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Archive for the ‘fat injections’ Category

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

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

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

Buccal Fat Pad for Fat Injections

Thursday, February 16th, 2017

 

The buccal fat pad is a well known reservoir of facial fat that can be removed in selective patients for a cheek thinning effect. The buccal lipectomy is an impressive procedure when one looks at the size of the fat pad as it is being extracted.

But beyond its potential aesthetic facial benefits, the uniqueness of buccal fat is that it is an encapsulated fat collection and it has a large lobules of fat within it. This suggests that this unique collection of facial fat may be metabolically different than other types of face or body fat. The role the buccal fat pad plays has never been precisely defined but it is not one of being a primary depot (collection) site for excess calories. This raises the question of whether buccal fat may offer advantages in fat transfer. (are the fat cells more hardy if transferred?)

Buccal Fat Pads for Lip Injections Dr Barry Eppley IndianapolisBuccal fat can be processed into an injectable form. The fat pads can be cut into small pieces and then passed slowly back and forth between syringes until it is in more of an emulsified form. It is then placed into one cc syringes for injection. One unique feature of this emulsified fat injectate is that it has a very linear smooth flow as it comes out of the syringe.

buccal fat lip injectionsThe quantity of fat that both buccal fat pads can provide is 10cc to 12ccs. This is more than adequate for many facial augmentation needs such as the lips and cheeks. Whether it may survive better than other fat is speculative. But because it does not require a liposuction harvest suggests that it might have a higher survival rate.

The main drawback to the use of buccal fat for fat injections is that the buccal lipectomy procedure must be concurrently done for an aesthetic purpose. Because it creates its own aesthetic effect buccal fat is not harvested only for convenience.

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

Fat Injections as a Scar Treatment

Sunday, January 29th, 2017

 

Scars are created by the reparative mechanisms of the body to heal a wound. The amount of scar tissue created varies based on a variety of factors. While effective at sealing and healing the wounds, the scar tissue is not normal and is not an exact replica of the tissue that it replaces or that surrounds it.

The surgical approach to scars is one basic method…cut it out and hope that less scar tissuemforms in its place. Or is some cases of scar revision a new line of closure is done so that it lays differently in the skin so that it may be less visible using the natural skin lines.

A newer approach to the treatment of scars is that of fat injections. The concept is to introduce new healthy cells (adipocytes, fibroblasts and some stem cells) that could potentially create new tissue that is more soft and supple. By breaking up the scar tissue and doing a secondary scar excision/revision if needed the scarred wound environment is changed. While this approach is theoretically appealing and there is lots of anecdotal clinical experience/results that provide support for its treatment benefits, the actual cellular biology of his approach is not well understood.

In the January 5th 2017 issue of the journal Science, an article was published entitled ‘Regeneration of Fat Cells from Myofibroblasts in Wound Healing’. In mice studies it was discovered that during wound healing fat cells (adipocytes) were regenerated from myofibroblasts. This was striking because scar tissue does not contain fat (or hair follicles) and that myofibroblasts are thought to be fully differentiated and incapable of being transformed into other types of cells. The myofibroblast is the most common cell type found in scars. Such myofibroblast reprogramming required hair follicles to trigger BMP signaling and subsequent activation of adipocyte transcription factors. Fat cells formed from human keloid fibroblasts when treated with either BMP or when placed with human hair follicle. Thus, the myofibroblast is a cell type that can be manipulated to treat scars in humans.

The theoretical benefits of these findings is that wound healing may be capable of being manipulated to create actual skin regeneration rather than scar tissue. Hair follicles have to be regenerated first after which fat can be formed. Factors are released from the hair follicles which causes myofibroblasts to create fat rather than scar tissue. The fat will not form without the new hairs, but once it does, the newly created fat gives the healed wound a natural appearance instead of leaving a scar.

Could drugs and treatment strategies be developed to turn myofibroblasts into fat and help wounds to heal without scarring? This is certainly the direction that this research suggests. Does this have any relevance to injecting fat into and around scarred tissues? Not exactly but treating early scar tissue formation with fat injections, as is commonly done today, may have a biologic basis after all.

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


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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