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Archive for the ‘fat grafting’ Category

Facial Fat Grafting and Platelet-Rich Plasma (PRP)

Saturday, February 24th, 2018

 

Fat grafting is the primary surgical technique to soft tissue augmentation of the face. The addition of fat cells has the potential to add retained volume while the presence of adipose-derived stem cells offers the opportunity for tissue regeneration. Such tissue regenerative effects may be able to be seen in the overlying skin with an improved appearance and elasticity.

Efforts to improve the potential benefits of the adipose-derived stem cells in the fat graft have been based on graft concentration techniques. Another potential method has been the addition of agents to the graft concentrate that can cause cell stimulation. While no one single agent has yet been identified that can do so, the most theoretically promising is that of platelet-rich plasma.(PRP) As an autologous concentrate from a blood draw, it offers a rich source of growth factors that can be mixed with the fat concentrate and may aid the regenerative effects of the adipose-derived stem cells. While the addition of PRP to a fa graft intuitively seems to be beneficial, there are few clinical studies that have studied such a facial lipofilling combination.

In the February 2018 issue of the journal Plastic and Reconstructive Surgery an article was published on this topic entitled ‘The Addition of Platelet-Rich Plasma to Facial Lipofilling: A Double-Blind, Placebo-Controlled, Randomized Trial’. In this paper the authors conducted a clinical study over three years in thirty-one (31) females who had facial fat micrografting done with both superficial and deep lipofilling on both sides of the face. The fat injected areas were then treated by secondary injection of either the saline (control) or PRP. Postoperative assessment was based volume retention at the nasolabial folds, skin elasticity, recovery time and patient satisfaction one year later.

Their results showed that the addition of PRP did not improve fat graft maintenance or skin elasticity improvement. PRP did, however, significantly reduce postoperative recovery time. This was judged by a quicker return to work and decreased time needed for the use of camouflaging agents for the post-injection bruising.

This clinical study of the potential value of PRP is hampered by the unknown question of how much concentration of it is needed. Since it is not a drug, no studies have ever been done to evaluate dosing. This is not to mention the various method/kits used to prepare it. Also should the PRP be mixed in with the fat graft or injected after the fat graft has been placed as the authors have done in this study.

How does platelet-rich plasma improve recovery after facial fat grafting? The hypothesis is it induces increased fibroblastic activity, increased collagen production and a stimulation of an enhanced inflammatory response.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Injections, Stem Cells and Injectable Scar Therapies

Monday, February 12th, 2018

 

Fat injections have become the modern day equivalent in plastic surgery of the ‘magic bullet’. Like antibiotics over 75 years ago (although not quite that dramatic) fat injections have become widely used for a variety of problems in plastic surgery from treating radiation-damaged tissues to cosmetic augmentations of the face and body. Clinical successes are numerous although the exact reasons why remains speculative and many research studies have been done around the world to provide insight into this question.

The assumption has always been, and there is a lot of evidence to support it, that the stem cells in fat is the secret ingredient. Because it is an autologous treatment and not a synthetically derived drug, this has to its widespread use way before an understanding of how it works has been determined. Fat injections are largely harmless and, as a result, they have been applied to many difficult problems. Scars can certainly be difficult problems particularly recurrent scar formations and pathologic variations thereof. Injecting fat into scarred and contracted wounds has a lot of appeal and clinical successes are widely reported.

In the March 2018 issue of the Annals of Plastic Surgery an article was published entitled ‘Adipose-Derived Tissue in the Treatment of Dermal Fibrosis: Antifibrotic Effects of Adipose-Derived Stem Cells’. In this review paper the authors explore the current scientific understanding of how fat injections may improve hypertrophic scars and other fibrotic skin and subcutaneous issues through various antifibrotic mechanisms. As is commonly believed it is the stem cells, or more specifically stromal cell–derived factors, that exist within the fat which generate its therapeutic effects on difficult scar tissue probolems. Their mechanism of action is primarily done by paracrine signaling. This turns on numerous molecular pathways for an antifibrotic action by modulating the central profibrotic transforming growth factor ?/Smad pathway which normalizes the function of fibroblasts and keratinocytes in the involved area. Other mechanisms are undoubtably involved, some of which are yet to be discovered and studied. But stem cell conversion into new fibroblasts and even adipocytes is one commonly believed effect that results in less scar and softer tissue as well.

Despite its widespread use and substantial clinical evidence of its benefits, the actual mechanisms of fat injections on scarred tissues is far from well understood. While its clinical use has spurned much scientific investigations in the past decade, the need to understand why it works in many different clinical situations ensures that an equal if not greater number of research studies will be done in the future. Such studies will likely lead to a drug-like therapy that provides a controlled effect through dosing and perfected delivery mechanisms. Decades from now what is done with fat grafting and stem cells will make what we are doing today look fairly primitive.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Processing Methods for Injectable Facial Fat Grafting

Sunday, February 11th, 2018

 

Fat grafting to the face has become an accepted and popular soft tissue augmentation method. Most of this fat grafting is done by injection given its versatility and ability to be done just anywhere on the face. By harvesting the fat by liposuction from a body site, it is processed and then injected. Given the highly unpredictable nature of such injected fat graft retention, much debate has been given for the various steps in the process to optimize graft volume retention.

The processing part of the harvested fat has been the most scrutinized part of the facial fat grafting process. Methods available include telfa wecking, gravity separation and centrifugation. Which of these three fat processing techniques methods results in better fat graft survival and volume retention? Lack of any standardization in fat grafting to date makes determining the best fat processing method difficult.

In the January 2018 issue of the JAMA Facial Plastic Surgery journal an original investigation was published entitled Three-Dimensional Volumetric Analysis of 3 Fat-Processing Techniques for Facial Fat Grafting – A Randomized Clinical Trial’. In this paper the authors compared three fat processing techniques with 3-dimensional (3-D) technology to determine the optimal fat-processing technique for improving the volume retention of injected facial fat. Over a one year period over fifty (52) patients with facial asymmetry were treated by facial fat grafting. The patients were equally divided into three groups based on the fat processing method of the injected fat, sedimentation (group 1), centrifugation (group 2), and cotton pad filtration. (group 3) After surgery patients underwent 3-D scanning before and at 1, 3, 6, and 12 months after surgery.

Assessment was done by determine the volume of the graft maintained with 3-D software. The mean (SD) percentage volume maintenance at 1, 3, 6, and 12 months postoperatively was, respectively, 49%, 45%, 43%, and 41% for Group 1cotton pad filtration group; 41% , 38%, 36%, and 34% for Group 2 centrifugation group; and 37%, 34%, 31%, and 31% for Group 3 sedimentation group. Variance analysis showed that the cotton pad filtration group demonstrated a statistically significant higher percentage volume maintenance in comparison with the centrifugation and sedimentation groups.

While the authors and their analysis showed the cotton pad infiltration method of fat processing produced better graft survival, I would take a slightly different take on their findings. At the least this clinical study shows that all three fat processing methods have success and advanced processing technology does not necessarily make for better fat grafting results. Cotton or telfa pads are certainly low tech but they work.

Dr. Barry Eppley

Indianapolis, Indiana

Techniques for Improved Safety in Fat Injection Buttock Augmentation

Sunday, January 21st, 2018

 

Buttock augmentation by injection fat grafting, known by the urban term of Brazilian Butt Lift or BBL, has been the fastest growing body contouring procedure in the past decade. Because it is ‘fat recycling’ procedure offers the dual benefit of reduction of undesired body contours by the liposuction harvest and the increase in buttock size by its relocation to this body area.

But despite its popularity and wide spread use, it has proven to also be a procedure that is not without its risks. Recent studies have shown that there are more major complications from this procedure than is commonly known with the highest mortality rate of any modern day cosmetic surgery procedure. Such events are related to pulmonary fat emboli in most cases. At roughly a death in every 3500 procedures done this is unacceptable in cosmetic surgery.

In the January 2018 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Staying Safe During Gluteal Fat Transplantation’. In this paper the authors review the important techniques of more safely performing fat injections to the buttocks based on patient selection, instrumentation, patient positioning and injection techniques based on buttock anatomy and vasculature. This is fundamentally about avoiding injuring deep gluteal vessels and inadvertently getting the fat transfer into them.

The anatomy of the buttocks is divided into superficial and deep levels. The superficial level consists of the gluteus maximus, gluteus minimus and tensor fascia late muscles. The deep muscles are smaller and include the piriformis, gemellus superior and inferior and quadratus femoris. The inferior and superior gluteal vessels originate from below the prirformis but emerge out onto the outer surfaces of the gemellus and piriformis. Most relevantly are these deeper gluteal veins which are surprisingly big (5 to 6m) and are felt to be the most common entrance for fat emboli from fat injections.

The danger one in buttock augmentation is a triangle between the posterior superior iliac spine superiorly, the greater trochanter laterally and the inferior ischial tuberosity. Deep fat injections should be avoided in this area in particular as that is where the deep gluteal vessels lie.

Preoperative patient selection should be on avoiding patients that have a history of deep vein thrombosis, pulmonary emboli, large varicose veins or sciatic nerve symptoms.

Fat injection buttock augmentation is done in the prone position with the hips flexed. (jack knife position) In this position the knees should be bent to avoid venous polling in the calfs. This position also allows for more certainty that the fat is injected into the subcutaneous and superficial muscles.

The injected fat should be done using larger cannulas. (blunt tipped and greater than 4mm in diameter) This cannula size combined with a continuous back and forth cannular motion significantly decreases the risk of venous injury and fat introduction. The buttocks should also not be filled to the point of high internal pressure where the fat comes squirting back out from the skin entrance site. By my own personal experience i would also only inject from a superior direction which, in the jackknife position, ensures a superficial injection plane and no change to get under the gluteus maximus muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Rejuvenation of the Hollow Upper Eyelid with Fat Grafting

Monday, December 25th, 2017

 

Loss of fat in the upper eyelid creates a hollowing which is commonly associated with an unaesthetic appearance. This creates a concavity or depression in the upper eyelid that results in a shadow. With this eyelid inversion or A-pattern more of the curvature of the eyeball and pretrial skin is exposed. In the side view this creates a distinct concave appearance. All together this absence of upper eyelid fat creates a more gaunt or aging upper eye appearance.

Volumetric restoration or augmentation of the upper eyelid requires the placement of fat. While fat grafting has been widely used all over the face, there is no consensus for how it should be done in the upper eyelid. Techniques vary widely from an open or closed approach and which plane in which to place the fat grafts.

In the November 2017 issue of the journal of Plastic and Reconstructive Surgery an article was published entitled ‘Fat Grafting in Hollow Upper Eyelids and Volumetic Upper Blepharoplasty’. In this paper the authors review their experience in thirty-two (32) women who had fat grafting to the upper eyelids over a four year period. The majority of these involved skin resection (26) with the remaining minority being augmentative only. (6) The term ‘volumetric upper blepharoplasty’ refers to a dual plane fat graft placement combined with orbicularis muscle imbrication. The average amount of injected fat grafting was 0.4cc in the deep plane (concave depression below the supraorbital rim) and 2.8cc in the superficial plane. (1mm over the eyebrow to a line 10mm above the ciliary margin) If skin for an upper blepharoplasty is to be removed it is secondarily done with the consideration of the tension that will be placed on the closure by the fat grafts. In each patient treated the inverted ratio was adequately corrected in the front view. In the side view the concave shape was converted into a convex one, regardless of the technique used. No infections were seen nor was any revision procedure done. Some far graft loss was seen in six patients but it did to affect their results.

Volumetric upper blepharoplasty is primarily a fat grafting technique in which any skin resection is complementary. The goals of fat grafting and the muscle plication is to increase the muscle volume. The skin resection serves to smooth out the upper eyelid and lower the supratarsal crease. This technique is really a paradigm shift in how upper blepharplasty can be performed although its application is to the subset of patients who have upper eye hollowing.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Grafting and World War 1

Sunday, December 24th, 2017

 

It has been said that many techniques used in plastic surgery, both reconstructive and cosmetic procedures, have their origin in war. The need to develop methods to treat devastating injuries of the face and body serves as the basis for innovation. This is best known in the development of many plastic surgery procedures of the face where World War 1 thrust surgeons of the day into a whole new world of missing parts of the face from trench warfare. Not only techniques but the surgeons that developed them live in the chronicled history of plastic surgery…long before plastic surgery was they established surgical discipline that it is today.

In the November 2017 issue of the Annals of Plastic Surgery an article was published entitled ‘Use of Fat Grafts in Facial Reconstruction on the Wounded Soldiers From the First World War (WWI) by Hippolyte Morestin (1869–1919)’ This pioneering French surgeon’s work during the Great War from 1914 to 1918 was on the large numbers of facial injuries that this conflict created. As head of a surgery department that specialized in the face, he developed numerous techniques using tissues from the patient’s own body to fill tissue defects in facial reconstruction. This paper focuses primarily on the fat grafting techniques and their aesthetic outcome used by Morestin during World War I. (he died one year after the end of the war)

Using documents and pictures from the archives of the Val-de-Grace Army Health Service, thirty-four cases published by Hippolyte Morestin dealing with facial reconstruction during the World War I were studied. Free en bloc fat grafts were used to fill craniofacial defects. While most of the grafts were harvested from the patient, fat grafts from other people were sometimes used. The goal of the surgery was to create more volume but benefits were also seen in improved skin healing and skin flexibility.

While done in a time before antibiotics and field and instrument sterilization were not developed, it is amazing that such tissue grafting worked at all. But its success then served as the yet unknown foundation for the fat grafting procedures done in plastic surgery today. While the exact reason why fat grafting works (and sometimes does not work) is not completely understood today, it is believed that other elements in the tissue (e.g., stem cells) are favorable for healing and cellular regeneration. While it was innovative over one hundred years ago to just graft tissue from one part of the body to the other and have some of it live, its application today in both reconstructive and cosmetic procedures is no less impressive.

For me the greatest relevance in Morestin’s work is the use of enbloc fat grafts. (not liposuction harvested and injected fat as is most commonly used today) Such fat grafts still have application today and I frequently use them in the form of dermal-fat grafts for small to modest face and body defects. While not talked or written about much today they still are a valuable tissue grafting technique which was really what was done in fat grafting in the first three-quarter’s of the last century.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Dermal-Fat Grafting Of Buttock Indentation

Monday, December 4th, 2017

 

Background: The buttocks are a frequent site for intramuscular injections due to the large mass and surface area provided by the gluteus maximus muscle. In children it is a particularly preferred injection site. Many different types of injectates can be introduced from antibiotics to vaccinations to steroids. Usually these are few negative side effects from using the buttock injection site.

One known side effect from buttock injections is with the use of steroids. When the dose is too high or placed too superficially the steroid collects in the tissues and creates fat atrophy. This can result in skin dimpling or an indentation. This effect is not seen immediately. It takes several months for it to appear and the progression of its effects may continue for up to six months after the injection.The steroid, triamcinolone (Kenalog), which is widely used is well known to cause this injection site contour deformity.

Reconstruction of buttock injection deformities is one by fat grafting. Whether it would be by injection fat grafting or the use of a composite solid fat graft depends on the size and depth of the indentation.

Case Study: This 19 year-old female had a left deep buttock scar/indentation from having aa steroid injection done as a child.  She had two more superficial ones of the right buttock. The left buttock scar remained deep through her growing years and only became bigger as she got bigger. It was deep and tethered to the underlying muscle.

Under general anesthesia and in the prone position, the buttock scar was excised and the skin widely released. A dermal-fat graft was harvested from the inner infraglutea crease. The overlying epithelium was removed and the grafts was placed dermal side down into the defect. The skin was closed over it. The right buttock scars were treated by fat injections which was harvested from the inner thighs.

Dermal-fat grafting is an almost forgotten form of soft tissue reconstruction. While injectable fat grafting is far more versatile, there remains a role for composite bloc fat grafting. Scars that are deep and tethered respond better to an open release from which a composite fat graft can be placed. It does require donor site and the infragluteal crease is one option.

Highlights:

1) Buttock indentations are commonly the result of injections.

2) Injectable fat grafting is indicated for less deep and broader-based buttock indentations

3) Buttock indentations that are associated with scar contractors are best treated by release and dermal-fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Injections for Improving Breast Cleavage (Intermammary Distance Reduction)

Monday, November 13th, 2017

 

The breast has many aesthetic features of which the sternal gap is one of them. The distance between the breasts is most commonly a consideration in breast augmentation surgery in an effort to create improved cleavage. But it can also be an issue in other forms of aesthetic breast surgery as well including breast lifting/reduction as well as in breast reconstruction.

Short of what an implant can do, reducing the distance between the breasts across the sternum requires soft tissue augmentation. Fat injection grafting offers an ideal method to do so. Fat grafting to the breasts has an established history although it has been typically applied in larger volumes for a breast augmentation effect.

In the November 2017 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Breast Cleavage Remodeling with Fat Grafting: A Safe Way to Optimize Symmetry and to Reduce Intermammary Distance’. In this clinical series the authors treated eighty-six (86) patients who underwent various types of breast reshaping surgery. Fat injections were done in the medial pole of the breasts to reduce the degree of separation across the sternum or for medial pole asymmetry. Before and after intermammary distances were measured before and after surgery.

Their results showed a significant reduction in the mean intermammary distance from an average 3cm to a 1.7cm distance at one year after surgery. Only one fat grafting complication occurred which was an oil cyst that required aspiration.

Submuscular breast implant augmentation offers an ideal time to create improved cleavage by fat injection grafting. The breast tissue above the muscle remains unaffected by the submuscular pocket and does not connect with the implant pocket. For those women with widely spaced breasts who are undergoing breast augmentation surgery, fat injections offers a reliable method to enhance their cleavage as well.

Dr. Barry Eppley

Indianapolis, Indiana

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


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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