Plastic Surgery Unplugged with Dr. Raghu: Episode 10

Welcome to an all-new episode of “Plastic Surgery Unplugged” with Dr. Athré. This podcast series highlights tips and tricks from the plastic surgery industry, and features special guests as well. Listen in for interviews with professionals and patients, and Dr. Athré’s own personal anecdotes from his work in the industry. 

In episode 10, Dr. Athré discusses the process, myths, and realities of fat transfers and fillers.

Listen on YouTube, Apple Podcasts, Spotify, Podbean, or Google Podcasts—and don’t forget to check out our archive of episodes 1 through 9. 

Don’t forget to subscribe and share with friends and family. Here’s episode 10: “Facial Fat Transfers and How They Work.” Thanks for listening!

[Audio transcription via]

Dr. Raghu Athré:

Hi, I’m Dr. Raghu Athre with Athre Plastic Surgery in Houston, Texas. The focus of this talk is fat transfer. Fat transfer is one of my most favorite procedures to perform as an adjunctive or as a secondary procedure. When I’m doing facial rejuvenation, I’d like to give the listeners some information about fat transfer, different types of fat transfer pros and cons, and why we do it. So there’s gonna be a lot of information that’s provided in this talk. So we hope you really enjoy the video. If you have questions, don’t hesitate to give us a shout, always subscribe to our channel, and we look forward to chatting with you. That being said, let’s move on with the, uh, the talk. 

When we age, when all of us age, we end up losing some amount of facial volume, a very key way of thinking about this is imagine someone who is older, maybe in the hospital, chronic illness, that kind of picture in your head, and you can really start seeing how the eyes start sinking back into the skull. And there’s hollowing in the temple regions. And the bones just seem so much more prominent. This is a good example of volume loss. 

So when we actually end up losing volume, we lose volume in many different ways. So we actually lose volume from our bone volume. So if we had the opportunity to take a CT scan of our skull when we were young, and then maybe every five years afterwards, and be able to calculate the volume of the bone of our skull, you would actually see that the bone volume actually becomes less over time. We lose some of that bone volume. 

Dr. Raghu Athré:

Now, not only do we lose bone volume, we also lose soft tissue volume. So the tissues, uh, become a little bit thinner. There’s less amount of fat and connective tissue. So all of these things are occurring simultaneously as we age. And when someone comes in to say, “I would like to do a facial rejuvenation procedure,” basically what we’re trying to do is turn the clock back. 

So when we turn the clock back, some of the things that we end up doing are lifting procedures, right? Like a facelift or a neck lift. And the reason we do that is because as we age these soft tissues start kind of falling down. So we’re losing some of the taughtness and the tightness of the tissues and those tissues are falling down. So a suspension procedure — like a facelift or a mid facelift, or a neck lift or brow lift, all these types of procedures — what they’re really doing is reopening those tissues and putting them back in the place that they originally started out. However, thus far, in these types of procedures, we have not done anything for the actual volume loss. 

Dr. Raghu Athré:

When I end up doing my deep plane facelift, I end up doing some degree of a mid-face lift, as well as part of the procedure. As I am doing this and re suspending those tissues, there is a slight amount of volume increase directly in that cheekbone area. As those tissues are put back to where they were, however, the overall volume has not changed at all. This is where I feel fat transfer plays a critical role in adding that extra icing on the cake. 

If you will, in terms of facial rejuvenation procedures, let’s put a quick little pause in this talk right here. We’re gonna jump to a different topic and we’re gonna come right back to this. Most of you who are watching this video have kind of seen, or maybe you’re a patient that has experienced fillers, things like Restylane, Juvederm Radius, you’re, you’re kind of bombarded in the news and current events about, uh, these types of procedures. 

Dr. Raghu Athré:

So what are these procedures actually doing? Well, they’re actually combating volume loss. So you’re actually adding volume to certain areas, whether it’s in here or the under eye region, in order to puff up the tissues and create the rejuvenated look. 

Similarly, another entity or another thing that can be used other than fillers is fat. Now fat has some inherent advantages over fillers. First of all, it’s readily harvestable. So what I mean by that is when you say I’d like to go and get a syringe of Restylane. You are purchasing one CC of high UR acid to be injected somewhere. Well, most of the time when we are injecting patients for facial rejuvenation, we’re injecting 12, 15, 18 CCS, maybe 20 CCS of filler or volume rather into the face to rejuvenate the tissues. And you can imagine that 20 CCS of filler or 20 syringes of filler is gonna be quite an expensive way to add volume.This is where fat’s primary advantage over all the other fillers comes in. 

Dr. Raghu Athré:

If you’re already undergoing a surgical procedure, i.e. a facelift or a neck lift or something like that, you have a significant amount of volume loss that needs correction. Fat is a great alternative. Now there’s lots of different ways of doing fat transfer. 

One of the oldest ways of doing fat transfer was you used a large bore cannula, which was basically about the size of a pencil, or maybe a little bit bigger, and you liposuck and you take that fat and you basically shove it into someplace else. Some of the problems we faced when using that type of technique in the face, you’d get a lot of lumpy bumpiness, you’d get a lot of contour irregularities. You would get things like granulomas and things, which would just not give you that smooth, natural, non-operated non-instrumented type of result. 

This is where microsomal fat and nano fat really come in. These are some newer techniques that are being used in order to give the fat a much more natural look. So a brief synopsis of the technique of how we inject the fat is as follows. 

Dr. Raghu Athré:

Once the face lift is done, there is an analysis of the areas of which need to be corrected. Some of the most common areas include the temporal hollows under eye area, a little bit into the cheek to accentuate the cheekbone, the, um, the pre-Jo sous or the, the tip of the Jo line in here, the lips, the smile lines in here, and the smokers lines. These are all common areas where fat can be injected. So kind of an inventory of where all we need to put the fat is first done. 

Once that’s done, we can basically figure out where we’re going to harvest the fat. Some of my favorite areas include the medial thighs, as well as the abdomen. A lot of my patients have already had some type of abdominal procedure, whether it be liposuction, a tummy tuck, or something to that effect, which may not make them a primo candidate for harvesting fat from the abdomen. Therefore, the medial thigh is normally one of my favorite spots to get fat. 

Dr. Raghu Athré:

The area is first anesthetized with a combination of anesthesia. As well as epinephrine in order to prevent bleeding. Once that mixture is kind of set into the tissues for about 20 minutes, we actually use a small bore cannula, which is very fine. It’s probably about two millimeters, um, in thickness to actually suck out the fat. The advantage of this is that the fat that’s being sucked out is actually, um, it doesn’t have much connective tissue and it’s already in a very small particle size.

Once that fat has been removed, that fat is first centrifuged to remove any blood component, plasma component of the fat, and the fatty acid or the oil component of the fat is also removed, leaving pure fat. That fat is then processed. 

Dr. Raghu Athré:

We have a technique where we actually process the fat through these small SS that basically makes the fat into a puree or a paté. And that puree can be injected through the same needle that your Restylane would be injected, which is a 27 gauge needle. So it’s a very, very fine, um, solution if you will — a fat that can be injected and you can inject it into very small areas into small or large amounts.

Now, the advantage that this has, or this technique has, is since you’re injecting this fat in a very purified, as well as smooth, uh, solution, you’re less likely to get contour regularities. You’re less likely to get lumps and bumps and less likely to get granulomas. So you really can go right into some of these very thin tissues like the under eye to get a smooth contour of this area. 

Dr. Raghu Athré:

The process of injecting fat probably takes all in all roughly about one hour to do from the harvesting, processing, and injecting. It’s normally done in conjunction with the facelift. And as you may have seen in some of my prior videos, I like using local anesthesia with oral sedation for most of my facial rejuvenation procedures. So the question comes up, can fat also be done under local anesthesia? And the answer to that is yes. 

Fat is very easily done under local anesthesia with the oral sedation in conjunction with a facelift or a neck lift or a blepharoplasty. Some of the advantages of doing fat are you get access to using large volumes of filling material, so it’s much more cost effective. The other thing that I wanna say about fat is that patients sometimes have the notion that fat is permanent, and that really is not the case. There’s nothing that is absolutely permanent. So even when we do a facelift, we cannot say that the result of that facelift is absolutely permanent. 

Dr. Raghu Athré:

Your face is not static. I’ve seen patients five to seven years afterwards, and they’re still holding the fat, however, your face does continue to age. So there is a chance that you would most likely come back 5, 7, 8 years after surgery for some additional amount of volume correction. Because during that time period, even if the fat is alive and is doing well, you may still be losing some of your inherent volume in your face skeleton, as well as your soft tissues. 

So all of this put together, fat’s a great filling, alternative over fillers, especially large volumes and large surface areas, as well as in conjunction with other facial rejuvenation procedures.

Dr. Raghu Athré:

I hope this talk has really been informative and you’ve learned a lot about fat and how fat can be used, how fat is harvested and some of the different techniques that we use in order to give you a better result. If you have any questions, don’t hesitate to give us a call at (281) 557-3223. Look us up. Our webpage is Come down to Houston, visit us, and definitely please subscribe to our channel. We look forward to meeting you.