a structure that had only been subtracted from throughout the previous history of nasal surgery. It solved many problems of nasal shape so well that it was universally adopted. It was not until decades later, after tens of thousands of tip grafts had been placed, that the grafts became more visible and unsightly as the skin of the nasal tip thinned. Many of these patients needed reoperation.
This is a common pattern of cognitive and technical evolution evident throughout human endeavor and plastic surgery. It is not reasonable to expect that every new procedure, drug, or concept be tested for decades, and one should be aware of the phenomenon.
Since the late 1980s, I have been using volume in the face, beginning with injected fat and later including off-the-shelf fillers. I remain a fervent injector of fat, usually in combination with face lifts, but years of fat grafting have left me with a long-term perspective of fat that I did not consider in the past.
Fat is a biological tissue, part of the human body, and subject to the body’s physiologic dictates. Exasperating personal experience and observation of patients over the past 33 years have led me to confirm what everyone knows: that there is a pronounced tendency for people to gain weight with age. Despite an ongoing obesity epidemic, this is not a universal phenomenon; women likely to gain weight with age tend to be the young, child bearing, and premenopausal. Older, thin, fat-depleted patients are not likely to gain weight if they have not already. Men do not have the same excuses but gain weight as well. This may take decades; gaining only 1 pound per year will result in gaining 25 pounds from age 40 to 65 years.
As known from the early days of plastic surgery, grafted tissue maintains the characteristics of the donor site, not the characteristics of the recipient site. It should be no surprise that this effect occurs in fat grafting, as the patient gains weight, so does the grafted fat. I am seeing this effect occur both in my patients and in other patients who have had fat grafting. Discussions with experienced face-lift surgeons with high-volume practices indicate that the issue is widely noted, although its incidence is not currently quantifiable. The majority of the patients were in their 30s to early 50s when they underwent grafting. Although the amount of fat placement is usually not known, most of the patients relate having enough treatment to alter facial contours, not just to fill a wrinkle or a crease. Almost all of these were accompanied by weight gain (although I have seen a few patients have visible graft growth even in its absence).
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