Fat Transfer Q&A: Everything You Need To Know

If you have been told you are too thin for a fat transfer, I hear that all the time, and that assessment is usually wrong. I also hear a second version of the same fear: after breastfeeding, the volume left, the skin stretched, and someone said the only way back is an implant, or they said you have to keep the implant you already have because taking it out means being flat again. So tonight. I want to take those four situations completely apart, deconstruct them one at a time: restoring volume after breastfeeding, doing a fat transfer at the same time as an explant, a basic natural augmentation with your own tissue, and the lean patient who was told there was nothing to work with. So let's obviously set this up. This is educational only. It's not a consult. It's not meant to be personal medical advice. I can. I cannot tell you, obviously, from a screen whether you are a candidate or not. That takes an in-person exam and your history. And what I prefer to do is a DEXA scan in addition to physical exam. And then I do— if anybody understands or has read my book about the SHARP methodology, we have a series of tests we like to include in addition to a very lengthy history about your travel history, where you lived growing up. All those things are potentially sources of toxicity exposure. So please take all these questions about surgery, your recovery, anything that you're concerned about, whether it's me as a clinician or another clinician that you were able to discuss these with, but those are the things to take to your provider. And once again, you know, welcome to the livestream tonight. I'm Dr. Robert Whitfield. I'm a board-certified plastic surgeon. I I have a clinic and a surgery center in Austin, Texas. So thank you for joining me. Excited to do this livestream tonight. And please share this livestream with a friend, a loved one, or someone who could learn from this discussion or is struggling with similar issues. Members of the Circle will have access to this whole stream on replay as soon as we're done. We'll get it up within the next 24 hours after it's had time to process. I want to start with Reframing the discussion because it changes every question that follows. An implant is a device, and devices have roles. I've used them throughout my career for breast cancer reconstruction and augmentation. About 6 years ago, we— 6 or so years ago, we stopped using devices and really transitioned to only natural transformations with fat for augmentation. And I'm not here To tell you every implant is a problem, that's not the goal of this discussion. Every device has a lifespan. Your body obviously builds scar tissue around everything that's foreign that's put in it. These devices can rupture and deflate if they're saline. They can rupture silently and/or be changed and painful if they're silicone devices. But— The silent ones are a little bit more difficult to figure out. At some point, obviously, they need to be exchanged potentially, removed potentially. And that's not to scare anybody. It's a medical device. That's basically how devices work. They're not meant to be lifetime devices. Your baseline obviously is your own tissue. Your own tissue is really going to change over time. Typically, when we're younger, we're thinner. And then as we age, I've had patients and my nurse practitioners talk about it a lot. People seemingly gain a cup size over time sometimes. So when a woman asks, what will I look like? She's often picturing the implant as the norm and everything else as a loss. So we want to obviously reverse that. The better question is not, What you lose when a device comes out. The better question is, what can we restore with your own tissue and what, what can we not restore? So fat transfer is not a filler you can dissolve. Fat is your own tissue source. It has cells that need to have blood flow and oxygen. It has its own blood supply. When we move it, we are transplanting it. It has to heal in that new position, that new space wherever we place it, whether it's face, breast, breast or buttocks. Here's the foundation I want you to keep for the next 20 minutes: prepare the patient, harvest the fat, process the fat, and then place the fat. And so these are things that I, I don't take them for granted. They're very specific in our process, and timing is very, uh, important as well. Harvest is not ordinary liposuction where you debulking area and throw that tissue away. We take fat intentionally from places such as the inner outer thighs, flanks, and abdomen, sometimes upper mid back areas for bra fat. Other sources can be arms. And sometimes, you know, from an instrumentation standpoint, we've really adjusted what we're doing to accommodate the fat. In these different areas, especially in low body weight patients. So processing then separates the fat from the fluid we use and from the blood and any other debris. We only want the usable fat, not a mixture of all the other materials that came out through the process of removal. And so we have a closed system that uses a vibration plate for this. And then, of course, the placement, I think, is a part that's a little confusing and may be portrayed incorrectly. Fat does not go where the implant used to sit. So you don't take an implant out and put fat in that space. It does not go inside the breast tissue because that can just result in cystic development in the breast or fat necrosis within the breast itself. It goes between the skin, so the outside skin, and the breast So males and females have breast tissue. Obviously females have more breast tissue normally, but there's a fatty plane above the breast tissue beneath the skin, and that's where the fat goes. Think of it for buttock augmentation. Obviously there's no breast tissue, there's just fatty tissue in the gluteus maximus muscle, so the fat goes in the fatty plane. We do not drop it in as a lump. We want to evenly distribute it across the areas where we're placing it so it has The ability to heal properly. And that's the result of that. To get a natural result, which is unlike a device which pushes things out, this is augmenting your existing fatty layer over your own breast tissue. So in the upper 2/3, there's more surface area to obviously augment. versus the lower third or below the nipple level. And the fat, once again, is trying to augment the fatty layer that we already have. Males and females already have a fatty layer over this area. And that, it creates a different shape, but that shape is a natural shape. It's not an augmented shape with a device. If you place too much in one spot or put it in the wrong plane, the blood supply it's trying to develop will be hampered. That is when people talk about things in terms of hardness or cyst formation or potential calcifications. Those stories are often, I think, more about the timing, the harvesting, the processing, and placement techniques. And then, you know, those all play a role and potentially can affect the outcomes. So now let's— we'll talk about some patients as examples, and these are patient profiles And you can just think about the types of profiles. Now, the first type of patient we'll say has finished breastfeeding, and the breast volume went up and down due to that. And so the skin usually does not fully recoil because it can't. So we'll say in this patient, she doesn't want to devise; she wants to obviously look. Like she did before. So how do we accomplish that? Breastfeeding and pregnancy stretch the skin, and as we get older, that skin does not obviously snap back. We lose elasticity and collagen over time. So the fat can restore some of the volume. Fat by itself does not correct any skin laxity. It cannot do that. If the skin envelope is already loose, a lift may be part of the plan. If the skin envelope is, um, appropriate than not. Fat alone obviously then may or may not be enough to give the change. And once again, this is a moderate change. It's not an augmentation with a device change. And, you know, we, although we're always looking to improve, it really depends on the patient's, once again, skin elasticity, their ability to donate the fat, and placement of the fat. And obviously, you know, when we're talking about fat transfers, we're talking— it's not usually a one-and-done. I would tend to always say that this is the result you can add to if you want that change and that improvement. And we can often restore the softness and the shape with your own tissue in this way. So less volume on a smaller frame can still read as a meaningful change. So even low body weight patients can improve from this. More volume on a larger frame may need— be needed for the same actual visual change. So there's actually no cookie cutter in terms of how much volume to transfer. Second kind of profile patient, we'll say, They have a device, they want it out, they want to have a holistic transformation with fat at the same time. This is one of our, you know, procedures that we're really working to provide the best results in. And that can be done in my practice. We do combine cases, simultaneous fat transfer explants, frequently. It's not unsafe and it's not potentially the right case and every client. So when I think of it, when I look at it, I want to have information about how someone's detoxifying. So for instance, today I had a call with somebody who already knew their genetics, and, um, they already knew they had a problem with a toxicity burden of a mold toxin. We don't know that they have other problems or whether or not They have specific things that may need to be treated, but we've already identified mold as an issue. And so that right there puts them into a different path because I wouldn't immediately have them do, uh, a fat transfer. I'd wait, get those results, see what we need to do to help them, to create the best timing for them. So simultaneous can mean, um, You know, one obvious procedure to the OR and then one recovery and then one set of fees associated with that. But the convenience should not outrank, is it the correct time? Is the person in the correct state of health for that? If the tissue, which many times has been compressed for years, or someone's inflammation is such that we can't help control it, Really, really large implants can also be a problem on a small frame. If the skin is really out of balance in terms of stretch, potentially waiting and doing it at a later time can be an advantage. When we combine explant and fat transfer, you know, we're doing several things at one time, controlling as many variables at one time as possible, removing the implant and the capsular tissue as we always do and send it off for PCR testing and pathology. We want to reconstruct the muscle there because that helps protect the rib cage and provide better support for the breast mound and the fat transfer. And decide whether the skin needs any type of skin lift. Then obviously get the fat in the fatty layer, and once again, not in the old pocket. So a large implant on a small frame is one of the hardest things to take care of for patients. There's not a lot of tissue To begin with, so you can't really rearrange the tissue. Many times if their implant has been replaced or they've been revised, the muscular layer can't be retracted downward and repaired like we try to do all the time. If it's a smaller implant, then we can deal with that a little bit easier. If it's a saline implant, we can deflate that, or someone comes in with one already deflated, we can sterilely take care of the other one. The, um, these are the realities of taking care of thousands of patients with these problems, not what the internet says. So if someone, um, has told you that someone says fat transfer is not safe, um, they would tend to need to reinforce why they feel that way. Fat transfer obviously is a little bit longer case, does require harvesting, processing, and placement. Putting in a device is obviously faster, but it has tracking and follow-up that's different than your own tissue. And the third profile of the patient we want to highlight is the patient who's already had an explant. They've already healed, and now they want more volume back, especially if The implant was really composing the majority of the volume. And so when I— these types of situations are, are ones that can be more critical in terms of body image. So if we have somebody that wasn't a good candidate, we tried to get them healthier and then do a low body weight fat transfer. We're just trying to put them in the best possible positions we can. Delayed fat transfer can be a very good option in this setting, and you and the surgeon then get a real example of, all right, what have the tissues done? If they had a lift, how much skin laxity is remaining? Is their inflammatory burden lower? Scarring can definitely make some areas less mobile, and that can change how the fat is positioned. But with scar release, you can do this percutaneously and help. If inflammation is still high, we still tend to pause. We'll have them do the Short Method. We'll have our team help get that under better control. So obviously for everybody listening, we have our own separate program, the Short Method. I wrote a book about it and you can learn about how to prepare and recover after surgery, whether it's with us or another provider. And the point is, this is not calendar dependent. This is like your health. You want to really focus on getting yourself in the best possible position. Prior to the procedure. And the fourth, uh, we'll say in the final patient is someone who doesn't want implants, wants a natural augmentation, a holistic transformation with fat, if you will. And so this is what I coined the holistic mommy makeover. Um, in this, uh, we take fat, same sources, and then we use that to rejuvenate the breast with or without a lift. And you can also do this as more of a contouring procedure, which can be a really a great bonus for patients. And that's why I termed it. Now, this is not a tummy tuck. So holistic mummy maker does not include the traditional abdominoplasty, no horizontal incision, no muscle tightening. So not everybody is a candidate for this. Want to make that super clear. And this was evolution of procedure I called smart tummy where I would do. Body tight, which is radiofrequency skin tightening in the first 1 to 2 centimeters of the tissues beneath the skin and fat of the abdomen above the muscular layer. We would then do liposuction and over that do radiofrequency microneedling with Morpheus 8. The evolution of that became doing instead of just the abdomen, removing an old breast implant, and then doing holistic transformation with fat. Or in the case where somebody didn't have an implant and they wanted to have that holistic transformation, we then would do the augmentation with their fat. Now, the myth that brings a lot of you here is you're too thin. So body mass, it's By itself is not the only deciding factor. I look at physical examination, and then we like metrics such as DEXA or DEXA scans. I don't prefer in-body for this. I look for donor fat in inner thigh, outer thigh, flanks, abdomen, mid-back, upper back, arms. Obviously, those are the most common places we would find fat. We do obviously probably a higher number of these than most, and less fat can still go a long way on a smaller person. That does not mean everyone is a candidate. There is not enough source fat, there is not going to be a good transfer, and the surgeon will just say no. Um, sometimes, um, you were told no probably after just a limited pinch test, or sometimes you were told to gain weight in order to have a transfer. Sometimes the honest meaning was this is not an operation that that particular provider does very often, and those are all different. Obviously, only one of them is about someone's body. So we want to be as accurate as possible when I assess people. And if I'm concerned, in conjunction with the scans and obviously in-person exams, then we can, you know, decide, is this the time, or is it time, uh, just to pause and wait and revisit it in a period of time later? Fat volume is not fixed. Uh, the way an implant volume is. An implant is a device that has a set prefilled volume unless it's a saline device, which you can adjust. Fat is your own living tissue and not all of it will heal. Obviously, some of it does not. Weight change later can change the results. So we want to maintain BMI or go up in BMI. We do not want you on or taking GLP-1s because transfer fat can be affected by that. And so there was a study that looked at this, and they felt the fat resus study stayed about 253 days after placement. In this study, it was about a 50% take. Now, For us, I've personally not seen low takes like that, and rarely, if ever, if there's any asymmetry. I mean, fat has been used for over 100 years as a filler, gained a ton of momentum in the early 2000s and 2010s. Now, I don't ever like overgraph people because I feel like that's missing The target— these patients need a very targeted, appropriate amount that fills according to what their tissues will allow, and overfilling can create too much pressure, as it's been discussed by, uh, plastic surgeons like Dr. Roger Khoury, who was one of the pioneers of fat transfers. Um, and I only place what it seems like the tissues will support. There's endpoints of physical examining the operated and operating room and something called podoedema. You see dermal swelling, that's really impractical to keep putting fat in there when you see that. And so in my own practice, I aim with preparation and careful placement for a much higher rate, and maintaining body weight and improving BMI actually in a healthy way can maintain up to 78% of this. And that's what recent studies have shown, and that's been our clinical experience. So weight matters. In that MRI study, you know, losing 1 BMI point after surgery was associated with a much, much smaller amount of maintained fat graft. But gaining was associated with keeping more. That's why I said that. So your transferred fat expands and shrinks obviously with you as you change and go through life or Or weight loss or weight gain. So I try to get everybody focused on maintenance of their BMI, doing weights, not high-intensity cardio exercises or interval exercises, avoiding GLP-1s. In those patients who are not experiencing metabolic problems, I don't really want them using them. Obviously, we want everybody to seek counsel from us. But unless they're experiencing a critical health issue where they need that, those medicines all work and they are, um, very effective in terms of they don't allow you to get hungry. Um, and certainly, um, you can really, if you don't do it right, uh, cause some harm, I think. Um, In addition, for those patients who are lower body weight or patients who need another transfer, a second fat transfer can help. First transfers are the ones that we really try to do a great deal on the first time and make sure that we help as much as we can in a cosmetic patient, a reconstructive patient. A reconstructive patient, it can be much harder because of their therapies they're getting for The problems they're experiencing or the hormonal therapies they're using or just their compromised immune systems. The variable I think that's missing in most of what I see in terms of outcomes is the preparation, and it's not really execution so much in the operating room. Preparation is very, very important. And Although it doesn't sound very usable in this day and age in terms of hooks, preparation is what you need in this case. When we move fat, that cellular material is taken from its current blood supply and has to develop a new blood supply. It survives by taking nutrition from the surrounding tissues until it can grow its own blood supply. If the body's in a more difficult state, that process is much harder. So preparation, once again, is paramount. Fat basically is acting as an endocrine organ. It stores your exposures. It talks to your immune system. And when inflamed, metabolically stressed fat is weaker in terms of thinking like fat transferable than healthier. And I always equate that to like, what is the patient experiencing? What's their toxic burden? What's their gut health? What sensitivities do they have? Let's try to get as many of those in the right side of the checklist for them as possible and improved. And having a healthier, less inflamed patient will help them heal overall. And we recover obviously through nutrition and our rest and supplementation. So it's always the same things for us. You know, the surgical process is made easier through preparation, whether it's through our run-up to the process with different therapeutic modalities or protocols. The night before, we do our own modified and more aggressive ERAS. And then in the pre-op area, I mark everybody and then we have our team. of anesthesia providers do ultrasound-guided nerve blocks. And then post-op, everybody is supported, um, and we reinforce obviously nutritional support. The day after surgery, everybody walks into the clinic and then they go through our recovery modalities: the Human Regenerator from Germany, the Flopresso from New Zealand that has the NanoVi running at the same time, the vertical hyperbaric chamber so you're not pressing to get up and down, you're sitting there comfortably, and then the— The big six foot tall Jew red light. So all these things are important. They're not, you know, perfect in isolation. You know what fat transfers will not do after we've got you through the process and they're healed? They they don't give you several cup sizes of change. They don't give you an augmented appearance like an implant would. It will not replace. Obviously, a lift if your skin is stretched out needs a lift. It will not erase every explant contour in one session, especially after a large device or one where the skin got really stretched out or the muscle could not be completely repaired. It will not make something on a mammogram incredibly difficult to be evaluated. Um, I've heard that and that's just not the case. Um, the, the screening is still very effective, uh, even with fat transfers. So obviously individual results vary. Um, and I get asked this a lot. Age is definitely not an automatic no in my practice. I have several really healthy patients who are in the 5th, 6th, 7th decades of life. I've recently explanted somebody in their 90s. Autoimmune diseases and diabetes are not automatic nos either. I think if you watch my stream a couple weeks ago, I had Jessica Ballard on and she has diabetes. She's talked about it. But they can change your preparation. They can adjust how we think about it, what we should potentially do for each patient. So if you've lost volume after breastfeeding, fat can restore some of what's left. The skin quality really decides whether a lift is important or will help. If you want to explant and have a fat transfer together, it can be done. Once again, we have this whole series of things we look at. We look at your genetic Detox pathways, your toxicity burden, your gut health, your food sensitivities, how are your hormones balanced? And then that helps us put you in the, in the position and on the right path for that. If you just want a basic natural holistic augmentation with your own tissue that can give a, a natural change, um, just remember that doesn't copy or mimic a device. If you were told you are too thin, obviously you need to get an in-person exam. You need to have things like a DEXA scan like I utilize. And Then have an honest discussion about whether or not you're truly a candidate or not. Once again, our discussions here tonight are educational only. I'm not examining anybody. I'm not making recommendations to anybody. You got to go see someone in person. And if obviously you want to see us, we're happy to help you. Um, we're going to go into the circle now. If you're not already there, there's a direct link. You can go to drrobscircle.com/live and boom. Get the link and get right in. You will not need a password in that setting. Okay, so with that, I am going to take a couple questions. Somebody's asked me on Facebook: Do I use or recommend PRP after to maintain a fat transfer? What kind of recovery time before returning to work? We do not use PRP, Stacy. In terms of recovery time for work. It's pretty straightforward in terms of if you have an explant above the muscle, 1 to 2 weeks. Explant behind the muscle, it's more muscle healing rather than where you're doing the fat removal from. So that's the thing that varies on recovery. You want to give everybody the chance to have good muscle recovery, and when you resume activities, uh, Our Courtney Dorado is our patient who's also a PT. You can find her on TikTok. She really has developed a great program for returning to training or exercise training of the chest after explant. And the, the thing with self-care is people come in and they spend about a week here with us. And then when they get home, I really have them concentrate on their diet and their rest and their supplementation. They do have to fill in gaps if they're having fat transfers. I recommend doing more hyperbaric therapy. I recommend doing more lymphatic massage. And those, those are the modalities I would focus on. But, um, yeah, always, um, your nutrition, rest. Supplementation. All right, what other? I guess I can turn this around. All right, let me turn this around and see if I have something on on Instagram I can do. All right. All right, sorry about that. Urban Instagram's probably like, what is he doing? Okay, so let me see if I have something on Instagram to answer. Yeah, I mean, I get this question about microdosing all the time. Microdosing is not a thing. It's not FDA approved. Providers do that who are experienced, and I know some who do it very, very well. But when you're doing a fat transfer, I caution you against that. Your inflammation is for a reason, and a GLP is not going to solve it. All right, I think that was the only question I had on Instagram. Let me see. All right, I'm gonna flip my TikTok around here. Oh, hold on. Let's see if I can turn this around now. Probably don't know how to do it. Yeah, I don't know how to do it. Oh, there we go. There we go. All right, look at that. Figured it out. All right, let me see what I got on TikTok. All right, my implants from Brandy. My implants are 13 years old. I've looked into fat transfer. I don't think I have BII candidate. Um, yeah, I mean We would just work you up like I just said, and that would give you the answers to that. But sure, you're the type of patient we, we always want to help, uh, put in the right, uh, direct— point in the right direction, I should say that. That's a great question, Brandy. Are you going to hop in the circle? And then in the circle we have— how many people do I have? Let me see. We have quite a few questions in the circle, so let me read all of these. And all right, here we go. Just one second, and I'll go through the questions in the circle, and then I'll just close everything out. And be in the circle. There we go. Okay, in the circle we have— does fat harvesting leave a lot of scars? No, you can't see the scars, Lisa. Grace, that's a complicated question because massive weight loss creates a lot of skin laxity, so that would be a totally different situation. Elizabeth, you should see my, uh, podcast I did with Sarah Minnick. I did 2 fat transfer— fat transfers for her for post-mastectomy explant. So, all right everyone, so now that we've gotten through the talk, I've taken a question off all the platforms. Here's what I want to do to make this simpler. I want everybody to move over to drrobscircle.com/live. We made a special way to get in. And we're gonna go there now. So if you go there, uh, Mrs. Tiff, um, Sarah Menik, I just did her second fat transfer and she had a post-mastectomy breast reconstruction with implants. I revised them. I did her explant. I did her fat transfer, her first one and her second one. I have seven new messages on TikTok. Oh my gosh! Where are the messages on TikTok if I have seven new ones? I don't understand. All right. So I'm gonna type in here the comment section. Go to Dr. Rob's. Backslash live, and you'll go right in, and you can join the conversation. So we have live chat going. You can head in there now. Okay, everybody go to drrobscircle.com/live. D-R-O-B-S-C-I-R-C-L-E dot com backslash live. Okay. All right. Who else do we have there? All right. Anything else? It's a front slash, not a backslash. Okay, Denise says front slash. It's going like this. It's a slash. Tiff, just go to, um, yeah, Tiff, just, uh, go in there. And check your, your junk if something happened with the email. So hop, everybody hop in there. Denise says it's a front slash. I thought I put it on the— can I put it on the screen somehow? I thought I did. Yeah, it's on my screen on Facebook, LinkedIn, YouTube, X, Substack, currently on Dr. Rob's Circle. .com and, oh, forward slash, that's what she means. You're right, Denise, I'm not a computer guy, as you can tell. Oh, Miss Caitlin's there. All right, are y'all ready to go over? Do I have all of the chat questions here? Let me see. All right, all right, y'all, I'm shutting these down. Okay. All right. I hope everybody could hear me okay. I feel like I was far away from the mic today, but that's just how it worked out. All right. So now we're just in the circle, and I'm gonna start taking these other streams out. And then we'll just be in the, the circle. Okay. Give me just a moment. I have to open a new window so I can see all the live comments in a new window. It's a little bit easier that way. Okay. All right, so now I have— Garland says, what is the science behind the upper chest after fat transfer? Why does it take so much time for that upper pole of the breast to fill out? Yeah, naturally there's not a lot of upper pole fullness. There never was inherently. Um, when we're all very, very young, if someone has a very short torso, they're going to have more upper pole. But upper poles are created by augmented breasts with implants. Creating an upper pole with somebody's own fat is never going to be As significant as a device. Yeah, Grace, I understand your question, but I don't actually do massive weight loss cases. Um, those are very difficult cases, and I haven't, um, done those— enough of them in my career to even be super helpful. So I will bow out of that one. Yeah, Elizabeth, that is a lot of surgery. I've done those operations. I've stacked deeps. I wrote a paper about that ages ago. And pap flaps, yes, um, those are all highly technical and you should go to somebody who's extremely experienced. For sure. That's a great question, though. That used to be my wheelhouse. That used to be all I did. I got to shut down these other streams. Hold on a second. All right. All right, we just came off of Rumble and we're going to remove Substack. We're gonna remove LinkedIn, gonna remove YouTube.