Fat injections into the face have come a long way since the pioneering work of Dr Sydney Coleman of New York in the early 1990’s. At that time, it was not certain that a permanent result could be obtained. In fact, many people thought the result was due to prolonged swelling! But this is not the case and it is now abundantly clear that the transferred fat, once it has taken, permanently survives in its new location without moving. In fact, the transferred fat continues to behave like the fat at the original site of origin. For example, hip and lower abdominal fat on the face continues to behave like hip and abdominal fat: so that if a person gains weight the fat cells increase in volume. Conversely if a person loses weight the transferred fat on the face shrinks just the same as it would were it still on the hip or abdomen.
In recent years, it has become apparent there is more to fat injections than first thought. It was noted, almost with disbelief initially, that the appearance of the tissues over the injected fat improves in quality in many people. The reason for this was subsequently found, the ‘body fat, is actually the largest source of stem-cells in the body and these have now become a major focus in theft transfer. The LIPOGEMS system is designed to maximise the amount of stem cells as it purifies the fat.
The greatest concern about injecting fat on the face, other than obtaining a sufficient result is that the fat may form visible lumps. These are prone to occur in areas with thin tissue, the areas that most often need fat, particularly around the eyes. This problem of lumps is frustrating and difficult to treat. But now, lumps can be completely avoided when using LIPOGEMS, because of the purification process.
After being prepared the fat is passed through a 1mm filter. Interestingly, fat which had previously been considered to be fine, is seen in the LIPOGEMS chamber to not be as pure as was thought; which may explain unexpected lumps.
This is a liberating breakthrough, but the use of stem-cells bring more benefits than the avoidance of possible lumps. Patients who previously had regular fat injections and now have LIPOGEMS, report other differences.
1) With LIPOGEMS, the swelling is much less, about half that with traditional fat injections. The recovery is also quicker, usually in a week or so
2) Bruising is dramatically reduced and often not present at all.
3) Discomfort and stiffness of the injected tissues during the healing is almost non-existent.
As a result of these advances, new horizons have opened up in facial rejuvenation. We are now proactive in recommending LIPOGEMS around the eyes. Not only does this improve the look of liveliness of the upper lids, the tissue tone and shape of the brow is also improved, so that it provides a subtle temporal lift effect by slightly raising the outer brow. The small amount of hollowing that develops across the lower lid at the top of the cheek is quite aging and can now be safely improved, often with the use of LIPOGEMS alone. Correction of advanced hollowing here may still require surgery: but LIPOGEMS are added for fine tuning.
The other advance is in the infiltration cannula. These are the very fine blunt ended tubes which are passed through the skin to place the LIPOGEMS particles. These are now even finer and more slippery as the fat particles are finer, so there is less tissue trauma as the finer particles are injected, with less swelling and a quicker recovery.
The LIPOGEMS system maximises a remarkable finding that was not known in the early years of fat injections (lipofilling). LIPOGEMS is a patented, closed microfat purification system that maximises stem cells and has been available in Australia only from the beginning of 2015. LIPOGEMS are used either to enhance a natural feature e.g. enlarging the lips, the lids or the jawline, or to correct volume loss caused by ageing. As the volume of the tissues become plumped up there is also a beneficial degree of tightening and lifting of slightly sagged areas to further improve appearance.
SNIFS is a new variation of fat injections in which the fat is reduced to even finer particles. This allows the fat to be injected using a fine hypodermic needle directly into the wrinkles, something not possible using fat previously . A traditional weakness of lipoinfiltration and fillers is that they are placed beneath the skin and don’t work directly on wrinkles. Now, with microfat injected through a fine needle, individual deep wrinkles can be reduced. The improvement may be of the order of 30% to 50%. Accordingly, a second, and possibly a third, treatment are recommended later to further improve, what was previously untreatable. Performed alone this is a relatively minor procedure. With personal experience there have been considerable improvements with the use of Lipogems to obtain more predictable and better results more easily. But so far there is simply no alternative. Other treatments using lasers, peels, dermabrasions always lead to permanent lightening whereas the lipogems results, especially with the second and subsequent treatments result in a real brightening quality of the tissues and the skin.
This is a completely new addition to the ‘fat injection‘ repertoire, in which the preparation process is taken to the next level. With nanofat what is being injected is nearly all stem cells so there is negligible addition of volume Stem cells are tiny in size compared to fat cells, they are only about 100th, the size of a fat cell! Nanogems are placed using a tiny needle to place a film of stem cells into the skin to rejuvenate and strengthen areas of weakened skin quality, especially of the ultrathin lower lid skin and fine wrinkles around the mouth.
The only risk with nanofat, is of disappointment with the result. But it is the beginning of a new era. The trade-off is the possible need for a subsequent treatment to achieve a the full degree of correction hoped for.
Many people are not sure what a facelift is expected to achieve, which is understandable when this word is trivialised by alternatives such as non-surgical lifts. In reality, when required there is no substitute for a proper, internal support type of facelift, which corrects laxity and sagging of the cheeks, jawline and neck to obtain a natural looking result that is also long lasting.
Some years of ageing changes are usually evident before a facelift is required. While injecting fat is not an alternative to this type of facelift, having LIPOGEMS performed at the right time may improve the appearance and so defer the need for a facelift as LIPOGEMS can very effectively camouflage early ageing changes. Soft tissue fillers are also used for this purpose but they do not have the stem cell qualities and are not permanent. Lipogems are then used to complement a facelift.
For people who have previously had the benefit of a good facelift, as the ageing changes slowly reappear, LIPOGEMS are used to regain the fuller youthful
appearance, deferring the requirement for a second facelift. This is provided, of course, that the original facelift was a quality one that obtained a proper correction. Even then, the secondary facelift is often a partial, lower face only while the upper face correction may be obtained using LIPOGEMS only.
During the first few days, when swollen, some people are understandably concerned that the fat injections have been overdone, but this concern settles as the swelling subsides rather quickly. With the controlled way the procedure is performed it is not possible to place too much fat and have too much of that fat survive in a first treatment.
The results are a definite but subtle enhancement. They are not dramatic or artificial as is seen with an ‘overdone traditional face-lifts’ and so often seen with people who have overdone fillers or overdone fat injections. Disappointment sometimes occurs when people become accustomed to, and came to like their appearance while some swelling remained! In this situation, a degree of disappointment is understandable as the last of the swelling resolves taking the fullness with it. But the positive is that there is no question that it would look better having a further Lipogems treatment.
Examination of the pre-operative photographs can be helpful at this time. By comparing the final result to the `before’ appearance and not the `swollen’ appearance, the degree of improvement can be realistically appreciated.
About a third of patients subsequently have more fat placed. As with fat injection in general, lipogems is done incrementally and this can be performed as early as three months after the original procedure or any time after that. The need to have more fat placed is a reflection of the biologic limit of what can be achieved at any one procedure when LIPOGEMS is performed. It does not mean that the original LIPOGEMS was not well done.
In most situations it can be predicted ahead of time whether a second and occasionally a third LIPOGEMS procedure will be required to achieve your desired correction. This will be discussed with you before you make up your mind to proceed with the first LIPOGEMS procedure. Obviously, when a further LIPOGEMS procedure is required, it is performed with full attention to detail, similar to the previous procedure. A further professional fee will be involved but with a courtesy fee reduction out of respect for the importance of having this.
The less mobile areas of the face, such as over the brow or jaw line tend to have more predictable results from fat injections. Whereas, highly mobile areas, especially the lips inherently have a greater need for secondary procedures.
Although the result cannot be guaranteed, most people find that their original objectives have been met, which becomes more apparent when comparing their post-operative face to their ‘before’ photographs. As with all surgery, there is no magic wand, so it is important to have realistic, but high expectations of the outcome, and to discuss your objectives fully in your pre-operative consultation.
LIPOGEMS is a minimal risk procedure; in fact, it would be the safest technique in facial rejuvenation. Infection, while possible after LIPOGEMS, is extraordinarily rare and recently it has been shown that the stem cells secrete a substance LD 30, which is a natural antibiotic. Another risk you may read about, is possible, although more likely with traditional fat injections, is the few reported casesin which some of the injected fat got into the circulation of the eye, as is a well appreciated risk with filler injections. With the more fluid content and easier injection with lipogems, this is even more unlikely.
Visible irregularities (lumps) tend to be more apparent in broad flat areas, such as the forehead, or where the skin is extremely thin such as the eyelid. However, this is not a major risk with LIPOGEMS, and is important advance! Irregularities are less likely to occur on thicker areas, as on the lips and cheeks. It is difficult to precisely ‘spot fill’ minor irregularities from aging of the lid cheek junction. At worst, a `touch up’ procedure may be required to add small volumes of fat should that be insufficient originally.
When LIPOGEMS is being performed alone, or with Skin Needling and Hydroxyapatite (coral) filler it is most often performed as a day procedure in our Centre for Facial Plastic Surgery in Toorak. Patients appreciate the convenience and comfort, compared to having a hospital procedure. Should the LIPOGEMS be planned as part of other surgery, particularly a facelift, the requirements for the latter determine where the surgery will be performed.
This varies on the extent of the procedure. If only localised areas are being corrected, such as the lip, which is completed within an hour, local anaesthetic is usually sufficient, although we provide some premedication to make this more comfortable. With a more extensive procedure, full face LIPOGEMS for example, which may take up to two hours most people it is more comfortable for most people to have the benefit of a light anaesthetic, but it is still performed in day surgery.
The fat used for the transfer can be taken from any area of the body, although the abdomen and hips are the most common location of excess. The highest quality fat is from the inner knees. Dilute local anaesthetic is first injected into the donor area, then when this is working the fat is obtained using a special needle. There is no incision or scar, although bruising is common, more so on the donor area than on the face. It may be considerable, particularly if you are a ‘bruiser’.
The aspirated fat is then meticulously prepared. This involves a comprehensive, but gentle washing of the fat in a closed chamber. Then the chamber, which also contains 5 stainless steel marbles, is shaken to microfracture the fat fragments to smaller particle size, which also activates the stem cells. When complete, the treated fat is passed through a fine filter and transferred to small syringes. Particular care is required to avoid trauma to the delicate fat tissue.
The technique of placing the fat is a crucial aspect of the technique. Specially designed fine needles are used to ‘weave’ droplets of the purified fat through the tissue where the augmentation is to be performed. The needle is inserted through tiny, scarless incisions on selected areas of the face and the fat droplets are meticulously placed at all levels and from different directions. The incorporated fat tends to take on the characteristic texture of the tissue being augmented. The multiple passes of the fine infiltration needle account for most of the swelling and possibly a degree of bruising of the treated areas.
The only aftercare required, are measures to reduce swelling and to relieve discomfort, if present. Iced compresses applied to the treated areas for the remainder of the day minimise swelling and discomfort. As with any bruising, there may be minor discomfort, which is relieved by everyday analgesics, such as Panadol or Panadeine for the first few days. Most discomfort is experienced from bruising of the donor area! The level of discomfort varies according to the extent of bruising. For lip augmentation there is minimal to modest discomfort only, whereas even a full-face treatment has only modest discomfort with LIPOGEMS.
The major disadvantage of having LIPOGEMS is the inconvenience of the swelling and bruising. Swelling always increases for the first 48 hours after the procedure before it starts to settle on the fourth day. While the face should not be scrubbed, getting it wet in the shower is not a concern.
Swelling during the first week may be such that it may be embarrassing to be seen socially. It is acceptable to wear makeup after 3 days, but it should be removed gently.
During the second and third weeks the swelling has usually settled so much to be, at worst, a nuisance. For a full-face treatment, it may take three weeks for the face to no longer look swollen. Even though no longer apparent, some residual swelling remains in the treated area for up to eight weeks.
Some people who are concerned that the duration of swelling could be inconvenient for them, elect to compromise the initial result, in order to reduce the duration of the swelling, by having less fat injected, knowing it is planned to repeat the procedure in the future
With the major advances in the facelifts I now perform, swelling and bruising from the lift is usually minimal and most of it comes from the fat injections! When LIPOGEMS are used, the facelift swelling is reduced, due to the action of the stem cells.