Dr. Ahn Jae-seok's Q&A 50 on small-volume, multi-session design fat grafting

Rather than filling a large amount at once, fat is grafted in small portions, and areas that are still lacking are then supplemented according to the volume that remains. The balance of the whole face is reassessed and redesigned at each session.

I began fat grafting in 2004 and have performed more than 15,000 procedures in total. This is the cumulative number of procedures including repeat sessions, not the number of patients. Based on this experience, I consider not only the injected volume but also the recovery burden and long-term facial change.

Besides better volume, many patients told me "I don't want to look too swollen" and "I want to get back to daily life without taking a long leave." To meet these needs, I developed a method that reduces the initial volume and completes the result over several stages.

Under the title 'New consumer-based fat transplantation technique-5th Design Fat Transplantation', I introduced a fat grafting method that considers the patient's daily life and a natural look. The presentation covered the purpose of small-volume, multi-session grafting, the changes at each session and the retention observed at the time.

It means refining the design while checking facial changes over about five stages. It reflects my judgement, from observing up to 10 sessions, that around five sessions is appropriate. It does not mean every patient needs the same number of sessions.

Instead of filling the final goal all at once, a slightly conservative amount is injected at first. The recovery and remaining volume are then assessed and the areas that need it are corrected further.

Over-correction fills more than the target in anticipation that part of the fat will be absorbed. The under-correction I use differs in that it avoids excessive volume early on and approaches the goal step by step as healing progresses.

It is hard to generalise like that. Fat grafting methods and volumes differ by practitioner and area. We describe our method not as a single figure for a procedure but as setting a conservative initial volume and refining the design over several sessions.

The change from one session can be relatively gradual. The advantage is that the areas you want can be adjusted while following the progress. We check together in consultation whether you want a large change at once or a gradual, natural change.

I focus on the balance of the whole face rather than the amount of fat. I look at how hollow areas connect with the surrounding contour, left-right differences and skin sagging together, and supplement what is needed at each session.

The presentation introduced an approach of grafting about 15 to 20 cc per session for the whole face. The actual volume is decided after checking face size, the degree of hollowing, the tissue condition of each area and previous treatment history.

Rather than trying to complete it at once, it allows the remaining volume and the areas still lacking to be checked at each session. It reduces the burden of the initial change and allows fine adjustment, but it requires the time and cost of several visits and procedures.

To find out at what number of repeat grafts the desired result is reached, I performed up to 10 sessions at roughly one-month intervals and observed the changes. Based on this experience, I organised a staged approach of around five sessions. This is my clinical observation and does not mean that an optimal number of sessions for every patient has been established.

Not necessarily. However, the small-volume, multi-session patients I have treated often needed several rounds of supplementation to reach the change they wanted. The actual number is decided by the initial hollowing and the change after each session.

Yes. In my clinical experience, some patients with very little facial fat went through the five-session course twice. Additional procedures are judged by the current tissue condition and the improvement that can be expected, not by increasing the number of sessions itself.

Yes. You can discuss further sessions after seeing the change and recovery from the first. However, if you started with a small-volume, multi-session plan, one session alone may not reach the final goal.

If you have reached the volume and balance you wanted, further sessions are not necessary. In my experience several rounds of supplementation were often needed, but whether to continue is decided by checking each person's progress and satisfaction.

To allow time to check recovery and the early change in volume. Blood vessel formation and tissue remodelling proceed in several stages, so this does not mean 'graft take is finished in a month.' As a rule we do not recommend repeat grafts at intervals shorter than one month, and we wait longer if needed.

Yes. A delayed schedule does not mean the effect of the previous session disappears. When you return, we assess the remaining volume and tissue condition and plan the next step.

No. Areas that are sufficiently filled are reduced or skipped, and the necessary amount is grafted mainly into the areas that are lacking. Redesigning at every stage is an important feature of this method.

Grafted fat first receives oxygen and nutrients from the surrounding tissue and must later connect to the blood supply to survive. Spreading it in small parcels makes the contact area with surrounding tissue relatively larger. However, reducing the total volume alone does not determine the graft survival rate.

The injected volume and the amount that finally remains are not simply proportional. If fat is packed too densely in one area, it may struggle to receive enough nutrients and blood supply. Injection must take into account what the tissue can accept.

From long clinical experience, I have described the contribution of one session as about 20%. However, this is not the same figure as a '20% survival rate of injected fat' measured by imaging. Because the injected volume and absorption differ by patient, it also cannot be calculated that five sessions of 20% make 100%.

Some fat may be absorbed early on, but fat that has taken can remain for a long time. How much remains differs by person and area, so the final result is not judged by the volume right after the procedure.

In my long-term clinical observation, there are cases in which I judged the volume to be maintained 10 to 15 years after grafting in around five sessions. However, the same duration or the same remaining volume is not guaranteed for every patient.

The presentation at the time records retention observed for 3 to 5 years. The explanation of 10 to 15 years comes from long-term clinical experience after that. When assessing long-term results, additional procedures and weight change must also be checked.

It can remain for a long time, but it does not stay fixed as it looked at the time of the procedure. Both the grafted fat and the surrounding tissue can be affected by weight change and ageing. Fat grafting does not stop ageing itself.

It is possible depending on the tissue condition. Even if previously grafted fat remains, volume loss can occur in other areas. In my practice there are also cases of additional grafting to suit a face that changed over time.

Fat that has taken can also change in size with weight change. So we record weight together, and if you are planning substantial weight loss, we advise discussing the procedure after your weight has stabilised. Volume may increase again when weight is regained, but returning exactly to the previous face is not guaranteed.

When volume decreases, existing skin laxity can become more visible. However, it cannot be said that fat absorption necessarily creates new sagging. Small-volume, multi-session grafting is not a way to completely prevent sagging or stop ageing either.

I use a washing method without centrifugation, with the aim of reducing tissue damage during fat processing. The force applied during centrifugation depends on the device's rotation radius and speed, so it cannot be described uniformly as a single g-force value.

In my clinical experience, I judge that the non-centrifuged washing method helps. However, research results are not consistent, and it cannot be said that survival is always higher simply because centrifugation is not used. The whole process of harvesting, purification and injection matters.

Blood, excess fluid and free oil are managed by carefully washing and separating with sterile saline. Not using centrifugation does not mean the harvested fat is injected without any processing.

SVF is the 'stromal vascular fraction' obtained from adipose tissue. It contains several types of cells, including adipose-derived stromal cells and vascular-related cells. It is different from isolating pure stem cells only.

The aim is to support the environment in which the grafted fat settles. Some clinical studies have reported improved fat retention, but the effect can vary with the separation method, cell composition and procedure conditions.

For people who find repeated visits difficult, we sometimes consider a plan of around two sessions that includes SVF. However, we cannot promise that two sessions will give the same result as five sessions of standard fat grafting. The actual number is adjusted to the volume needed and the progress after the procedure.

If repeat visits are possible, staged standard fat grafting is discussed first; if several visits are difficult, for example because you live overseas, the need for SVF is considered. The criteria are your ability to visit, medical suitability and the expected benefit relative to the additional cost, not nationality itself.

It can be considered for areas lacking volume, such as the forehead, temples, cheeks and chin. Under-eyes and nasolabial folds may also be candidates depending on the cause, but if pigmentation, protrusion or sagging is the main problem, fat grafting alone is unlikely to solve it. Areas such as the nose and between the brows in particular require careful assessment of vascular risk.

If a lack of volume is actually confirmed, fat grafting can be considered. However, facial change after orthodontic treatment involves several factors, such as weight, the chewing muscles and changes in the teeth and jaw, so whether fat is lacking is assessed first.

Fat grafting is used in many areas besides the face. However, the facial small-volume, multi-session plan is not applied to other areas as it is. Breasts and buttocks in particular require separate assessment and safety standards suited to the area, and buttock fat grafting carries a risk of fatal fat embolism.

We first distinguish hollowing from sagging. Fat grafting is considered for volume loss, but if sagging is the main problem a different approach may be needed. For the eyelids, skin laxity is distinguished from ptosis, and the suitability of laser, thread lifting and surgery is assessed separately.

It can be, but the type, location and remaining amount of the existing material and any inflammation are checked first. Hyaluronic acid filler can be dissolved if needed, but not every filler can be dissolved, and it does not always have to be removed first. For repeat fat grafting too, the tissue condition matters more than the number of times.

In my experience, I have observed volume being maintained after fat grafting even in a 78-year-old patient. However, eligibility is not decided by age alone; general health, medications, skin condition and anaesthesia risk are assessed together.

The injected volume is adjusted to avoid excessive early volume. In my experience some people said the swelling was less than expected, but the volume of injected fat and swelling caused by the procedure are separate. Because swelling differs between individuals, I do not describe it as a 'procedure that causes no swelling.'

The relationship between posture and facial swelling may be observed in practice, but there is not enough evidence that forward head posture or a straight neck increases swelling after fat grafting. Swelling should be looked at together with several factors, including the extent of the procedure, tissue response and underlying conditions.

Please be sure to tell us about the medications and supplements you take before the procedure. Aspirin and anticoagulants can affect bleeding, but stopping them on your own can raise the risk of blood clots. Whether and how long to stop is decided by the treating doctor in consultation with the prescribing doctor, and we do not give a blanket instruction to stop for one week.

In my practice there have been cases where light daily activities the next day, or returning to work on Monday after a weekend procedure, were possible. However, this depends on the intensity of your work, swelling and bruising, and discomfort at the harvest site. If you had sedation, simply waking up does not mean recovery is over, so you must follow the instructions on going home, being accompanied and not driving.

Some patients have told us that no one at work or at home noticed they had the procedure. However, we cannot guarantee that no one will notice. Before important events such as a wedding or a photo shoot, please consult with plenty of time to spare, considering that swelling and bruising may remain.

At Seoul Cheongdam Dr. Anapa Clinic, we make a plan based on the change you want, your schedule for returning to daily life, previous treatment history and health condition. It is good to check together the expected injected volume, number of sessions and interval, total cost, whether fat is harvested, stored and reused, the need for SVF, the anaesthesia method and response to side effects, and the follow-up plan.