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Archive for the ‘fat grafting’ Category

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

Fat Grafting to the Foot – A Prospective Study

Saturday, July 9th, 2016

 

Fat Grafting to the FootFat grafting is now widely done throughout many areas of the body and face. Because of its injection placement, fat can be virtually placed about anywhere. The benefits of fat grafting through the introduction of healthy tissue and perhaps loading the site with new stem cells can have regenerative and healing properties. Fat grafting continues to find new applications through all surgical specialities.

Loss of fat in the foot (pedal fat pad atrophy) can cause a variety of painful and dysfunctional symptoms. The loss of tissue thickness and the increased load bearing on the foot can cause pain that may not be adequately relieved by support and external padding. Fat grafting into these foot areas would seem to be a logical treatment although no objective studies have been published with the use of fat grafting to the forefoot.

In the advanced online July 2016 issue of the journal Plastic and Reconstructive Surgery, an article appeared entitled ‘Fat Grafting to the Foot – A Prospective Clinical Study’. In this paper twenty-five (25) patients were studied in a prospective randomized manner with 13 receiving fat grafting (Group 1) while the other 12 (Group 2) received conservative management over the course of a year. Ten patients in Group 1 underwent fat injections into both feet with a mean volume of 4.8cc per foot. At one year, Group 1 patients had improved foot function, less pain, and greater work/leisure activities. Group 1 had no change in tissue thickness, whereas in Group 2, the right 3rd metatarsal tissue thickness decreased significantly. Foot pressures in Group 1 did not improve. However, Group 2 had a significant increase in left foot pressure. When comparing the groups at 1 year, Group 2 had significantly higher foot pressures and forces than Group 1.

This is the first study that provides short term evidence that fat grafting into the foot improves pain and prevents worsening of foot pressures. Such fat grafting has previously been hypothesized that it can potentially create these effects. This paper provides clinical evidence that this fat grafting effect is real. It is known how exactly this effect occurs although it can be presumed that it occurs by the addition of viable tissue cells and improved vascularity, effects well known when fat is injected elsewhere in the body. The next question is whether such injected fat is maintained long-term in a body area that is exposed to high pressures.

Dr. Barry Eppley
Indianapolis, Indiana

Fat Grafting A Custom Skull Implant Visible Edge

Tuesday, May 10th, 2016

 

Custom skull implants have become a successful method for correcting many types of skull deformities where augmentation is needed. Interestingly, and perhaps not surprisingly, many aesthetic skull deformities are most apparent in men due to a ‘lack’ of hair. Whether the exposure of the skull is due to a shaved head, a short hair style or a thinning scalp cover, the shape of the skull becomes readily apparent.

Custom Occipital Implant design Indianapolis Dr Barry EppleyOccipital Dents Custom Skull Implant result Dr Barry Eppley IndianapolisBesides the shape and thickness of the skull implant design, it is especially important in custom skull implants in men to pay close attention to all edges of the implant. All of the implant’s edges (360 degrees) needs to be a feather edge. Even a 1 or 2mm edge will create a visible step off (edge transition) that will eventually be seen when all swelling subsides and scalp tissue contraction occurs around the implant. Early results after surgery in the first few months will appear smooth but by six months after surgery a visible edge may be seen.

When treating visible edge transition in an aesthetic custom skull implant, there are two traditional treatment options. The implant may be remade and a new one placed. Or the existing implant may be removed, the slight edge shaved down and reinserted. Neither of these two implant modifications options are particularly appealing.

Skull Implant Edge Transition Fat Grafting Dr Barry Eppley IndianapolisSkull Implant Edge Transition Fat Grafting result left side Dr Barry Eppley IndianapolisAnother option would be to perform fat injection grafting along the visible edge of the custom skull implant. Fat grafting is minimally invasive and can be performed with no significant recovery. While the scalp is not known to have a high fat graft take due to its inherent tightness, it does permit fat to be injected into it. In a single case in which I have treated a visible anterior edge of a custom skull implant with fat grafting, it’s visibility was essentially eliminated and persistently so at three months after the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Lip Fat Injections using Buccal Fat

Thursday, April 14th, 2016

 

Lip augmentation is a popular facial filling procedure that has been done by a wide variety of materials. Synthetic fillers, fat injection and implants have all be done with well known advantages and disadvantages. The perfect lip augmentation material, however, remains elusive

Of all the known injectable fillers, fat has a high appeal but is the most vexing. Fat is a natural material that is unique to each patient and everyone has enough to harvest to do lip augmentation. But even in small volume placements like the lips, its retention and survival is far from assured. In fact, substantial clinical experience has shown that the lips actually have one of the lower rates of fat grafting success on the face. Whether that is due to high motion activity of the lips or their lack of much native fat tissue is unknown.

The donor site for lip fat injections has been harvested from just about every body donor site imaginable. No one knows if the donor source of fat grafting affects how well the fat graft takes although it is hard to imagine that it does not play some role albeit even if it is a minor one.

Buccal Lipectomy intraop Dr Barry Eppley IndianapolisOne donor source for injectable fat grafting that has not been previously described is that of the buccal fat pad. There is more than enough fat in the buccal fat pads for transfer into the lips. But buccal fat pad harvesting should not be routinuely done due to potential undesired aesthetic tradeoffs of facial hollowing that could occur in many patients. But for those patients with rounder faces that desire facial slimming, a buccal lipectomy can be aesthetically beneficial.

Buccal Fat Injections to Lips Dr Barry Eppley IndianapolisHarvested buccal fat pads can be pass back and forth to create an injectate that can easily be injected through a small blunt-tipped cannula. And for the buccal lipectomy patient who also desires lip augmentation this can be a superb method of fat recycling/redistribution.

Buccal Fat Lip Injections result Dr Barry Eppley IndianapolisDoes fat from the buccal fat pads survive better than other donor sites. The fat is clearly different in being encapsulated and with much larger globules. It is tempting to hypothesize that it survives better than subcutaneous fat, and I suspect that it does, but it remains to be scientifically proven.

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.

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