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Archive for the ‘fat injections’ Category

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

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


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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