Sydney plastic surgeon, Dr John Flood, explains that liposuction and fat transfer are two separate procedures and should be treated as such. Lauren Alexander reports.
Fat transfer is becoming a popular procedure for giving the face a younger appearance. As we age the face loses volume, often resulting in sagging skin and a gaunt appearance. To determine what the patient really wants – a fat transfer or a facelift – their expectations must first be determined.
Sydney plastic surgeon Dr John Flood explained: “When someone comes in requesting a facelift I do a thorough analysis of their face and find out what they want to look like. If they want to look more youthful then that usually means a plumper face.”
In consultation he uses the example of Sharon Stone. Showing a younger and older picture of Stone it is easy for patients to see in which photo she is older. “This is because in the older photo while her skin is still tight she is very chiselled whereas the younger picture her face is plumper. If the patient wants to look chiselled then a facelift may suit them, if they want to look younger then fat transfer is probably the way to go.”
Using a technique of liposuction, fat can be removed from other areas of the body and reinjected into the face where it’s needed. However the process is slightly different than liposuction for fat removal alone and these differences are vital.
“Fat injection isn’t a matter of just performing liposuction“, said Dr Flood. “It is important to look after the fat cells. It’s just like doing a graft – the fat cells must be treated carefully to survive.”
The percentage of fat cells that survive the transfer ranges between 50 to 75%. If the fat cells do resorb, the patient may require a further injection after 6 to 9 months.
To do this the fat is aspirated under very low pressure. Dr Flood prefers to take the fat from the abdomen or the inner knees. Liposuction for fat removal uses a tool called a cannula, which is between three and five millimetres in diameter. However, for removing fat that will be transferred into the face a special one millimetre cannula is required. “Those fat cells you aspirate with liposuction can’t be used”, explained Dr. Flood. “They are unsuitable since they are damaged cells and they will die.”
The fat cells must be living to survive in the face. To do this they need a supply of blood which brings them oxygen and glucose. The key to a successful fat transfer is ensuring healthy fat cells are being injected and that blood vessels will be able to grow around them before they did.
Dr Flood explained: “Once the fat is removed it is centrifuged to separate the fatty oils from the true fat cells. Of 10mls that I aspirate, there will be 4mls of pure fat cells and 6mls of fatty oils and blood.” Once the pure fat cells are separated they are placed into glass injection syringes with a blunt tip needle.
“The fat is injected in 0.1 millimetre tunnels. These tiny tunnels allow blood vessels to grow into them”, said Dr Flood. “Where it is injected depends on the area. If it is put into the lips, it must be put into the muscle layer because there’s a better blood supply there.”
Under the cheekbones for instance, in the sub malar hollow, the fat can be injected both deeply and superficially. “To build out structure the fat must be injected deeply. When you want to improve skin tone and fill out wrinkles it can be injected more superficially”, said Dr Flood, stressing the need to always use tiny amounts. “The areas to avoid are around the eyelids – I don’t ever go there. I think it looks terrible and is a difficult thing to correct and has complications.”
Some of the fat will die regardless and when it does, it usually disappears. However, if large amounts are injected, sometimes it can cause scarring that feels hard underneath the skin and tethering can appear. If it is injected in tiny amounts the likelihood of this occurring is minimal. “It is important to take your time and do it gently. Injecting large smounts will result in less surviving”, explained Dr Flood.
The procedure can be performed under local anaesthetic with intravenous sedation or under general anaesthesia as a day surgery procedure. Afterwards a pressure dressing is applied and remains for 24 hours to minimise any bruising and swelling. After 48 hours the patient can gently massage the area to ensure there are no lumps or bumps.
The bruising or swelling may take about five days to subside but most patients can go back to work within a couple of days. “Most patients will see a result straight away. But to see the final result it takes between 2-4 weeks.”
If the patient wants a fat transfer to the face only a relatively small amount of fat needs to be extracted. If the patient wants a liposuction procedure for fat removal as well, the first thing to establish is what the patient wants to achieve. “It’s very important to determine what the patient wants from liposuction”, said Dr Flood. “What are their goals and what are their expectations?”
One way to establish this is through visual communications such as old photos or picture of what the patient likes. “I try to find out what they used to look like and try to get them back to their body shape before it changed. Also looking at pictures of what they like will help me know if they are realistic”, explained Dr Flood.
A visual communication also helps the surgeon and patient understand each other. Dr. Flood explained: “I can have different terminology than the patient. When someone says I want to get my thighs done – what does “thigh” mean? The whole thigh, the front, the sides? When they show me a picture I can see exactly what they mean.
Once it is established what the patient wants to achieve from the liposuction, the process is explained in detail. When the liposuction surgery is actually taking place the fat being removed for “debulking” is treated in a different way as the fat removed for reinjection into the face.
While the two procedures go hand in hand the approaches are different. Establishing this at the beginning of the consultation is important to gain a successful result for the patient.