Deep Facial Lines

Fillers? Or Fat transfer??

David Santos MD FACS


Over the years, our understanding of the causes of facial aging has evolved.  Specifically and notably, fat atrophy has become a significant leading concern and cause for the typical architectural changes that occur with facial aging.  Loss of facial fat and the creation of deep facial lines becomes more and more a concern as we age.  So it goes without saying that we have become significantly more motivated to restore the volume that has been lost and refresh the youthful facial characteristics.  Volume restoration has become more and more important over the last 10 and 15 years.  Certainly, in the plastic surgeon’s armamentarium, the balance of skin tightening, skin resurfacing, and restoration of the sagging tissue is important, but the improvement and loss of volume of the face has become a paramount.






Hyaluronic Acid is the most common and most widely used synthetic filler which nicely reduces contour abnormalities and loss of volume (examples Juvederm®, Restylane®, and Voluma®).  Other common fillers include Radiesse® (calcium hydroxylapatite) and Sculptra® which is a poly-L-lactic acid which will induce a collagen synthesis due to an inflammatory process.  This provides increased volume over time.  Sculptra, Restylane, Juvederm, Voluma and Radiesse are easily provided in the office with minimal downtime, bruising, or discomfort.  These procedures are safe, easy, and in experienced hands provide excellent results.  The downside is that they tend not to be permanent.  Juvederm, Restylane, Radiesse are reported to last 9 to 12 months, Voluma 24 months, but Sculptra has been reported to be long lasting on the order of many years.





Fat injection or fat grafting is another common source for “filling” to achieve facial aesthetic rejuvenation and restoration of volume to the face.  Fat is best harvested from the abdomen, as the abdomen tends to have a greatest amount of stem cells and associated growth factors which theoretically provides the best result on transfer.  After the fat is harvested, through tiny incisions within the facial folds, it is processed in a sterile manner and then re-injected immediately and directly into the areas of concern, commonly the nasolabial folds, marionette lines, sub-malar areas, temporal area, and other facial regions.  This is done under oral sedation and local anesthesia.  Small blunt cannulas are utilized and this is generally a comfortable and safe procedure.  For most individuals, fat is readily available, particularly in the abdomen or the thighs.  There are some individuals who are significantly thin and render fat harvesting somewhat difficult.  Newer fat grafting techniques have improved the success rate, such that, a large majority of patients experience long-lasting results for years or more.






There are a number of arguments for and against either of these two options, but nonetheless, both are essentially correct answers.  There are a number of elements that go into the appraisal of this solution which all together should be explored.  Specifically, the area of the face to be treated plays a significant roll in determining the best answer.  The eleven-line or glabellar furrow between the eyebrows is best treated with combination of Botox as well as synthetic filler.  Fat placement is this area tends to absorb in a high frequency and so is essentially not commonly performed in this area.  Another area best treated with filler is the lateral crow’s feet along the lateral portion of the periorbital area.  Additionally Cupid’s bow or the philtral columns over the upper lip are best treated with filler.  These small areas can nicely and consistently be enhanced with meticulous placement with a small amount of hyaluronic acid.  Fat essentially works poorly in these areas:  glabellar, crow’s feet and philtrum.


Another important factor which influences the decision process as to which volume restorative method one should utilize is related to the predicted time of effective treatment success.  Hyaluronic acid such as Restylane® and Juvederm® tend to last nine months and rarely greater than a year.  Voluma, which is a more cross-linked material and somewhat newer on the market, tends to last a little bit longer and some say up to two years.  Sculptra is a little more expensive than the hyaluronic acid, but tends to report a longer and sometimes indefinite effective success rate; however, when utilizing fat injections, so often this successful treatment is achieved that is indefinite.  There are of course instances where touchup or repeat fat delivery is required at 6-12 months after initial procedure.  However, this is an infrequent requirement.  So, when looking for a long-term solution, fat grafting is an excellent option followed by Sculptra and then to a lesser degree Voluma.


The cost is a factor as well.  Initial cost tends to make fat grafting with its procedure room, local anesthesia, and technician requirements as the more costly; however, over the long run with the need for repeated injections with hyaluronic acids and other fillers, the fat grafting becomes a less expensive proposition, particularly as you calculate out year after year costs for repeated hyaluronic filler injections.


Furthermore, peripheral stem cells associated with fat harvesting, particularly in the area of the abdomen have been suggested to improve surrounding tissue quality including the skin.  This is a direct result of cellular differentiation from the stem cells lending itself for a nurturing and rejuvenation effect to the surrounding tissues (skin).  Pictures of overlying skin on before and after results after post-fat grafting treatment suggest improvement in the skin quality and youthfulness.  This is something that does not happen with simple fillers such as Sculptra®, Voluma®, or Restylane®, so when thinking on a more natural and more therapeutic treatment, fat grafting is arguably a better option.


First initial treatments are probably better suited for fillers.  With an initial treatment with the filler, there is a significant confidence that the filler will resolve and disappear within one or two years after treatment.  Therefore, if the result is not satisfactory, it is not a permanent result.  It is sometimes desirable to see what the results of treatment are, so that the individual patient can determine whether or not this is really something of value to them.  Placement of fat can be a permanent result, so essentially it lacks the temporariness that some patients might deem to be desirable.  Also, enzymatic injections (hyaluronidase) can dissipate the injected hyaluronidase; therefore reversing any effect in the rare case the injection is unsatisfactory or unsightly.


Fat Injection and CO2 Laser Before Karyn BuchananFat Injection and CO2 Laser After Karyn Buchanan - Copy

Before                                                                                             After   (fat transfer and Laser resurfacing)





Essentially, it comes down to each individual’s situation, circumstance, anatomy, overall desires, etc. etc… This will render the decision between fillers versus fat grafting as a tailored judgment decision.  Both answers are correct.  See:

Fat Grafting

A facial plastic surgeon with a significant degree of experience can take all the elements listed above and more to provide the best recommendation depending on the patient’s desires, areas to be treated, history of previous volume restoration history and other factors.


Commonly patients will elect to have the less costly initial trial with a synthetic filler first and see for themselves their overall results.  Most often, after seeing the nice success of filling in the aging lines and after the filler goes away after a year or more, patients will then elect to have the more “natural” and longer-lasting choice of fat transfer.




David Q Santos MD FACS

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Dr. Santos