One of the most common points of confusion I hear during consultations is patients trying to decipher between implants or fat grafting. This is especially true when they hear from another surgeon that cheek implants are necessary for feminization and/or that fat grafting “does not last”.
The truth is: it depends. There is not a right answer that applies to every person’s face. There is not a sexual dimorphism basis for actually increasing the size of one’s cheeks as part of facial feminization surgery – having larger or smaller cheeks is not inherently feminine or masculine.
CHEEK IMPLANTS – THE GOOD AND THE BAD
Cheek implants have one main selling point: they are very reliable in terms of affecting a shape. However, the shape and placement of those implants often is often imperfect and they also have the drawback of having close to a 3% infection rate, if an implant gets infected then it is necessary to remove the implant. If one implant is removed, it usually makes sense to remove both so that the patient does not have an awkward appearance.
Cheek implants also do not tend to affect the anterior and medial most portion of the cheek or malar region because of the location of the maxillary branch of the trigeminal nerve prevents practical placement of an implant in this region. Therefore patients tend to be left with a bulbous or exaggerated appearance in the lateral part of their cheek while their under eyes appear more hollow and the anterior part of the cheek remains under projected.
Another issue in particular to trans women is that transfeminine patients have often lost a significant amount of weight as part of their transition, and implants in very thin patients often tend to look exaggerated and visible while lacking the finesse of other techniques.
MY CLINICAL APPROACH
My main application for facial implants on the cheeks in patients is when there is significant asymmetry. In that case I will create a custom made implant for that individual patient based on a 3D CT scan of their skull in order to provide for better symmetry.
When there is not significant asymmetry, I will generally choose fat grafting. The other main benefit of fat grafting to the face is that you have a very versatile ability to sculpt the entire face in a way that you cannot do with facial implants. You can easily add fat to areas such as the temple, the zygomatic arch area, the cheek, the under eye areas where people often have depressions or dark circles, and you can add volume to the nasolabial folds therefore adding youth to the face. This versatility is not present with facial implants and is one of the main adaptive selling points of using fat transfer.
The other selling point of using fat grafts is that fat grafts have an abundance of stem cells that become activated during the transfer process and there is demonstrated evidence in the medical literature that, over time, fat grafts will improve skin quality, thickness, and texture. This is a completely impossible outcome with facial implants.
Surgeons who do not offer fat grafts or do not do them well will say that fat grafts do not live. This is a deceptive statement. The “true” story is that not all of the fat that is injected survives the transfer and usually around ⅓ of the fat that is transferred does not live. However, the remaining portion of the fat that survives is in fact permanent. This has been well studied not only in the laboratory but in real world academic research and any statement to the contrary is simply false.
Therefore, my most frequent go to technique is using fat grafting with the exception of a few unusual circumstances.
To be completely forward, I should say that fat grafts tend to not have quite as predictable an outcome as implants do, however, I feel that our patients have been extremely satisfied, and it provides the opportunity to go back and add some additional fat or touch up certain areas. That type of finesse is not possible with facial implants. Fat grafts avoid most of the risk of infection that an implant will often hold, it doesn’t have the same risk of injury to nerves in the face that facial implants do, and of course holds the possibility of improving skin quality.
THE BEST WAY TO GET AN ANSWER FOR YOUR FACE
A thorough consultation, essential facial imaging, thoughtful planning, and precise measuring is the key to getting a stellar result. We encourage you to have this discussion with us if you have any lingering concerns about which technique is right for you.
Dr. Deschamps-Braly is a board-certified plastic and craniofacial surgeon specializing in facial plastic surgery, orthognathic (jaw) surgery, and craniofacial surgery for adults and children. He is also one of the world’s foremost leaders and innovators in facial gender confirmation surgery.