How I use Permanent Facial Fillers: Fat Transfer, Silicone, Bellafill(Artefill)

In my clinical practice I use both temporary and permanent facial fillers depending on a mixture of budget, desires, and safety. Although permanent fillers carry the risk that they are indeed permanent, I believe that it is important to delineate safety guidelines and also to express how I use them based on those constraints. There are three principal permanent fillers that I use for facial augmentation and enhancement: fat transfer, silicone, and Bellafill(Artefill). In this article I would like to explain how I use each of these products for optimal results.

First, let me summarize the temporary products that I use. It is only one product, hyaluronic acid, by two manufacturers/companies: Medicis that distributes Restylane and Resylane Lyft, and Allergan that manufactures Juvederm. I believe that they are both good and are like Coke and Pepsi. I do not have a strong feeling that one is substantially better but I tend to use more Restylane around the eyes, as I believe it tends to stay put a bit better; and I prefer Juvederm for lips, as it can be a bit softer. However, for the most part, they are interchangeable; and also reversible using a dissolving product known as hyaluronidase if need be.

Fat Transfer at 1 Year with silicone lip enhancement prior to Bellafill(Artefill) “touch up” under the eyes and into the chin area.

I have a thriving practice with permanent fillers too, a large reason is that I feel entirely comfortable and skilled in using permanent fillers, which by their very nature are irreversible and carry risk. Each permanent product that I use I do for a specific purpose and do not feel they are entirely interchangeable. By understanding the risks and benefits of each type of permanent filler I am able to use it to optimal advantage.

Let’s first discuss fat grafting, which is a surgical procedure, requiring that fat be harvested from one’s belly and/or thighs to be placed into the face. The real benefit of fat transfer is for an individual who is at least late 30s with enough aging that would justify having this procedure. Every decade that goes by after that, fat grafting becomes actually the most financially beneficial procedure because I always say “fat is free”. In other words, I do not have to take an expensive single syringe off the shelf of filler product and place it into the face. Instead I can harvest whatever I want and place it wherever I want. Oftentimes individuals feel then that I will overfill their faces, which this is simply not the case. Actually, when you put a little bit of fat in many small areas of aging, the entire face actually can look less fat and also significantly more balanced and rejuvenated. However, fat grafting has its limitations and risks. The limitation is that fat transfer cannot correct little tiny areas of the face with as much precision as a filler targeting that same area. For example, the smile lines are an area that I truly believe fat is too soft a product to get reliably consistent results. However, there is nothing like fat grafting to provide a uniform, global rejuvenation, which would be cost prohibitive with fillers in someone with enough aging to justify a fat transfer. In general, I think the risk of fat grafting occurs in someone that is too young (let’s say late 20s or early 30s) before they have had children yet and in which I cannot determine whether they will gain significant weight later in life. In short, I think the risk of a fat transfer is in someone who gains 20 to 30 pounds afterward because the fat unlike other fillers is a bioactive material so it is not good looking if you gain weight. Fortunately, if you lose the weight, the face that I built is restored to its former glory. But that risk of significant weight gain is very important to understand. Interestingly, I have found that weight loss of even 10 to 15 pounds does not seem to take my fat graft results away. That is why I recommend if someone is going to have a fat transfer to do so before some moderate weight loss rather than afterward.

Silicone injections have carried with it a lot of misinformation and confusion. For example, I am well known for my lip reduction procedures to correct very badly injected silicone lips. Fortunately, I do not have to correct the lips that I have created but I had had to do that for the lips created by my overzealous colleagues instead. If silicone is placed with very small droplets spaced out by at least one month between treatments, the silicone will not migrate. The reason is that microdroplets of silicone are held in place by the surrounding collagen when only a little is placed at a time. I also believe silicone is very good for the lips because the product is very soft, especially when someone kisses you. I also use silicone to manage acne scarring and have had life-changing results for my many patients who have failed all other methods of treatments. However, because only small amounts of silicone can be placed at any given time, I do not believe that it is safe or even reasonable to build up an entire face with silicone. That is why I use it only in the lips, for acne scarring, and other very small areas of facial correction. One more word on the lips: when I use silicone in the lips I am always worried that it will not age well for someone for two reasons. First, very full lips can look natural in a young face but not in an older face because it will not match. Second, too much applied to the upper lip can also start to hang further, covering the teeth more as one ages thereby aging someone. Accordingly, I tend to prefer to use only conservative amounts in someone in her 30s but could be persuaded to be more liberal as one ages so long as the result stays natural. Fortunately, when I inject the lips I tend to be very conservative in the upper lip, which when overinflated can first of all look unnatural and second age poorly as one matures. Therefore, I believe that I keep people pretty safe even at a young age if they have silicone in their lips using my technique.

Bellafill has become a workhorse for me to augment various areas of the face. My favorite area to use Bellafill is in the smile lines. The reason for this is twofold. First, I find that temporary fillers like Restylane do not tend to last a long time in this area so one can reach injection burnout relatively quickly. Since Bellafill is twice the price of other fillers I try to be as judicious as I can when I fill the face since it is so expensive. Since it is a permanent filler, I also do not tend to start using it until one’s thirties and even then only in the folds. Every progressive decade I use more of it more liberally. I can use it just like Restylane or fat now that I have cannulas (blunt instruments) that allow me to safely and accurately place the product around the eyes and into the temples, which I could not do in the past. I also love to use Bellafill in individuals who have had a fat transfer and have a result that is near perfect but would like a little “touch up” in an area that I know further fat would risk overfilling or be too imprecise to correct. For example, a little bit more in the tear trough or filling the smile lines are two great areas to transform a very good fat-graft result into an amazingly excellent one. Bellafill however is not safe in the lips as it becomes lumpy so I only use Juvederm/Restylane or silicone there. If I forgot to state it, I also do not like fat in the lips because I think the recovery is too long, the absorption rate is too high, and the results are inferior to silicone and fillers. I know that this summary of all the risks, benefits, and limitations of each of these permanent products may be a bit overwhelming but I believe I can personally guide you when I see you in person regarding all of the above products in your goal for overall facial enhancement.

Samuel M. Lam, MD, FACS is a board certified plastic surgeon. To learn more about Dr Lam’s facial rejuvenation procedures in Dallas, Texas please call 972.312.8188 to schedule a consultation. If you would like to ask Dr Lam a question about face rejuvenation please visit our face rejuvenation forum.