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Archive for the ‘fat grafting’ Category

Hand Rejuvenation with Injectable Fat Grafting

Thursday, September 28th, 2017

 

Fat grafting through an injectable technique has enjoyed widespread popularity over the past decade. Because of its ubiquitous presence throughout the human body and its relatively easy extraction by liposuction, fat injections have been done in just about every external feature of the human body. In addition to its volumizing capability, such injected fat has also been shown to have some skin rejuvenation properties as well.

Aging of the hands is characterized by loss of fat and skeletonization of its structural components with thinning and wrinkling of the overlying skin. The introduction of one’s fat into the dorsum of the hands, therefore, may be viewed as the best form of hand rejuvenation. The fat reinflates the back of the hands and as yet unknown factors contained within the fat contributes to skin rejuvenation as well. 

In the October 2017 issue of the European Journal of Plastic Surgery an article entitled ‘Hand Rejuvenation with Fat Grafting: A 12-year Single-Surgeon Experience’. In this article, the authors present their protocol for hand fat grafting with over a decade of clinical experience in doing it in 65 patients. Fat is harvested in a standard fashion and is prepared without centrifugation. (decanting) It is injected in a proximal to distal approach above the dorsal deep fascia and between the 1st and 5th ray. The average amount of fat injected ranged from 10 to 30 ccs. The majority of patients (84%) were satisfied. Picture results at one year show that they average fat take was high. Other than some temporary prolonged swelling in a few patients, no long-term complications were seen.

This clinical paper with good patient volumes show that fat takes fairly well in the thin tissues of the back of the hand. This may seem a bit surprising given that the natural fat layer is very scant in this body area. The biggest issue in fat grafting to the hands in my experience is not how well the fat takes but in making sure it has been placed in a smooth a layer as possible to avoid lumps or an irregular contour. I find that digital molding of the fat or using a roller helps in smoothing out the fat injectate.

With fat grafting for hand rejuvenation, it should not be forgotten to treat the outer skin as well. Fat injections can be combined with laser and chemical peeling to improve the skin texture as well as BBL (broad band light) to help treat brown spots.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Buccal Fat Grafting of the Labiomental Fold

Wednesday, September 27th, 2017

 

The labiomental fold is a small and often overlooked facial feature. Lying between the lower lip and chin, it is a crease or fold of varying depths amongst different people. Why a labiomental fold even exists at all is a function of many factors including chin projection, the attachment of the mentalis muscle to the bone, the size of the soft tissue chin pad, the depth of the intraoral vestibule and the size and projection of the lower lip.

While often thought irrelevant, it becomes a more important aesthetic issue in chin surgery particularly that of augmentation. Since the labiomental fold is a fixed anatomic structure, its appearance will be affected by increasing chin projection almost regardless of the method to do so. As the inferior chin comes out further, the superior labiomental fold by contrast will look deeper. There is nothing a chin implant or a sliding genioplasty can do, on their own, to make the labiodental fold less deep.

Softening a deep labiomental fold requires a direct approach whether it is an injection technique or an implant. Injecting filler or fat is often not rewarding as the tightness of the fold makes it hard to get a good push outward.

An alternative strategy is to perform a full release of the dermal attachments of the fold above the mentalis muscle through an intraoral approach and then place a soft tissue graft. A fat graft is a good choice for the filler material and can come from a variety of sources including a dermal-fat graft and a solid fat graft like that from the buccal fat pads. (as shown here)

Release of the deep labiomental fold well above the bone level (north of the mentalis muscle and not south of it) is the key for successful fat grafting in efforts to soften it.

Dr. Barry Eppley

Indianapolis, Indiana

Tear Trough Fat Grafting During Lower Blepharoplasty

Saturday, June 10th, 2017

 

Lower eyelid aging creates a number of well known aesthetic deformities. From excessive skin, herniated orbital fat, malar-palpebral grooves to tear troughs, the anatomic changes to the lower eyelid have been well chronicled. Tear troughs and the correction of this nasojugal groove have been treated by both injected fillers and fat as well as different surgical blepharoplasty techniques.

The surgical correction of the tear trough deformity has included orbital fat transposition, release of the orbitomalar ligament and tear trough implants….or some combination of them. While these can be done using an external skin or an internal conjunctival approach, the most consistently effective is the external approach or the skin-muscle flap technique. Its enhanced visibility allows for the redistribution/rearrangement of local tissues to a reproducible autologous rejuvenation effect.

In the June 2017 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Micro Free Orbital Fat Grafts to the Tear Trough Deformity during Lower Blepharoplasty’. In this paper the authors report their results of 32 lower blepharoplasty patients who had their tear trough deformities treated by the addition of micro free fat grafts with an average followup of one year. In their technique they minced any removed orbital fat pockets into small 2mm to 3mm grafts. (micro free fat grafts) These are then placed into a space created by the release of the orbitomalar ligament. Their results showed consistent good improvement of the tear trough deformity. No patients developed infection or lid deformities. One reoperation due to sclera show was needed (3%) while temporary conjunctival swelling occurred in just over 10%.

Traditional lower blepharoplasty techniques in the face of tear trough can often leave them looking worse by exacerbating the appearance of the preoperative hollows or dark circles. The concept of not merely discarding herniated orbital and reusing it either through pedicled flap transposition or free fat grafts is a logical one. What is appealing about free fat grafts is that they are more versatile than a peddled flap. They can be placed more consistently, in greater volumes and with more precise placement. Such solid small fat grafts have been known to survive for as long as thirty years ago with reports of the use of ‘pearl fat grafts’ in the face.

Free fat grafting of the tear trough during lower blepharoplasty can be done with fat harvested from anywhere not just the use of orbital fat. Small grafts taken from the buccal fat pad is a good example of a regional fat donor source. Whether its survival is as good as orbital fat can not be determined but there is no reason go think that it would be less.

Dr. Barry Eppley

Indianapolis, Indiana

Nanofat Grafting

Sunday, May 28th, 2017

 

Injectable fillers are the most common method used today for a wide variety of facial volumizing effects. Ideal for patients that want an immediate result that avoids surgery, the selection of almost twenty different fillers provides a filler type for every patient’s needs. Despite these advantages injectable fillers have one major downside…lack or persistence. Despite manufacturer’s efforts to improve their longevity, permanent injectable fillers that have a good safety profile are not on the near horizon.

Fat grafting offers an injectable material that does have the potential for a permanent augmentation effect. Its problem, however, despite this potential is that it is wildly unpredictable. Different intraoperative processing methods and harvest sites have been used but the concept of optimizing fat cell survival remains not completely worked out. In addition, traditional fat grafting creates a thicker more putty like material which does not lend itself well to a smooth linear  injection like that of synthetic injectable fillers.

An alternative fat grafting method is that of micro- or nanofat grafting. In this technique the fat graft is micronized or emulsified into a much more liquid mixture. This can be done by machine or manual technique. The intent here is not too focus on fat cell survival but to create an autologous scaffold by shearing the fat into small particles. This not only adds volume by injection but provides a bio-scaffold framework onto which new tissue ingrowth may occur. If PRP (platelet-rich plasma) is added to the nanofat graft a potent autologous regenerative matrix is created that far surpasses the biologic response to a synthetic injectable filler.

The physical benefit of nonfat injections are that they act like injectable fillers. Their emulsified nature allows them to be injected from very superficially into or just under the dermis or into deeper tissue planes. Such particulated fat grafting has been shown to result in improved skin quality that is maintained out to six months to year

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Augmentation by Fat Injections

Sunday, April 30th, 2017

 

Forehead augmentation can be done using a variety of materials and methods. It is probably most popular worldwide in Asians who often have a flatter and less convex forehead shape. While the use of synthetic materials is the most effective and assured forehead augmentation method, m both in terms of shape and longevity, it is an invasive procedure that requires some form of a scalp incision to have the forehead implant material placed.

Given the success of injectable fat grafting for facial voluminization, whether it could work as well in the forehead remains an intriguing consideration as another option for forehead augmentation in select patients.

In the March 20178 issue of the International Journal of Plastic Aesthetic and Reconstructive Surgery a paper was published entitled ‘Micro-autologous Fat Transplantation (MAFT) for Forehead Volumizing and Contouring’. In this paper The authors report on 178 patients (167 female, 11 male) over a 5-year period with an average nearly three year followup. Using harvested fat that was prepared by centrifugation, the forehead was augmented by an injection gun device. The procedure took under one hour to complete and averaged around 10ccs of injected fat. Not complications occurred such as infection, irregularities  or nerve injuries occurred, The authors reported that over 80% of the patients were satisfied with their results.

The proper title for this paper should have been Small Volume Forehead Augmentation by Injected Fat. With an average injection volume of just 10ccs of fat placed the amount of forehead augmentation obtained was very modest and in the central forehead location. In my forehead augmentation experience such a small amount of forehead augmentation would satisfy few patients even with an uncomplicated outcome.

But for those patients that seek very modest forehead augmentative changes, fat injection is a good technique as it avoids any scar from incisional access and has no significant risks. Like all fat injections, the survival and persistence of the fat transplants are not assured. But low volume micro fat grafts in the facial area has a known high rate of retention and the forehead should be no exception..

Dr. Barry Eppley

Indianapolis, Indiana

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


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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