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Dr. Barry Eppley

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Archive for the ‘stem cells’ Category

The Role of Stem Cells in Injectable Fat Grafting

Sunday, February 20th, 2011

The continuing evolution of fat grafting in plastic surgery has seen it become more dependable as well as new applications being developed. Popular target areas for fat grafting have focused on the face, breast, and buttocks. Some equate fat injections to that of synthetic injectable fillers. But beyond their injectability, there are used for entirely different purposes. Fat grafting is for larger volume problems and are used in the hope they provide some more permanent effect.

Fat grafting is not the equivalent of typical injectable fillers. Instead, it is less stiff and behaves more like a liquid…it has little substantative pushing effect on a specific tissue site. That is why if you try and use injected fat to lift up or diminish a fold or wrinkle, it does not work very well. Regardless of whether it even survives, it does not have a focused displacement effect. For areas that are very adherent, such as deep creases, folds, and lines, it just can not efface them. These commonly perceived areas of fat injections have high failure rates and that experience contributed to the perception that injected fat doesn’t work very well. Fat injections are best used as a volume fillers for the treatment of facial contour areas.

The biggest reason that fat grafting has become more accepted today is technology. Advances in harvest methods and processing (concentration) are the two main areas of improvement. Less traumatic harvesting methods that enable better quality fat to be obtained creates fat tissue that even looks better. Getting rid of extraneous liquids and debris, whether it be centrifugation or less powered purification methods, creates a more homogenous injectate material.

But the one thing that has really tipped the balance to wider acceptance and usage is that of stem cells. The realization that high concentrations of stem cells reside in fat has raised the potential that they can be used for better volume preservation and even promote healing in difficult wounds. The stem cell has been given magical properties even though whether it really has any benefit to a fat injection is far from an established medical fact. Many anectodal claims are being made about skin quality improvement and anti-aging tissue effects. While the science has yet to provide proven support of these observations, the potential of it has propelled injectable fat transplantation into one of the hottest topics in all of plastic surgery today. Once scourned and held in disrepute by most plastic surgeons, fat grafting today has undergone a complete reversal of medical acceptance…and the well known stem cell is helping it along.

In performing fat injections into the face and hands, I have observed some changes in the quality of the skin overlying grafted fat.  Sun-damaged and aging skin seems to improve in some patients (I didn’t say all patients) more than one would anticipate  just from the push of the volume from the fat under the skin alone. This newly injected fat appears to be contributing to improved healing into the areas where it is injected. From breast lumpectomy defects to facial scars, there does appear to be some healing benefits. Research suggests that these positive effects on the skin may be from exogenous factors from stem cells. Since fat has the greatest number of stem cells of any tissue in the adult human body, their potential influence is likely. The presumed effect is that they promote earlier and more abundant blood vessel growth into the surrounding and overlying tissues. This has been shown to be true when fat is injected under skin with severe radiation damage. With a new or more normal blood supply, severely radiation damaged skin becomes healthier.

How the stem cells in fat grafts may contribute to better volume preservation is more speculative. Earlier revascularization may play a role in helping some of the mature and intact fat cells survive the transplantation process. Stem cell conversation may also play a role. Once known as merely preadipocytes, some stem cells may be induced to differentiate into fat cells. That may explain the observation that injected fat volume may go down early on after surgery only to rebound months later.

Even though injectable fat grafting is rapidly becoming a common procedure in plastic surgery, there are a lot of very important questions we need to answer before we can conclude it is all that it is being touted. Currently, the marketing of it sometimes exceeds what is scientifically known about it. (e.g., stem cell facelift) We need to learn the optimal way of processing fat tissue and we really need to get some accurate information about how long fat grafts last. Much of the clinical work being presented  lacks quantifiable measurement. The good news is that injectable fat grafting is perfectly safe, we just don’t know yet the extent of its benefits or for what problems it is most effective.

 Dr. Barry Eppley

Indianapolis, Indiana

Stem Cell Facelifts – Science or Science Fiction?

Friday, November 5th, 2010

The long known presence of stem cells in fathas led to an exciting wave of scientific and clinical efforts to harness the potential of this ‘wonder’ cell.The real question is wondering what benefits stem cells can really offer.Why do we have cells that lie around dormant in our fat but yet has the potential to turn into any type of cell and grow new tissues if properly stimulated? The reason must be as a reserve for new tissue regeneration should that be needed.

Given the ease from which fat can be extracted through liposuction, whole new uses are being derived for what may be capable with stem cell-derived fat grafting. (SCFG) Fat is being injected all over the body by plastic surgeons, mainly because it is easy to do and perfectly safe. Injected fat has many body uses from body contouring to facial rejuvenation. For the body, buttock augmentation and breast reconstruction (lumpectomy defects) are being widely done. Fat breast augmentations are being approached more cautiously but is gaining some momentum also. The other good body use is that of hand rejuvenation, using the injected fat to fill hollows between the extensor tendons and to camouflage prominent veins.

The face, however, is the most widely implanted body part for fat injections. More recent research in facial aging has shown that we loss fat in our face as we age. This facial deflation is one of the reasons that we look old and contributes to skin sagging. This has led to younger people getting fat injections at an early age and fat injections being used as part of a facelift procedure for more advanced degrees of facial aging.

In the most contemporary spin of fat grafting to the face comes the Stem Cell Face Lift. The concept is that stem-rich fat grafts combined with skin tightening makes for a better facelift result. Proponents claim that the patient’s own stem cells provide a regenerative effect that gives a significantly better end result in face lift procedures with longer lasting results and has a youthful restorative effect on one’s skin. The skin is claimed to be changed with smaller pore size and less wrinkles and pigmentation.

While controversial, this newer Stem Cell Facelift uses an activation process that is believed to activate the stem cells once they are injected with the fat. While laying dormant in the fat donor site, they may only be beneficial if they are brought to life in their transplanted location. Various stimulation methods are being proposed including the addition of chemical stimulants and even low-level laser light therapy. This newer process is to be differentiated from just plain old fat grafting to the face (which is not that old) by applying amethod to trigger and activate the stem cells either during or after the fat transfer. It is claimed that patients receiving fat injections alone done the traditional way, without the advantage of activation, will see little to none of the actual stem cell’s regenerative effects on the face and skin.

How is a Stem Cell facelift done? A typical facelift operation is an outpatient procedure done in around two to three hours or longer if other facial procedures are done with it. The fat is removed by liposuction from a favorable location, usually the stomach from inside the bellybutton. The harvested fat is then concentrated and purified. Prior to injection it is “activated” or enhancers are added. My current method is to add a mixture of PRP (a platelet-rich concentrate) and Matristem collagen matrix. PRP is obtained as a blood extract from the patient once they are asleep. The high concentration of growth factors in platelets, is a known potent source of cell stimulation. Matristem is an extracellular matrix which comes in a powder form and is an off-the-shelf product. Mixed in with the concentrated fat graft, it adds a potential source of collagen stimulation and matrix onto which stem cells may attach and proliferate. Once all the elements of this elixir are obtained and mixed together as the final step, the fat is then selectively injected and the facelift completed.

With all of this being said, is the Stem Cell Facelift actual science or more science fiction? Is it hype or hope? At this point I would say a little of both. The real scientists of stem cells would most certainly tell us that the use of stem cells isn’t that simple. While stem cells have been extensively studied and their properties recognized, how to harness their potential and make them work is far less clear. While moving them from one place to another in the body just seems like it should work doesn’t make it so. This is the principle of what I call a ‘trueism’ . A trueism is anything on the surface that just seems so logical and natural that it is obvious that it works or is true. The problem with trueisms is that most of them, on closer inspection over time, are shown to be not true at all. Stem cells and their effects on facial aging has the potential to be a great example of a trueism. They certainly are associated now with a lot of hype.

Conversely, the hopeful part of a Stem Cell Facelift is that it is a perfectly natural procedure that has no harmful effects, an almost organic procedure if you will. It is all the patient’s own tissues and may exemplify the appealing concept of ‘heal thyself’. Because one’s own cells are being used (recycled?), it is not a procedure that requires FDA approval or that of any governing medical organization. (so don’t be misled that it is an FDA-approved procedure or technique) At the worst, one gets the benefit of fat grafting whether the stem cells really become alive or not. And the use of fat grafts to the face with our current appreciation of what happens as our face ages is a proven benefit.

Dr. Barry Eppley

Indianapolis Indiana

Fat Injections and Stem Cells in Plastic Surgery – Hype or Hope?

Monday, October 18th, 2010

The use of the words ‘stem cell’ and ‘reconstructive surgery’ is a charismatic combination that brings to mind a simple and seemingly obvious biologic solution. With the knowledge that fat cells are an excellent source of adult stem cells and liposuction is an easy way to get them, the procedure of lipofilling or fat-stem cell injections is irresistible. This has prompteda wide range of purported stem cell procedures in plastic surgery from breast reconstruction to facelifts. The unfiltered dumping of promotional ‘stem cell’ procedures on the internet has understandably galvanized the public, sometimes traveling afar to get these procedures.

But despite the simplicity of reprocessing fat from one body location to another, the science offat grafting and the stem cells that it carries is extremely complex and very poorly understood. While stem cells in the laboratory in a petri dish can be reliably studied and quantified, what happens in human tissues is still largely unknown. I suspect the science of stem cell transplantation will one day be the equivalent of a complex chess game compared to the simple ‘checkers’ of the blood coagulation cascade.

In normal human tissues, which is the best of circumstances, we have trouble getting injected fat grafts to reliably survive and maintain volume. Numerous gurus in plastic surgery tout that the success of fat injections is technique-based and, if certain recipes are followed, good results are sure to follow. There certainly is merit in concentration processing and careful placement of the fat into the donor site but these steps are not the complete answer. Every plastic surgeon who has ever done fat injections in any numbers have had lips and faces which deflated rather quickly or whose buttocks never got much of a sustained augmented result. Technique accounts for some of these failed results but it can’t account for them all. I suspect that if an honest survey was done of plastic surgeons who have done fat injections, and they had actual long-term follow-up, the successes would still be dwarfed by the volumetric failures at this point in time.

With successful fat injection grafting, is it the fat cells which survive, the conversion of the adult stem cells, or some combination of both? Almost assuredly it is some combination of both but the why and how is unclear. One factor that appears to be critically important is the site of injection and the extracellular matrix (ECM) into which it is placed. The ECM of the donor site has been shown to have a very strong influence on the ultimate cellular behavior of the injected cells. In cosmetic applications, the ECM of the donor sites are almost always normal.

But what of that of damaged tissues where the ECM is clearly altered or abnormal? The irradiated breast lumpectomy site is a prime example. The collagen and the blood vessels in the tissues are scarred and less prone to normal healing. Yet anectodal reports and a few reported clinical series show an improved tissue quality and some volume retention even in the face of an abnormal ECM.

Fat grafting and the stem cells it may contain is going to continue to find expanded clinical uses. The appeal of an autogenous or natural solution to both cosmetic and reconstructive tissue problems is just too great. The axiom of ‘Body…Heal Thyself’ just seems like it should work, whether one views that from a biologic or religious perspective. My hope is that the fat/stem cell therapies today do not become the failed hype of the growth factor science from twenty years ago where much scientific effort has resulted in just a few scant healing products.

From a patient’s perspective, it is important to realize that fat grafting by injection today may contain stem cells, but it is not a true stem cell treatment…at least not just yet. Their presence in the injected fat is an ‘incidental’ by product of the process. What they do and whether they are of benefit may be good medicine by default. When touted as a ‘stem cell therapy’ however is purely promotional and is bad medicine by intent.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Grafts and Stem Cells – Exciting Potential for Plastic Surgery

Friday, October 23rd, 2009

The idea of using one’s own tissue to heal thyself has been a romantic medical goal for decades. Plastic surgeons have long employed this approach by moving body parts around beginning with skin grafts a century ago to microvascular tissue transfers more recently. But taking individual cells and having them grow or turn into new tissues in a human body is far more challenging. Such an approach, however, is a hot topic of almost all medical specialties today.

Because of plastic surgeons’ familiarity with fat, from composite grafts to liposuction, the use of autologous fat-derived adult stem cells is being looked at for many medical applications. Plastic surgeons are interested in its promise for cosmetic face, breast, and hand rejuvenation, post-lumpectomy breast reconstruction, as well as in the repair of burned or irradiated tissues. But their use is promising for other medical areas as well  including the treatment of damaged heart tissue, salvage of diabetic and poorly vascularized limbs, and maybe even to grow new bone or nerves.

In the recent issue of Plastic Surgery News, an article looked at the impact plastic surgeons involved in stem cell research are having in this frontier area of medical research. From a basic science standpoint, there is no question that fat contains a lot of stem cells and isolating them in a petri dish has not been difficult. How to implant them, have them survive, and turn into the type of tissue you want are the hot beds of fat-derived stem cell research. Delivery and activation are the keys. Most feel that a biodegradable scaffold or matrix is needed although current clinical work employs the fat itself as the carrier and matrix. Its simplicity is appealing but unproven as the optimal method. Much of the biology of fat stem cells is more theoretical than proven as of yet. No one knows the long-term safety of using these cells or even if they are capable in humans of turning into the tissues that one wants. Despite the amount of scientific activity that is ongoing, more rigorous studies of any proposed techniques are needed.

From a clinical standpoint, fat injections (which presumably contain viable stem cells) has been going on for nearly a decade. For facial volumetric augmentation, fat is almost the gold standard and appears to work reasonably well. Although the take and maintenance of the graft is variable based on what part of the face is treated. Some are touting ‘stem cell facelifts’ but this is marketing getting way ahead of the science. Its use in breast reconstruction is in its infancy with mixed early reviews. For small lumpectomy defects, it shows real promise. But the limits of volume prevent total breast reconstruction or any near approximation. The use of external stimulation for the grafts through the Brava system, although somewhat cumbersome, is a novel approach that likely stimulates implanted cells. Irradiated skin of the breast or face shows significant improvement by fat grafting through a revascularization effect with resulting improved overlying skin quality. A novel approach to Dupuytren’s contracture is the use of percutaneous needle release and fat grafting. The injected fat appears to prevent the released ligament from meeting up again and the needle ligament incisions eliminates the long recovery from the traditional open approach.

One of the biggest issues with fat grafting is the lack of standardization of donor site, preparation, and injection techniques. Because different fat grafting methods are used by various plastic surgeons for a wide range of applications, it  becomes difficult, if not impossible, to know the exact biologic effects that fat grafts are causing. And why in many cases they don’t work as expected or hoped. Even in my own Indianapolis plastic surgery practice, I will often mix PRP (platelet-rich plasma) with fat grafts in the theoretical belief that the higher concentration of growth factors will improve graft take through cellular stimulation.. But is this hope or reality? This alchemy concept only further muddies fat and stem cell’s unknown science.    

The potential to treat certain plastic surgery problems in a less invasive manner, using the body to heal itself so to speak, is in some ways an almost holistic approach. While this stretches the definition of holistic medicine, fat grafting and stem cell applications will ultimately define a niche in medicine. It will certainly change the approach that plastic surgeons take to some of our aesthetic and reconstructive problems. It is just going to take more time and scientific effort to reap the benefits of current ongoing work.

Dr. Barry Eppley

Indianapolis, Indiana 


Stem Cell-Enhanced Fat Grafts for Facial Rejuvenation

Tuesday, September 29th, 2009

The use of fat has long been thought of by plastic surgeons as an ideal injection material for facial augmentation and rejuvenation. With no chance of rejection and more than an adequate amount of usable graft available from almost every patient, its appeal continues to grow. It s biggest drawback, however, is that it is unpredictable with uncertainty about its long-term permanence.

Because the injected fat must quickly acquire a new blood supply to survive, the use of large amounts of injected fat during a single session are particularly prone to postoperative resorption. Hence, the concept of a technique known as Structural Fat Grafting or microfat grafting. With this well known process, small amounts of fat through many small injection tracks to gradually build up the desired volume.  Because each injection deposits only  a small amount, it is easier for new blood vessels to grow into it more thoroughly resulting in more fat that persists.   

While structural fat grafting is a technical improvement, there is still a need for further advancements. For the past few years, the stem cells in fat have become an area of interest. Researchers have been developing methods to process fat so that the fragile stem cells in fat can survive the transplantation process. One experimental method has been to  separating out these stem cells and than add them to a fat graft where they can become differentiated and grow into fat cells, replacing those fat cells which will not survive the grafting process. This is a method of supercharging an injectable fat graft.  Several manufacturers  either have or are developing equipment that does exactly that.

The emergence of many non-surgical options for facial rejuvenation, such as Botox and injectable fillers, makes for good improvement and they can easily done. But these results are not permanent and must be repeated. Enter the concept of more predictable fat grafting. Some have called the integration of stem cells and fat grafting a “Stem Cell-Enhanced Facelift”. By removing fat from the patient’s body,  processing it in a special way, and then injecting it back into the same person’s face, some surgeons claim that the results are both natural looking but skin quality and tone is improved. The supposition is that the growth factors contained in the implanted  cells stimulate some degree of skin renewal.

 While the concept of a knife-free facelift done under local anesthesia with a short downtime and long lasting results is still largely a dream for most, certain facial rejuvenation patients may benefit. Loss of facial volume and certain wrinkles on an aging face may use stem cell – enhanced fat injections. (lips, nasolabial fold, lateral facial volume loss) During a traditional facelift, fat injections can build up other needed facial areas which are not addressed by the removal of skin laxity.

Barry L. Eppley, M.D., D.M.D.

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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