EXPLORE
Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Archive for the ‘fat grafting’ Category

Processing Methods for Injectable Fat Grafting

Sunday, March 19th, 2017

 

Fat grafting as a method of both soft tissue reconstruction and aesthetic augmentation has taken on a dominant role in plastic surgery the past decade. Between the wide availability of donor tissue, its relatively easy harvest and subsequent injectability, it is no wonder that autologous fat transplantation has become so popular. But despite its many favorable features, the predictability of the procedure remains…unpredictable. It is felt that what may have the greatest impact on how well fat survives the injection process is how it has been prepared.

Centrifuged Fat Preparation for Fat Injections Dr Barry Eppley IndianapolisIn the March issue of the journal Plastic and Reconstructive Surgery a paper was published on this topic entitled ‘A Comprehensive In Vitro Comparison of Preparation Techniques for Fat Grafting’. The authors harvested fat from the lower stomach region in 14 patients and processed the fat by decantation, centrifugation and membrane tissue filtration. The resultant preparations were examined by electron microscopy and cell viability studies. The number of stem cells present and their character was assessed by cell surface markers and whether they could differentiate into adipose cells.

Adipocyte cell cultures Dr Barry Eppley IndianapolisTheir results showed that neither preparation method caused significant cell damage nor were measurable differences seen in overall cell viability. Neither method of preparation showed a significantly higher number of adipocyte-derived stem cells. The maximal amount of adipocyte concentration by water removal was achieved by membrane-based tissue filtration. In conclusion, while the properties of liposuction-aspirated fat were influenced by the processing method they were not significantly different. Centrifugation and membrane-based filtration are preferred when possible when access to such devices exist.

This is just one of many laboratory studies that have looked at how the preparation process influences the eventual fat injectate. Despite many proponents as well as manufacturer claims of the superiority of one processing method over another, in vitro and clinical evidence has provided no conclusive proof of one best method. This paper continues to show that some processing method is better than none. Given the many variables in the fat grafting process it may also be that the preparation method is not the critical element, or at least as important as we think, in improving fat injection survival.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Dermal-Fat Graft Chin Reconstruction

Monday, February 6th, 2017

 

Background: Soft tissue deformities of the chin are not uncommon and are created by a variety of etiologies. Trauma is the most common cause but developmental chin deformities also occur from hemifacial microsoma and autoimmune diseases from linear scleroderma for example.

Treatment of any soft tissue defects of the face are done by fat injections today. Their ability to introduce a natural soft tissue graft and to do so in a non-incisional method has a lot of appeal. The downside of injectable fat grafting is the unpredictability of its survival or persistence. But the potential need for multiple injection sessions is still worth the lack of creating incisional scars in most cases.

The dermal-fat graft is the original fat grafting procedure that dates back to World War I.  Technically the original technique was an enbloc fat graft. (without the dermis) A dermal-fat graft works because the blood vessels are hooked back up quickly within days to a week after implantation. It also helps that fat cells have minimal working parts to them. (just a nucleus) But their success is restricted to smaller graft sizes. Their disadvantages are that they require a donor site harvest and an incision for their placement.

Soft Tissue Deformity of ChinCase Study: This 45 year-old female suffered a traumatic injury to her chin which resulted in soft tissue atrophy due to the resultant hematoma. The left side of her chin was thinner and had soft tissue contraction and an obvious external deformity. She has some numbness of the mental nerve distribution on that side but a normal working marginal mandibular branch of the facial nerve.

to chin intraopUnder general anesthesia, a 4 x 6 cm dermal fat graft was harvested from the lower abdomen. Through an intraoral approach, a vestibular incision made dissecting out branches of the mental nerve. The chin soft tissues were released and a pocket made. The dermal-fat graft was inserted into the pocket and trimmed. A mucosal closure was done over the graft.

Dermal Fat Graft Chin Reconstruction result front view Dr Barry Eppley IndianapolisDermal-Fat Graft Chin reconstruction result oblique view Dr Barry Eppley IndianapolisHer three month after surgery result showed a near normal chin contour that was fairly soft and supple. No further surgery was required.

The dermal-fat graft is often overlooked in today’s plastic surgery where the injectable fat graft dominates soft tissue reconstruction. While the dermal-fat graft has its limitations, in the properly selected patient it can offer a one-time soft tissue grafting method of reconstruction.

Highlights:

1) Soft tissue deformities of the chin are best treated by fat injections.

2) Fat injections do not always survive and multiple injection sessions may be needed.

3) A dermal-fat graft provides a large soft tissue grafts that can be placed through an intraoral approach with good survival.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Buccal Fat for Lip Injections

Tuesday, January 31st, 2017

 

Lip augmentation by injections is one of the most common injectable filler treatments of the face. It has been done since synthetic collagen fillers were introduced way back in 1981. Since then many different injectable filler materials have been used but the ideal lip augmentation material remains as yet undiscovered.

Fat would seem to be an ideal soft tissue injection material given its autologous source and as a natural part of many soft tissue sites. Its main disadvantage is how well it survives the transplantation process which is highly variable. Of all areas of the face into which fat is transplanted the lips are known to have a low rate of success. There are no proven reasons why this is so but it has been conjectured that the high movement and distortion of the lips contributes to injected fat absorption. It could also be that there is little natural fat in the lips and that makes it a poor recipient bed.

Buccal Lipectomy intraop Dr Barry Eppley IndianapolisThe donor source of the fat for lip augmentation may also be a contributing factor. Most fat harvests are taken somewhere on the trunk, usually the abdomen or the inner thighs. Whether this is optimal fat for facial transplantation us unknown. This is ‘body’ fat which may not be ideal for use in the face but it does offer convenience and a relatively large supply. Another option for lip augmentation is the buccal fat pad. It offers more than enough fat for the lip  and is easily harvested through an intraoral approach.

Buccal Fat Pad Lip Injections Dr Barry Eppley IndianapolisSince the buccal fat pad is a solid source of fat rather than obtained by liposuction, its use  as an injectable source of fat may be overlooked. But the buccal fat pad can be sectioned into small pieces and placed into a syringe. Between two connected syringes it can be passed back and forth to create a more injectable consistency.

Whether buccal pad survives better in the lips is not known although in my fat injection lip augmentation experience it does. Its only drawback is that there has to be an aesthetic reason to harvest the buccal fat pads so no adverse facial effect is seen.

Dr. Barry Eppley

Indianapolis, Indiana

Shoulder Groove Fat Grafting in Breast Reduction Surgery

Tuesday, January 17th, 2017

 

Breast reduction is a combination reconstructive and aesthetic body contouring procedure. It relieves the musculoskeletal symptoms from large hanging breasts as well as lifts and reshapes it higher up on the chest wall. While it does so a the expense of anchor-pattern scars of some length, it is a tremendously effective operation for the large breasted woman.

One of the classic physical signs of breasts that are too heavy for one’s body frame is the presence of shoulder grooves. These occur from the compression of the bra straps on the skin from the weight of the breasts in a bra. Shoulder grooves occur partially from fat atrophy from the constant compression of the bra straps compressing it down on the muscle. They can occur as quite striking and deep on some patients, particularly those with very large breasts.

An interesting question is whether shoulder grooves resolve/go away after a breast reduction. In theory they should go away as the weight of the breasts is relieved on the supporting bra straps. There are, however, no studies which have ever evaluated the resolution of these after breast reduction surgery. Since their presence partly occurs from fat atrophy one could presume that they will persist even after a successful reduction and lift of the breasts.

Fat Grafting Shoulder Grooves at time of Breast Reduction Dr Barry Eppley IndianapolisA treatment for shoulder grooving at the time of breast reduction surgery is fat grafting. Fat harvested from the abdomen can be used to inject into the shoulder grooves. These are beneficial in the deepest of shoulder grooves. It usually takes 20cc to 30cc of concentrated fat into each shoulder groove.

Fat Grafting Shoulder Grooves Breast Reduction Dr Barry Eppley IndianapolisInitial fat take is fairly good and many will show good persistence out at six months after surgery. While the pressure of a bra strap is never completely negated and is certainly not a favorable feature for fat graft persistence, it does not appear to have a completely adverse effect on fat grafting to the shoulder grooves.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Fat Injection Breast Augmentation Outcome

Monday, January 16th, 2017

 

Background:  Breast augmentation is the most common as well as recognized body contouring operation. Performed through the placement of an implant, its after surgery volume retention is assured. Its downside is that the use of a gel or saline-filled device makes it susceptible to numerous long-term implant related issues and further surgeries.

Fat injection breast augmentation (FIBA) is an appealing alternative to the use of implants in an elective aesthetic procedure. Since the breasts are composed of fibrofatty tissue, adding fat would be a natural and well accepted augmentation tissue. In addition, some patients do have excess fat they would like to get shed and putting in the breasts at the same time is more than a logical exchange.

But many younger women with small breasts have thin body frames. There can be a correlation between breast size and body habitus in some women. Even in women with some visible fat to harvest, it is important to remember the ‘halving principle’ in injectable fat grafting. This goes as follows…half of the harvested liposuction aspirate is removed by concentration, the concentrated fat is split or halved between the two breasts and half of the injected fat will be resorbed. (or 50% volume retention)

Understanding this principle helps patients to determine if fat injections are a good choice for their breast augmentation as well as to have realistic expectations about the volume increase outcome.

Case Study: This 20 year-old female wanted to have breast augmentation by fat injections. She did have some modest fat to harvest from her abdomen and flanks and was well informed that this approach to her breast augmentation would result in a very modest change at best.

Fat Injection Breast Augmentation Dr Barry Eppley IndianapolisUnder general anesthesia she had 845cc of liposuction aspirate harvested from her abdomen and flanks. The aspirate was concentrated down to 430cc of injectable material which was used to inject 215cc into each breast.

Fat Injection Breast Augmentation result front view Dr Barry Eppley IndianapolisFat Injection Breast Augmentation result obloque view Dr Barry Eppley IndianapolisHer one year after surgery results showed a visible augmentation benefit that was about a 1/2 cup size increase. She eventually decided to get breast implants for a much larger result.

Fat Injectionk Breast Augmentation result side view Dr Barry Eppley IndianapolisFat injection breast augmentation is a very appealing alternative to implants but patient selection is critical. Until the science of fat grafting is better understood and fat cell survival can be increased, its use in breast augmentation will remain limited to those patients seek very modest breast size increases.

Highlights:

1) The success of fat injection breast augmentation depends on how much fat one has to harvest and how much survives after being injected.

2) Enlarging the breasts by injectable fat grafting usually result in modest change in the range of a 1/2 cup bra size or so.

3) Potential patients need to consider the ‘halving principle’ when considering augmentation by injectable fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Nanofat Injections for Periocular and Perioral Skin Rejuvenation

Sunday, December 25th, 2016

 

Fat grafting of the face through injection has become a standard therapy for many facial anti-aging and reshaping surgeries. The placement of processed liposuction-derived fat has been well known to result in an improved skin appearance. There was initially some debate as to whether this was just a temporary effect due to swelling or whether actual skin rejuvenation occurred through the stimulation  of stems cells in the fat.

It is believed that adipose-derived stromal and stem cells (ADSC) in autologous fat can create regenerative changes in facial skin when into the dermis and subdermal layers. This would be most useful in the thinner skin around the eyes and mouth which is a frequent location of skin wrinkles which are hard to improve by any method other then laser resurfacing.

enhanced-nanofat-injections-dr-barry-eppley-indianapolisIn the January 2017 issue of the Aesthetic Surgery Journal the paper entitled ‘Skin Rejuvenation and Volume Enhancement with the Micro Superficial Enhanced Fluid Fat Injection (M-SEFFI) for Skin Aging of the Periocular and Perioral Regions’ was published. This 65 patient clinical study looked at the efficacy and viability evaluation of fat harvested with extremely small side port (0.3 mm) cannulae without further tissue manipulation for the correction of aging/thin skin in the periocular and perioral regions. The results were evaluated by histological and cell culture analysis as well as retrospective clinical assessment by a 1 to 4 rating scale.

Their results over a one year period showed no intraoperative complications or visible lumpiness/irregularities. Histologic analysis showed mature viable adipocytes with a strong stromal component. At one month after injection clinical improvement was rated at around 3.5 out of 4. At six months after injection the clincial assessment dropped to 3 out of 4 or less. Following the addition of platelet-rich plasma (PRP) to the injectate,  there was a greater proliferation noted in the M-SEFFI compared to the SEFFI (0.5 mm).

The authors conclude that M-SEFFI is effective and results in lump free skin rejuvenation and volume enhancement. The extraction of smoother stem-cell rich autologous fat tissue is useful in correcting the fine lines of facial skin aging.

nanofat-injections-to-periocular-skin-wrinkles-dr-barry-eppley-indianapolisM-SEFFI is what is also known as nanofat. This is the liquid residual that remains after the concentration of liposuction-derived fat grafts. It can be injected alone or mixed with PRP. Either way its thin consistency allows for it to be injected through a 30 gauge needle into the dermis, unlike more traditional fat injections. This study is limited by the short-term followup and it does not conclusively prove to me that it really causes a true skin rejuvenation effect. But it is a completely harmless technique whose theoretical appeal can not be denied. And it is the only type of fat injection that is thin enough to be placed directly into fine wrinkles.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Scrotal Enlargement by Fat Injections

Monday, November 28th, 2016

 

There are numerous options for elective plastic surgery of the male genital region. Various penile lengthening and enlargement procedures, testicular implants and scrotal lifts are all options for the man who seeks penoscrotal enhancements.

The size of the scrotum is largely determined by what lies within. The size of the testicles is largely responsible for the scrotal sac size. But the size of the testicles can not be increased naturally through hormone supplementation or other non-surgical methods. There is the concept of wrapping a shelled out testicular implant around the existing testicle to increase its overall size as one surgical option.

scrotal-enlargement-by-fat-injections-dr-barry-eppley-indianapolisThe other surgical option for scrotal enlargement are fat injections. Just like fat injections are used all over the body for soft tissue augmentation, they can be safely inject intothe scrotum as well. The scrotum is not known as a large repository of fat but it does have fat amongst its various tissue layers.

Given its relatively small body size and the low volume of fat that need to be injected, fat survival in the scrotum would be expected to be high. Using blunt cannulas and low pressure injection, fat can be safely placed through the scrotum without injury to testicles or the vas deferens.

Besides scrotal enlargement, one other invaluable use of fat injections to the scrotum would be in preparation for testicular implant placement when one has had prior irradiation. Fat injected into tissues that have been irradiated is well known to improve its vascularity and make it more amenable to surgical manipulation with a lowered risk of healing and infectious complications.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Bicep Augmentation by Fat Injection

Saturday, November 26th, 2016

 

Muscle augmentations are done throughout the body using a variety of soft solid silicone implants. The arm is no exception as bicep and tricep augmentations are done by placing the implants on top of the muscle but under the fascia through small armpit incisions.

But not every male who desires bicep augmentation wants to have an implant placed. The  other alternative is a natural one using one’s own fat. Soft tissue augmentation through fat injections is now a well recognized procedure. It offers an increase in soft tissue volume, like the size of a muscle, that is directly dependent on how much fat is injected and how much fat survives.

bicep-augmentation-by-fat-injections-dr-barry-eppley-indianapolisWhether bicep augmentation can be done by fat injections also depends on how much fat one has to harvest. Using the ‘halving principle’ of fat injection outcomes, 50% of the fat that is harvested is lost by concentration and another 50% is lost by resorption after injection. Since the typical bicep implant is in the range of 100cc to 200cc in size, it would require around 1500cc of liposuction aspirate to achieve a similar result using fat.

Bicep augmentation by fat injection is really reserved for those men who are already having some significant liposuction done. While the upper arm bicep region is a relatively small body area, it still requires more injected fat volume than one would initially think.

Dr. Barry Eppley

Indianapolis, Indiana

Labiomental Fold Release and Grafting

Sunday, October 30th, 2016

 

The labiomental fold is the natural indentation that exists between the lower lip and the chin. It resides about 1/3 of the vertical distance between the lip and chin and is present in almost everyone to some degree. While called a fold, it is not really a fold but an indentation that is reflective of the lower extent of the vestibule intraorally. It exists because this is the level of where the origin of the mentalis muscle is as it takes off from the bone surface. Some fibers of the muscle insert into the deep dermis of the chin pad. Since one of the functions of the mentalis muscle is as an elevator of the central lower lip,  the indentation can be come deeper with expression.

Very deep labiomental folds are often associated with short lower facial heights. Conversely, increased lower facial heights have more shallow effaced folds. Patients with normal lower facial heights have variable labiomental fold shapes. The aesthetics of the labiomental fold should be considered in any chin procedure since bony movement of the chin or its onlay augmentation is well known to affect the fold shape.

Another surgical issue that can affect the labiomental fold is intraoral surgical access to the chin. This requires cutting through the bony attachment of the mentalis muscle and then reattaching it during the closure. While not usually causing a labiomental fold problem the first time, repeat surgical entry may cause excessive scar tissue or a mentalis muscle reattachment that is very tight. This can make the labiomental fold deeper and/or feel very tight/stiff.

labiomental-fold-release-indianapolis-dr-barry-eppleyTreatment of the tight or deep labiomental fold requires release and placement of an interpositional graft. A tight or scarred down labiomental fold represents loss of normal tissue and/or its elasticity. Trying to alter the mentalis muscle is not going to make it more free or release the labiomental fold tightness. Labiomental fold release is done by going through the mucosa (usually the old incisional scar) down to the mentalis muscle. But the mentalis muscle is not cut through or completely released. In some cases the more superficial fibers of the muscle are released if that helps make a deeper pocket or better releases the overlying labiomental fold.

labiomental-fold-release-and-grafting-dr-barry-eppley-indianapolisThe interpositional graft placed beneath the labiomental fold can be of several material types. Choices include either cadaveric dermis material (e.g. Alloderm) or an autogenous dermal-fat graft. I favor the fat graft option since it is softer and provides more tissue volume. An injectable fat graft technique is an option but I don’t think it is an effective as actually opening the scarred area and applying a large fat graft into the open space.

Most tight labiomental folds after chin surgery resolve over time. But if a tight and restrictive labiomental fold persists after 6 months or more of healing, release and tissue grafting is a treatment option.

Dr. Barry Eppley

Indianapolis, Indiana

Lower Blepharoplasty for Fat Injection Removal

Wednesday, September 7th, 2016

 

Treatment of tear trough and under eye hollows has been revolutionized by the use of injection materials. Using either resorbable injectable fillers or fat taken from the patient, injection under the eyes can fill out sunken areas creating a rejuvenated appearance. Although there are advocates for either synthetic fillers and fat, both materials can have good success in the lower periorbital region.

While many patients have good improvement in their tear troughs and under eye hollows with injections, not all patients do. The under eye area is the most technique sensitive area of the face for any type of injection. The thin tissues of the lower eyelid reveal any asymmetries and irregularities of the injected material. This may not be apparent for several days or weeks when any swelling has subsided. In some cases too much volume ends up creating the appearance of lower eyelid ‘bags’ which the patient is swelling and will go away on its own.

Solving these lower eyelid injection materials is fairly straightforward with hyaluronic-based injectable fillers. Enzymatic digestion with hyaluronidase injections can rapidly remove any excess material. But this is not the case with other types of injectable fillers (e.g. Radiesse) and fat injections for which no reversal injections exist.

lower-blepharoplasty-for-injected-fat-removal-dr-barry-eppley-indianapolislower-blepharoplasty-injected-fat-extraction-dr-barry-eppley-indianapolisSuch materials can only be removed by direct excision through an open eyelid approach. By exposing the deeper eyelid tissues under the skin any problematic material, such as fat, can be directly removed. Injected fat looks different than lower eyelid compartmental fat and is fairly easily identified by its linear horizontal orientation. It can be carefully lifted out from the tissues in which it is embedded.

For those patients so afflicted with undereye contour problems from injected fat or particulated synthetic fillers, excision is the only effective treatment. Like all lower blepharoplasty procedures the subciliary and lateral canthal incision usually heal in an inconspicuous fashion.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

Read More


Free Plastic Surgery Consultation

*required fields


Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits


Categories