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Archive for the ‘fat injections’ Category

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

OR Snapshots – Fat Injection Deltoid Augmentation

Sunday, November 6th, 2016

 

Implants are most commonly used for aesthetic augmentation of numerous muscle areas of the body. These include the chest (pectoral implants), calfs (calf implants), and buttocks. (gluteal implants) Less frequently performed, although no less successful, is that of the upper extremity of the biceps and triceps muscle.

One other muscular augmentation area of the upper extremity is that of the deltoid muscles. Known as the shoulder muscle, it is mass of three muscle bellies that provide width to the shoulders. While deltoid implants can be made from modifications to contoured carving blocks, it is a difficult area to get implant positioning from a remote incision.

fat-injection-deltoid-augmentation-dr-barry-eppley-indianapolisWhen possible deltoid augmentation should be initially attempted by fat injections. My experience has been that fat injected into the deltoid muscles has a decent rate of survival and retention. It also has the aesthetic benefit that its augmentation effect creates a broader surface area enhancement which is more comparable to the wider shoulder area.

Fat injection deltoid augmentation is done primarily subfascial and into the muscle. The subcutaneous tissues over the shoulder are usually fairly thin. All three deltoid muscle bellies should be injected. The usual fat volume injected is between 150cc to 300ccs per shoulder area.

Whether fat injection deltoid augmentation should be done over deltoid implants depends on how much fat the patient has to harvest. Because of the lower concentration rates of fat harvests in men, one should have at least 500cc to 750cc in harvest volume.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Injection Scar Treatments

Sunday, September 18th, 2016

 

The management of adherent scars or scar contractures are difficult problems. to improve. Like all scars the tissues are not normal and many scars have an actual tissue deficiency as part of their makeup. Traditional surgical approaches include excision, geometric skin rearrangements and skin grafting. Non-surgical injection treatments include steriods (Kenalog) and 5FU as a pharmacologic approach to soften the scar tissue.

Autologous fat grafting has become an extremely popular procedure for a wide variety of soft tissue augmentations. While the survival of the injected fat is far from an assured outcome, some fat take almost always occur. This technique has proven its worth in such pathologic conditions like irradiated tissue where it helps improve the quality of the tissues through improved blood flow and adding new tissue volume.

In the online edition of the September 2016 issue of Plastic and Reconstructive Surgery, an article was published entitled ‘Effectiveness of autologous fat grafting in adherent scars: results obtained by a comprehensive scar evaluation protocol’  In this report the authors study the effects of fat injections on adherent scars to determine if a single treatment of injected fat could create a functional sliding layer underneath the scar. Forty patients with adherent scars received fat injections and were measured before and at three months after the procedure. The primary outcome parameter was scar pliability as measured using the Cutometer device as well as patient and observer assessments. The Cutometer showed a 22% improvement in elasticity and a 15% improvement in maximal extension. Both patient and observes felt the scars were better. Color differences between the scar and normal skin did not change.

Many plastic surgeons have used fat injections to treat problematic scars and they have experienced variables level of improvement. Some have undoubtably seen cases of very good improvement as have I. This is the first study that has quantitatively documented the benefits of fat injections on this type of scar. The improvement in the scar undoubtably comes from some restoration of a tissue layer under the skin. (subcutis) Of equal interest is that this tissue response to the injected fat occurred after a single treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Grafting A Custom Skull Implant Visible Edge

Tuesday, May 10th, 2016

 

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Fat Injections for Chin Dimples

Sunday, May 1st, 2016

 

Chin dimples appear as a central circular depression on the soft tissue chin pad. They are differentiated from chin clefts which are vertical depressions of variable depths in the lower central chin pad going down to the lower level of the chin bone. It is believed that chin dimples occur because of a soft tissue defect in the underlying muscle and fat layer. Since the chin is formed by the midline union of brachial arches in utero, dimples represent some small area of failure to merge.

Chin dimples can be seen as an attractive facial feature (often to those who do not have them) or an undesired facial feature to those who do have them. Fortunately there are surgeries available to either create or reduce/eliminate chin dimples to satisfy either desire.

Over the years I have used numerous methods to remove the unwanted chin dimple. Injectable fillers are the simplest method to reduce an unwanted chin dimple but they are not permanent. The one permanent option would be the use of silicone oil injections (Silikon 1000) although it is not FDA approved for soft tissue augmentation.

Fat Injection Chinj Dimple technique skin release Dr Barry Eppley IndianapolisFat injections for chin dimple reduction are the mainstay of treatment today. They are both natural and have a chance for some permanence. The key in doing them is to do a needle release of all tissues under the chin dimple skin. Using an 18 gauge needle it is inserted centrally beyond its beveled edges. It is then rotated around 360 degrees  allowing the bevel edge of the needle to act like a small scalpel.

Fat Injection Chin Dimple technique fat injection Dr Barry Eppley IndianapolisOnce the soft tissue release is done, fat is injected using a 2mm blunt cannula. The cannula is inserted perpendicular to the skin entrance and directed down into the muscle. Fat is injected on withdrawal of the cannula slowly, making small .05ml deposits on the way back up to the skin. It is important to ‘stack’ the fat deposits so a maximum push on the dimple indentation occurs. Usually about .5ml to .9mls of fat are injected for small dimples and up to 2mls for larger ones.

Fat Injections to Chin Dimple result oblique view Dr Barry Eppley IndianapolisFat Injections to Chin Dimple result front view Dr Barry Eppley IndianapolisFat Injections for chin dimples usually accomplish a significant reduction although not a perfectly flat smooth skin surface. It may be necessary to perform a second fat injection treatment for optimal chin dimple correction/elimination.

Dr. Barry Eppley

Indianapolis, Indiana

Lip Fat Injections using Buccal Fat

Thursday, April 14th, 2016

 

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Fat Injection Breast Augmentation

Saturday, April 9th, 2016

 

Background: The consistent success of breast augmentation over the past five decades has been because of the stable volume provided by an implant. But breast implants are not perfect, are prone to failure and need to be replaced over one’s lifetime, For these reasons some women understandably would prefer a more natural breast augmentation method.

Increasing soft tissue volume by fat injection is now widely used for many face and body areas. The breast has not been excluded in the growing world of fat transplantation and, in conjunction with the buttocks, is the commonly fat injected area of the trunk for both aesthetic and reconstructive purposes.

While the appeal of fat graft augmentation is high for the breast, very few women actually qualify for it. Between limited or inadequate fat donor sites and the desire for breast augmentation size increases beyond what fat grafting can achieve, the number of women who undergo fat injection breast augmentation by fat injection is 1% or less of all women who undergo breast augmentation surgery.

Case Study: This 19 year-old female was bothered by some modest fullness of her abdomen and flanks and the small size of her breasts. While she did not want breast implants, she was interested in whatever breast size increase she could get by recycling her undesired fat from the abdomen and flanks to the breasts.

Fat Injection Breast Augmentation Indianapolis Plastic Surgeon Dr Barry EppleyFat INnjection Breast Augmentation Dr Barry Eppley Indianapolis_edited-1Under general anesthesia, her abdomen and flanks was harvested of 925cc of fat using a power-assisted liposuction device. The fat was processed by filtering and washing for a total concentrate of 360ccs. The breasts were injected with 180ccs per side.

Fat Injection Breast Augmentation result front view Dr Barry Eppley IndianapolisFat INjection Breast Augmentationk result oblique view Dr Barry Eppley IndianapolisFat Injection Breast Augmentation result side view Dr Barry Eppley IndianapolisWhen seen at three months after surgery, her breasts showed a very modest sustained size increase of about a 1/2 cup per breast. Her result is not equivalent to a 180cc breast implant due to some partial fat absorption.

Fat injection breast augmentation (FIBA) is always a gamble as the result is limited by both donor site availability and fat survival/retention. It is a procedure for those women whose greatest priority is on fat reduction body contouring and any secondary gain they can get in breast size increase.

Highlights:

1) Fat injection breast augmentation (FIBA) can produce a visible but modest increase in breast size.

2) The amount of fat that can be successfully added to the breasts is a function of how much fat one has to harvest and how much fat survives the transfer process.

3) The final breast volume obtained by fat transfer will be far less than what is extracted by liposuction.

Dr. Barry Eppley

Indianapolis, Indiana

Earlobe Fat Grafting

Thursday, March 24th, 2016

 

Earlobe Aging Dr Barry Eppley IndianapolisLike all other facial areas, the ear undergoes its own aging issues. The portion of the ear that is comprised of cartilage is rigid and undergoes little change throughout life. But the earlobe is different because it contains no structural support. It is composed only of skin and fat and is attached to the inferior end of the ear cartilaginous framework. As a result, it will undergo the typical signs of aging which is deflation (fat loss) and wrinkling of the skin. These two changes will also make the earlobe longer.

Fat grafting to the face is a well known strategy to manage loss of volume due to aging. While the earlobe is small, could it also be rejuvenated by fat injections?

In the March 2015 Advance Online Issue of the Aesthetic Surgery Jounral, the article entitled ‘Earlobe Rejuvenation: A Fat Grafting Technique’ was published. In this paper the authors assessed before and after results from twenty patients (40 earlobes) who had been treated by fat injections. The earlobes were assessed for volume, number of fine wrinkles and deep creases and total vertical earlobe length with an average followup of over two years. Earlobe fat grafting created improvements in the size of the earlobe and in the reduction of fine wrinkles. But no real improvements were sustained in vertical earlobe length and or deeper linear skin creases. No infections or skin healing problems were seen in any of the patients.

Far grafting has the advantages of being a natural material and one which can be placed virtually anywhere by injection. It remains unpredictable, however, in its survival and retention of volume. But it is well known to have some skin rejuvenation properties which presumably is greatest the more that the fat survives. The earlobe is a very small recipient tissue site so substantial fat graft would not be expected. But this study substantiates that some fat will survive and help provide a bit of rejuvenative effect.

Dr. Barry Eppley

Indianapolis, Indiana

Foot Fat Grafting for Chronic Pain

Wednesday, March 16th, 2016

 

Foot Fat Grafting for Chronic PainChronic foot pain of various causes is a not uncommon problem. Pain that emanates from the heel pad region of the foot is most frequently due to plantar fasciitis (bottom of the heel) and Achilles tendonitis. (back of the heel) While some heel pain problems resolve by conservative measures such as rest, shoe support, stretching and non-steroidal anti-inflammatory medications, others are unremitting and require more invasive treatment. The use of steroid injections and plantar fasciotomy surgery are traditional options when conservative therapies fail.

While the use of steroid injections and plantar fasciotomies are reported to have fairly high success rates, they are not complication free. Steroids are well known to cause soft tissue atrophy with repeated use or high dose injections. Plantar fasciotomies have the potential to cause flattening of the arch and heel numbness as well as rupture of the plantar fascia.

Fat pad atrophy is being recognized as a leading contributor to heel and ball of the foot chronic pain in some patients. The heel as well as the ball of the foot have specific fat pads that are separated and encased by fibrous bands. They help to absorb the shock on the foot bones that naturally occurs from walking and running. Thus the logic of good athletic foot wear with shock absorbing materials. But should the heel fad pad become thin or even mostly lost, pain will develop with the surface of the bones as well as the tendons and nerves now more exposed to being compressed between the bones and the surfaces that the bottom of the foot contacts. High levels of repetitive activity from running or cycling or overuse of steroid injections to treat chronic foot pain are common sources of fat pad atrophy. Diabetic, overweight and older patients are especially prone to fat pad atrophy

Centrifuged Fat Preparation for Fat Injections Dr Barry Eppley IndianapolisWith the widespread use of injection fat grafting today, it is no surprise that such transplantation into the foot to treat chronic pain from fat pad atrophy was inevitable. Like everywhere else in the body where it is used, the appeal of using your own tissues and the allure of its stem cells make foot fat grafting a logical treatment option. The placement of concentrated fat, usually harvested from the abdomen or thighs, using small blunt-tipped cannulas makes injecting into the foot incisionless and fairly risk free.

The heels and balls of the feet are unique places to inject fat, not only because of the tight tissue spaces, but because of the compressive forces that it will be exposed to after surgery.  Fat usually takes up to six weeks after surgery to determine how much survives. So avoiding athletic activities like running and cycling, high heels and long standing times should be avoided during the first month after surgery. Not all injected fat survives after any injection treatment but avoiding excessive trauma to the fat cells during the early transplantation period seems logical.

Fat Injections For Foot Rejuvenation Dr Barry Eppley IndianapolisFoot fat grafting is relatively new and has not been extensively studied or used to date. Whether the foot is a ‘favored’ or ‘disadvantaged’ for injected fat take is not precisely known. I know from personal experience that foot fat grafting into the toes web spaces works fairly well and is maintained. But whether the bottom of the`foot is equally favored remains unknown. Other important issues beyond survival with foot fat grafting is how well it works for pain reduction, how the fat may be distributed in the foot with chronic weight bearing and how well it sustains its volume over time These are other foot fat grafting issues are awaiting results from ongoing clinical and research studies.

Dr. Barry Eppley

Indianapolis, Indiana

An Enhanced Material for Eye Fat Injections

Saturday, March 5th, 2016

 

Aging around the eyes occurs just like that of the rest of the face through loss of volume and thinning of the skin with wrinkle formation. While a variety of well known surgical techniques are available to rejuvenate the eye area (blepharoplasty and browlifts), the use of eye fat injections  is still regarded as precarious by many surgeons. This is because fat injections are extremely prone to irregularities in the thin eyelid skin creating a high potential for an unsatisfactory aesthetic outcome.

Enhanced Nanofat Injections Dr Barry Eppley IndianapolisTo overcome the problem of lumps and irregularities in periorbital fat grafting, the use of ‘nanofat’ has been touted. The term nanofat is a bit of a misnomer as it is really the use of the liquid extract of concentrating fat leaving it devoid of alomost any viable or intact fat cells. Presumably the liquid nanofat contains stem cells although I have yet to see reports that has been proven by cell culture studies.

In the January/February 2016 issue of the JAMA Facial Plastic Surgery journal, an article was published entitled  ‘Fluid Fat Injection for Volume Restoration and Skin Regeneration of the Periocular Aesthetic Unit’. In this paper the authors describe their techinque for injecting fat around the eyes. They have named their eye fat injection technique superficial enhanced fluid fat injection. (SEFFI) With this technique they do not process the fat but rely on the small size of the side ports of the harvesting cannula to use only small fat lobules immersed in a stromal component. This fat extract is then mixed with platelet-rich plasma. (PRP) This admixture contains viable fat cells, adipose-derived stem cells derived from the stromal vascular fraction and the platelets from the PRP. The concentrate of PRP makes up 10% to 20% of the total mixture to be injected. This creates a fine yellow paste-like mixture that flows through smaller needles in a more linear fashion which dramatically reduces the risk of lumps or irregularities.

In the video accompanying the article, it shows an injection of the SEFFI material flowing easily through a 23-gauge needle with the consistency of a synthetic hyaluronic acid filler. The SEFFI material is injected into the brow and upper eyelid sulcus above the eyelid crease including at the apex of the A-deformity at the medial third of the upper eyelid. The lower eyelid is approached from its lateral side to correct the temporal depression at this level, and it is extended along the infraorbital hollow, the eyelid-cheek junction, and the tear trough just below the medial canthal tendon. Most of these eyelid areas would be off limits with traditional fat grafting due to the high risk of fat irregularities.

It is clear that improving the use of eye fat injections requires particulation of the traditional fat graft. Liquifying the fat and adding PRP makes both biologic and technique sense when injecting into this sensitive facial area.

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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