Archive for the 'fat' Category
While now nine different synthetic injectable fillers exist for the cosmetic treatment of facial lines and wrinkles, none of them are permanent. As they are all artificially-created materials, the body will eventually absorb or break them down so their plumping effect dissipates with time. Fat from your own body remains as a very appealing injectable filler material with its own set of advantages and disadvantages.
Because fat is taken from your own body, it will never be rejected or cause any type of foreign-body reaction issues. But although it is your own tissue, its survival after being transferred to a new site by injection is not a sure thing. In fact, the unreliability of fat injection volume retention has plagued its use for over 50 years. Today we have learned and use certain techniques that help improve how well fat survives after it is harvested and injected. One thing that is certain is that the face does better with fat graft survival than the rest of the body. This is because that smaller volumes of fat are needed and injected which gives it a better chance of regaining a blood supply and surviving. Also, the face has a very robust blood supply (better than from the neck down) which makes more blood vessels available (and hence oxygen) to starving fat cells struggling to survive.
An interesting study on facial fat grafting and how well it survives was published in the July 2008 issue of Aesthetic Surgery Journal from Spain. In this study, 26 patients with HIV disease were treated with fat injections. HIV-positive patients were chosen as they usually have severe facial wasting (fat loss) which makes determining how fat grafts have survived easier to measure as little surrounding natural fat tissue remains. By CT scanning and computer measurements, they were able to show that a persistent (out to one year) change in the amount of facial fat present after the injections was maintained. This is particularly significant given that the HIV patient is challenging for a fat graft to survive over time given that their retroviral drug regimen had already destroyed the patient’s natural fat.
Despite the appeal of fat injection grafting, it does have several disadvantages. First and foremost, it can not be placed into lines and wrinkles in the skin. Fat grafts are thick viscous materials that have to be injected through fairly large needles. All of the synthetic injectable fillers are materials whichi flow easily through very small needles. Therefore, fat grafts must be injected under the skin which makes them good for adding volume and plumping facial areas. Like the synthetic innjectable fillers, they can be used for lip and cheek-lip groove augmentation. But they should not be thought of as lines and wrinkles treatments since they can not be placed directly into the skin. Secondly, fat grafts are not ‘off-the-shelf’ injectable fillers. They require fat to be harvested, processed, and then injected. This entire process must be done in a sterile manner, which means that they can not be done in the typical office setting most of the time. Because of this consideration, I usually use fat grafts when the patient is having other surgery and we can take advantage of the operating room environment. Outside of having surgery, I will use synthetic injectable fillers in the office setting when no recovery and an instantaneous result is most important to the patient.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Despite the more recent public awareness of fat removal by liposuction and fat injections for volume addition in the past 20 years, the use of fat in plastic surgery has been around for over 50 years. The history of liposuction dates back to the early 20th century with the famous first case of unsuccessful liposuction in a ballerina who subsequently lost her leg. Necessary improvements in liposuction techniques made it an everyday procedure in the United States by the mid-1980s. Fat transfer or transplantation work by the famous plastic surgeon Dr Peer in the 1950s started by establishing that big pieces of fat don’t survive as well as small ones. The important concept of the need for blood vessels to grow into the transplanted fat as fast as possible for survival was established by this first experimental work.
As we sit here today, what do we know about fat transplantation? Certain aspects of fat transfer do work well and have been used for years. The ‘old’ dermal-fat graft, while completely unknown to the public in general, is still a reliable method for correcting small contour problems or acting as an interface to thicken up some areas. Its problem is that it results in a scar from the harvest (must take skin and a thin layer of fat) so this is only good if you already have a scar somewhere or the scar is more ‘tolerable’ if the procedure is being done for reconstructive purposes rather than purely cosmetic. Small whole pieces of fat can work well but you have to again get the ‘chunks’ from somewhere (scars) and you then have to get it in where you need it. (possibly more scars?) So, these whole fat grafting methods can reliably work but their uses are more limited due to scarring.
Fat injections today remain, by far, more widely done than whole fat methods because they cause little if any scarring and their placement can be more precise……even if they do not work as well. Despite what is frequently touted, fat injections are unpredictable in how much actually ‘takes’. That is why overcorrection is always done. Why do they not always work well? The harvest of the fat, through liposuction, dices it into many minute pieces and kills some of the fat cells. Therefore, what is injected is some portion of liquid fat that will simply be resorbed. While we strain the fat obtained by liposuction, and this helps get rid of loose liquid and blood, and makes it more ‘concentrated’, there still is ‘dead’ fat in the concentrate. What we have not mastered, yet, is how to make those fat cells that survive this hazardous journey grow in their new home, rather than merely survive.
Recent scientific work and interest has been in the awareness that stem cells, which in theory can grow into any type tissue, are in great numbers in fat tissue. Why do these not grow after being injected with fat into more fat? Perhaps we have just not found the right trigger yet….whether it be a drug to mix with it or the type of fat injected.
The beauty of fat injections, despite their unpredictability, is that they are generally safe, easy to do (in the operating room), and the availability is plentiful in most patients. As plastic surgeons, we will continue to work with fat and I am confident one day we will turn it into a more reliable soft tissue filler.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
As a plastic surgeon, I certainly am asked and do treat a lot of fat concerns. Whether it be liposuction treatments for fat removal or fat injections for adding volume somewhere, plastic surgeons probably handle more fat than any other medical specialty. Yet, we still do not understand much of its physiology and its response to treatments that we routinuely do.
In looking around at a lot of fat in the body, we do know that it is not all the same. Nor is its functions similar. Most patients think of fat as an unnecessary evil and that its only purpose is to store excess fat and be a source of annoyance and embarrassment. While many fat areas in the body are indeed ‘depot’ areas. Many other fat areas, however, are not. For example, fat in the cheek and temple area (the buccal fat pad) is not a depot area but is intended to serve as buffer between the jaw muscles and allow them to glide smoothly and not interfere with each other. Why the buccal fat pad, for example, goes away in the HIV patient due to the antiviral medications (and fat forms on the back of the neck…the buffalo hump deformity) is not understood at all. For the sake of simplicity in patient consultations, I divide fat into depot and non-depot sites. (although not entirely scientifically accurate) So when a patient asks me, for example, during a liposuction consult if the fat will come back, my answer is…..if it is removed frm a depot site such as the stomach, then if you gain weight after surgery it may most likely come back….if fat is removed from a non-depot site, such as the inner knees or neck, it is much less likely to do so.
Fat transplantation, or fat injections, also remain a somewhat unpredictable procedure. The procedure is very appealing because it is your own natural tissue but, unfortunately, that does not mean that it always survives well (and maintains volume) after surgery. Much effort has been put into doing the obvious, such as minimizing the trauma to the fat by the way it is extracted and prepared to be injected as well as how it is placed. But, yet, how well it works is still unpredictable. We know even less about whether where it comes from (stomach vs. knee, for example) makes any difference in how well it works.
Fat, despite its preponderence and ever-presence, still has mysteries that remain to be unlocked. Fat is a hot research topic now because of the stem cell load that it carries. It is better than bone marrow in this regard as there is more of it and it is easier to get out. No one has ever thought of fat before as being a healing tissue. I frequently wonder as I watch a cannister of fat fill up during a liposuction procedure…..as to what potential benefits we may be throwing away.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
htp://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
As a plastic surgeon, I get the ‘oportunity’ to see lots of fat-related concerns and, in the new world of bariatric plastic surgery, get to see patients who either still are or were obese prior to their bariatric bypass surgery. Looking at fat excesses, and I have to assume that the average U.S. citizen is fatter today than 10 or 20 years ago (that is what every report I have read on the subject says), it appear overly simplistic to assume that the problem is one as basic as too much in, too little out…..or to put it another way….someone’s weight problem is merely a function of greed and sloth. This is fairly well recognized today as much greater credence is given presently to the concept that I grew up with known as a ‘glandular’ problem. Today we refer to it as a genetic predisposition or a familial tendency towards weight gain. But even accepting that premise (which I believe has a lot of truth) still does not seem to explain the great diversity of body types one sees and how they respond to their lifestyle. I see lots of hospital employees , for example. who carry a gallon of water with them every day and purportedly eat very little but never loose a lot of weight. And then there are others who pretty much eat what they want and yet remain fairly trim.
In reading Michael Hanlon’s book, ‘10 Quyestions Science Can’t Answer (Yet)’, he reports a fascinating study as a spin-off to the movie Supersize Me in which the journalist Morgan Spurlock ate nothing but from a McDonald’s menu for several weeks. His weight gain and other ailments are well chronicled including the onset of incipient liver disease. In 2006, that ‘experiment’ was repeated in sweden under more controlled circumstances using 18 volunteers. While all subjects gained weight, they did in surprising variable amounts and some gained very little. Some subjects cholesterol levels actually dropped! And none developed the elevated liver enzymes until much later in the study. (one month in duration) What does this prove? At the least it suggests that increased fatness, if you will, is more than just calories. It a complex interaction of diet, genetics, intestinal absorption capacity, and probably something in the fat cells themselves that has yet to be described.
As I look at the tremendous variability in body types that I see everyday, and listen to the complaints of patients who have valiantly tried to reduce body areas they do not like (contrary to popular belief, we really don’t see a lot of tremendously overweight people for body contouring surgery), I have come to realize that for many of them their ‘problem’ is really a surgical one. Nothing short of sucking out or cutting off of the excess can really make a difference for them. Diet and exercise certainly helps but is not the final solution for many.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medcal Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
‘Indianapolis