Acne Scars, Fat Transfer At A Glance
- Best Results1-3+ sessions
- Treatment Recovery0-8 days
- Procedure Time30 to 60 min
- Skin SpecialistDermatologist
- Duration of ResultsMany years
- AnaestheticTopical, gas or light sedation
- Back to WorkNext Day- 7 days
- Cost$$ - $$$
Fat Transfer For Acne Scars
Fat transfer is also known as fat grafting. Stem cell transfer is essentially transfer of fat cells known as adipocytes along with growth factors to distant sites. The advantage of fat transfer is that we are using your own cells to replace deficits in other areas of the body, including facial volume & atrophic acne scars.
FactsFacts on Fat Transfer for Acne Scars
- Fat contains cells to provide volume
- Fat also contains stem cells
- Stem cells can give rise to collagen producing cells
- Fat is harvested from sites such as the abs, flank & legs
- Resorption of fat is variable, ranging from 15% to 60%
- The number of sessions varies from one to three
What is fat transfer?
In a nutshell fat transfer or grafting takes fat cells from fat rich areas such as the abdomen & flanks, transferring the donor to fat poor areas of the face.
In the context of acne scars, atrophy (holes, divots, depression) can be classed as primary dermal (easy to treat with microneedling, RF, lasers, peels, stamping), primarily hypodermal/ subdermal/ subcutaneous (harder to treat). For deeper scars that lack collagen & fat, building blocks such as dermal fillers or fat is required to ‘fill up’ the depressions. Transferring fat is one such way of filling up facial depressions.
What type of acne scars are amenable to fat transfer?
Fat transfer is primarily aimed at improving deep atrophic acne scars. This pattern of scarring is best visualised with angled lighting. There are two types of atrophy, superficial atrophy, namely pick & boxcar scars, & deep subcutaneous atrophy, usually associated with rolling scars & marked tethering. Fat transfer is ideal for the latter.
The cheek, temples & perioral (around the mouth) are my most frequent fat transfer sites.
What are the advantages of fat transfer?
Longevity, natural autologous donor (your own cells) & theoretical transfer of fat cells with naturally occuring stem cells are the major advantages of fat grafting.
Once the graft establishes past the 16-20 week mark, in the majority of cases results will be long lasting. As the donor is your own fat, allergies & reactions do not occur.
Fat transfer without centrifugation also preserves your body’s stem cells. These stem cells can proliferate to become collagen producing cells such as fibroblasts. Growth factors harvested from the donor site can theoretically benefit scar tissue & improve skin quality.
Can fat transfer increase collagen?
Fat transfer also transfers stem cells, along with adipocytes (fat cells). In theory ASCs or adipose stem cells can differentiate to form keratocytes (skin cells), fibroblasts (collagen producing cells), endothelial cells (vessels), adipocytes (fat cells) & many more cell lineages. The amount of actual tissue produced from ASCs can not be quantified, nor can they be predicted at this moment in time. Most patients get some improvement in skin quality which can be attributed to stem cells- especially in the context of micro, or nano-fat transfer. The latter is devoid of adipose tissue.
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What are the disadvantages of fat transfer?
The major disadvantage of fat grafting – transfer is predictability of the end result. If I employ dermal fillers my usual correction is 1:1, meaning that we can predict with certainty of the volume obtained with hyaluronic acid. This is why HA fillers are so versatile in cosmesis. Fat transfer is less predictable with resorption rates of 5% to 50%, even if newer more stable techniques are employed. Fat is more labile than hyaluronic acid or collagen stimulating fillers in the context of both weight loss & weight gain.
The other disadvantage of fat is malleability, however micro & nano fat can give smaller size droplets. For larger areas of grafting, higher volumes are required. Fat, unlike some fillers, lack ‘G’ prime properties making them harder to employ as structural building blocks. Hence overcorrection is a rare side effect of fat transfer.
Arterial occlusion is a rare side effect of fat transfer. Unlike HA fillers where there is a reversal agent, fat can not be ‘dissolved.’ In the context of how I perform this procedure (larger bore cannula), this side effect is extremely rare.
How many sessions will I require?
1-5+ depending on the severity of acne scars, the amount of atrophy, your metabolism , uptake or resorption of fat, & your end goals. The main disadvantage of fat transfer is the unknown variable of initial fat absorption by your own immune system. Though I practice ‘high survival’ fat transfer (a relatively recent advancement in how we transfer fat), the graft survival rate can still vary from 50 to 95%.
In some cases only one session is required, in cases of marked atrophy with lots of subcutaneous – deep scarring, multiple sessions are required for optimal correction.
Are the results permanent?
Results are generally longer lasting compared to hyaluronic acid dermal fillers, however the initial uptake may not be as good. When fat stabilizes at 12-16 weeks, longevity is more predictable. A few caveats; firstly if one loses weight, normally in the region of 4-7% of baseline weight, fat resorption may be seen. Chronological aging will also deplete fat.
Expect duration of improvement to range from 4 to 12 years. If fat decreases in this time, ‘top ups’ with fat or dermal fillers may be required to maintain results. Superficial placement of fat (microdroplets) into the dermis lasts 2-4 years on average.
Who is the ideal candidate for fat transfer?
Patients who lead a healthy lifestyle with a stable weight are ideal candidates for atrophic acne scar fat transfer. In the context of weight, a variance of less than 4-5% of your usual body weight is acceptable. Too much weight loss can result in absorption of facial fat, whilst weight gain of 8% or more may increase the size of the adipocytes in the graft site.
Other factors that contribute to graft survival include smoking, diet, exercise & your body’s immune system.
Why is it vital to control acne or place it in remission before fat transfer?
Inflammation is the enemy of healing. This applies to fat transfer as well as other procedures including lasers, microneedling, RFM, subcision & deep peels. If you have active inflammation, it distracts your immune system by deferring cells to ‘fight’ sites of inflammation, rather than concentrate on building collagen & repairing damaged tissue.
Deep inflammation from acne is also in the level of fat transfer (sebaceous glands). Fat transfer should ideally be a sterile procedure.
Can fillers be combined with fat transfer?
Yes. In some cases I combine fat with off label fillers to give synergistic results. I prefer to combine with collagen stimulating fillers rather than HA fillers. Combination treatments enable better volume correction in some patients with large atrophic scars. Cheeks & temples are characteristic sites. This is done on a case basis as of this current date of writing (2021), evidence of combination therapy is still uncertain.
Can lasers be combined with fat transfer?
Depending on the skin layer I treat, lasers can be performed in the same session. I do not laser on the same day if the level is superficial or intradermal placement. Lasers & other devices are used if there are superficial scars (pick, boxcar scars, pores), fat transfer, dermal fillers & subcision target deeper dermal & hypodermal deficits.
What is my prefered donor site for fat transfer?
Abdomen, flanks, & legs. Many pro’s and cons’. Many studies have shown that donor sites do not matter, other studies have shown that adipose tissue harvested from the legs are more stable in the context of weight gain. My most frequent donor sites are the abdomen & flanks.
Why is it important to look beyond scarring & also focus on age related atrophy?
Probably the biggest hurdle I have is to convince patients that there are many other factors that come into play when it comes to revising acne scars. Tissue support is integral.
With age, the support for scar tissue & the dermis diminishes, this means there is increased laxity & a reduction of collagen, elastin, dermal matrix. Providing support for the dermal layer can only be achieved in one of two ways, namely matrix support in dermis – fat layer with dermal fillers, or support with fat. That’s it. Lasers, microneedling, energy devices can only do so much (improve skin quality, increase collagen). Replacing volume & resorting support, even if scars are not revised will indirectly improve scars. This is especially important in patients who have lost weight, who are slight of build, or who also exhibit age related changes as well as acne scars. Look beyond the scars in this group.
Is fat transfer painful?
No, this procedure is well tolerated. I often employ both local anesthesia as well as mild sedation. For bigger procedures I use deeper sedation. Pain following the procedure is minimal, often controlled with paracetamol only.
What is the cost of this treatment?
Costs will vary depending on the complexity of the procedure. In Australia Medicare may cover some of the associated costs, including surgical revision & ablative lasers. A benefit applies if the procedure is performed for objectively severe acne scars.
Medicare does not cover cosmetic procedures such as fat transfer for ageing, cosmesis, enhancement or improvement in skin quality.
Davin’s Viewpoint on Fat Transfer
Time to re-explore this after a decade. Initial efforts of fat transfer was more miss than hit. Why? Because until recently, the exact formula for transfer or fat grafting was unknown. Today we know the science of increasing graft survivability including extraction techniques, processing & transfer. The process is still not 100%, however survival rates for fat cells have certainly improved.
Fat can be used to treat atrophic scars, primarily cheeks, around the mouth & in the temples. Once past the initial ‘take-up’ stage, results are relatively predictable in the context of longevity. I do believe the next 10-20 year will be exciting as we figure out how to incorporate stem cells into the mix. In some cases I employ a dilution of collagen stimulating dermal fillers to further amplify the remodelling process.
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