Filler or Fat: How Do You Choose?

When a patient asks, should I have filler or fat, how do you advise? That was one of the key questions posed by L. Mike Nayak, M.D., St. Louis-based facial plastic surgeon, during the “Fat vs. Fillers: Change My Mind,” session in his virtual Medspa Mastery course that took place earlier this year.

The answer is based on many considerations, including age, number of treatment areas and what those areas are, according to panel member Christian A. Prada, M.D., F.A.C.S., a St. Louis-based plastic surgeon.

“These are all going to come into play in terms of deciding whether filler or fat’s going to be better…,” he says. “Patients can come in and they're interested in one thing or the other and I just tell them, ‘you're going to do much better with filler. Go that way. That's how I would treat my wife if she needed something, or [go] the other way [if that’s the better option].”

Johnathan Sykes, M.D., F.A.C.S., a facial plastic surgeon in Beverly Hills and Sacramento, Calif., says he educates patients on the differences and leaves the choice up to them.

“I tell them, honestly, about all the things, pro and con, of fat and filler. If it's a more globalization thing, I like fat. If it's a patient that's going into surgery, I like fat. And that's my bias. If it's a patient that wants more spot treatment or a structural treatment, like her cheeks are drawn, I like filler. …I answer all their questions and I let them make a decision,” he says.

For Samuel M. Lam, M.D., F.A.C.S., a facial plastic surgeon in Plano, Tex., he generally prefers fillers in terms of longevity, predictability and cost-effectiveness.

“My patients have durability with fillers, so I no longer make the argument that fat is more durable than fillers,” he says. “Honestly, I would love to put 20 syringes of fillers in, but it's cost prohibitive. So I do fat if their weight is stable. And that's one point about safety is… to avoid issues with weight gain. That's something that doesn't occur with fillers. [With] fillers you have to worry about granuloma.”

Dr. Prada says he generally recommendation filler for younger patients who don’t want the downtime or require much volume.

“They're going to do much better with a very quick, in and out treatment. They do not want to have a week or two of swelling on their face. They just want to have the lips look a little bit more plump. And I've always found when I put fat into the lip, [patients] can go through four-to-six weeks of having this Daffy Duck look that they don't like.”

The Lip Debate

When it comes to lips, not everyone thinks fat is a good idea.

“I think, as we know, areas that have more motion in the face seem to disrupt the attachments in the fat and you just don't get as much take,” says Dr. Prada. “I don't find that [fat] take in the lip is nearly as good as it is over the zygoma.”

And there are additional reasons for opting for filler vs. fat in the lips, according to Dr. Sykes.

“…We can be more precise with a filler than we can with fat,” he says. “[With] filler we can either dilute it, we can put very tiny amounts, we really can control that amount that gets there. If we put a small amount of fat near the surface [of the lip], it may gain a really good blood supply and become a lump. So I love filler for lips. The patient says to me, 'I want to fatten my lips because I want it to last forever,' I try and reeducate them.”

Dr. Lam concurs. Not only does he avoid putting fat in the lips, but he also discourages the use of fat in isolated areas.

“If someone comes in and [says], ‘Just fix this tear trough with fat,’ I'm going to say, do fillers. Of course, there's risk with fillers but that's my approach to it.”

Dr. Sykes agrees that fillers are a good choice for smaller areas and can offer a higher level of precision.

“If I’ve got a small area, I like the idea of using filler in that area, because it makes sort of sense of not going to the operating room not harvesting, from an area,” he says. “As far as the tear trough is concerned, I think we can be more precise with [a] fine 30-gauge needle than we can with that fine cannula, putting little lumps — even though they're micro lumps — of fat in that area.”

Next: Fillers for Post-Fat Grafting Finesse