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Posts Tagged ‘fat grafting’

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

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

The Use of PRP in Fat Grafting

Monday, February 22nd, 2016

 

Injectable Fat-grafting, also known as lipofilling, has become a standard plastic surgery treatment in a wide variety of aesthetic and reconstructive needs of the face and body. Although technical improvements have increased the concentration of fat cells injected, the amount of fat graft survival is still unpredictable and far less than 100%.

Platelet Rich Plasma injections Indianapolis Dr Barry EppleyVarious methods have been suggested to increase graft take beyond mere concentration including the addition of adipocyte-derived stem cells (ADSC) or platelet rich plasma (PRP) to name the most common methods. How effective these fat graft supplements are, however, is speculative and has yet to be studied in any randomized clinical trials.

Beyond the volumetric enhancement observed after an injectable fat grafting procedure, skin rejuvenation benefits do occur such as improved skin elasticity and suppleness as well as reduced pore size. The presence of ADSC and PRP in a fat graft has been suggested to aid wound healing as well as produce tissue rejuvenation. These supplements achieve these improvements either by improved fat cell survival, stem cell conversion, or new blood vessel ingrowth through the effects of numerous growth factors. They influence the migration, proliferation and differentiation of several cell-types including endothelial cells for angiogenesis and fibroblasts for deposition of extracellular matrix.

Fat Graft Gravity Separation Dr Barry Eppley IndianapolisThe effects of PRP is probably most likely due to improved vascularization. It is generally accepted that the growth factors present in PRP stimulate wound healing, tissue remodeling and revascularization. Different concentrations of PRP have shown to induce varying effects on fibroblast and endothelial cells.  The ideal ratio of fat to PRP volume has not been established in human fat grafting. One would logically assume that  the more PRP the better. The maximum PRP that can be mixed into a fat graft is going to be a function of the size of the fat graft. In the face higher rations of PRP:fat graft are gong to be able to be obtained. Given that most disposable PRP-kits produce just 3 to 4 mls of PRP concentrate, the ratio could be anywhere from 5% to 15% in facial fat graft volumes of 10 to 35cc injectate.

Fat Graft Survival Indianapolis Dr Barry EppleySeveral cell culture studies have shown that PRP is a dose-dependent inducer of ADSCs with a two- to fivefold increase in cell numbers when compared to controls. Since increasing the number of ADSCs in a fat graft had been shown to have a positive effect on graft take, PRP offers a relatively simple method to do so. In larger body fat grafting (e.g., buttock augmentation), however, the ratio of PRP to fat graft volume is so low (< 1%) that it would have no effect.

Despite positive laboratory in vitro results of PRP in fat grafting, more recent clinical studies have failed to show a positive difference with its use on fat graft survival. Thus the use of PRP in fat grafting, while theoretically appealing, yet remains to show convincing clinical proof of its effectiveness. But its natural derivation as an extract of the patient and its simplicity of preparation will continue to have clinicians who believe in its science further its use in fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Injection Fat Grafting after Buttock Implants

Saturday, February 20th, 2016

 

Buttock augmentation can be done by two different methods. The most popular method today is the Brazilian Butt Lift (BBL), more generically known as fat injection buttock augmentation. It is popular because many people have excessive fat and this is a method of fat redistribution that creates improved body contours. Conversely buttock implants is less commonly done and with a longer recovery time.  It is reserved for those women who do not have enough fat for a BBL buttock augmentation procedure.

While often seen as an either/or approach, buttock implants and the Brazilian Butt Lift can be complementary to each other in certain patients. In women that do not have enough fat to harvest for a significant buttock augmentation effect, buttocks implants can be initially placed. Often this will be adequate for many patients. But for those buttock implants placed in the intramuscular location, the size limitations of the pocket or the lack of adequate lateral volume near the hip area may create a desire for a second stage fat injection treatment.

Fat Injections after Buttock Implants Dr Barry Eppley Indianapolis2nd Stage Fat Injections after Buttock Implants Dr Barry Eppley IndianapolisWhile the amount of fat a patient has may be inadequate for a full BBL procedure, most patients will have enough for a smaller contouring BBL procedure after buttock implants. A few hundred ccs of fat injected around the upper and outer perimeter of the buttock implants can create a fuller and more shapely buttock augmentation result. This is perfectly safe as the plane of the fat placement remains above the muscle and well away from the implant pocket.

Injecting around buttock implants that are above the muscle (subfascial plane) is a bit more treacherous. While fat injections can still be done, it is critically important the injected fat does not violate the implant capsule. If that should happen, there is a substantial risk of creating an implant infection.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Fat Grafting Chin Dimples

Tuesday, December 29th, 2015

 

Chin dimples are a not uncommon but anatomically perplexing facial feature. Sitting as a round central depression on the soft tissue chin pad, it serves no functional purpose other than a distinctive facial adornment. Like all facial dimples the cause has been shown to be caused by an underlying muscle deformity, specifically that of the mentalis muscle. Unlike its close cousin, the vertical or Y-shaped chin cleft, there is not an associated underlying bony deformity. Chin dimples and clefts are known to be an inherited trait on a dominant gene with variable penetrance.

The most common treatment to reduce or eliminate a chin dimple is by using an injectable filler. All of the commercially available injectable fillers can be used although their results will not be permanent. The use of silicone oil offers a permanent injection method although it is not FDA-approved for any facial augmentation procedure. Before placing any injectable filler a saline injection test should first be done to ensure that the dimple will be pushed out rather remaining indented and creating a ‘doughnut’ deformity.

Chin Dimple Release Dr Barry Eppley IndianapolisOne potentially permanent injection treatment option is that of fat grafting. Since injected fat is far more viscous than any injectable filler and does not have good linear flow, the bed into which it is injected should first be released. This can be done by using an 18 gauge needle placed in the center of the dimple and then rotating it around 360 degrees. The beveled edge of the needle will act like a small scalpel blade releasing the skin from its deeper attachments.

Chin Dimple Fat Injections Dr Barry Eppley IndianapolisOnce the chin dimple is released, a small amount of fat can be injected into the released subcutaneous space. This usually takes anywhere from .2ml to .5ml of concentrated fat. No one can predict with certainty how well injected fat takes so it is possible a second injection treatment may be needed. Three months should be allowed to pass to judge the retained injected fat volume.

There are alternative approaches to treating the chin dimple indentation done through an intraoral approach with muscle repair, but injection fat grafting offers a minimally invasive technique that has a high rate of success.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Fat Grafting after Breast Implant Removal

Tuesday, September 22nd, 2015

 

Background: Breast implants provide a volume enhancement to the breasts that in many cases will last a lifetime. While no breast implants last forever, most women choose to replace them when that need occurs. But a few women eventually choose to remove their breast implants due to problems such as capsular contracture, pain and implant failure. Usually this occurs in older women (age 60 plus) who have had first and second generation implants that have been in placed for thirty or forty years.

Very old breast implants are usually silicone and often have ruptured years ago. The breasts will feel firm and have some degree of capsular contracture. Due to their hardness they often are painful or at the least uncomfortable. Usually the breast tissue has also slide off of the hard and high implant so that some significant breast ptosis exists.

Removal of old ruptured breast implants and their capsules (not always necessary) is straightforward to do and will solve all of their associated symptoms. But the change in breast size/volume can be dramatic and may leave some women feeling that they have had a mastectomy. Immediate breast reconstruction with injectable fat grafting can hekp abate this loss.

Case Study: This 65 year old female wanted to have her breast implants. She had silicone implants placed 43 years ago which were above the muscle. They had always felt firm to her but after the few years they had become ‘tighter’ and more uncomfortable. A mammogram showed bilateral implant ruptures with surrounding calcifications. She wanted her implants removed but was not interested in a breast lift despite her sagging.

Fat Grafting to Breasts after Implant Removal intraop Dr Barry Eppley IndianapolisUnder general anesthesia, her ruptured breast implants and their capsules were removed through her original inframammary incision. The capsules were removed because they has a lot of calcifications and contained some silicone material. The breast tissue was sewn down to the pectoralis fascia. Using her abdomen as a donor area, 1400 ccs of fat aspirate was removed. The fat was concentrated down to 550ccs and 275cc was injected into the upper pole of both breasts to replace some of the lost volume from the implant removals.

Fat Grafting after Removal of 40 Year Old Breast Implants result front view Dr Barry Eppley IndianapolisFat Grafting after Removal of 40 Year Old Breast Implants result oblique view Dr Barry Eppley IndianapolisWhen seen at three months after surgery, the amount of retained fat in her breasts could be appreciated. While the amount of volume was not the same, it was better than that of the complete loss of all upper breast pole volume. In addition all of her breast pain was gone and her breasts were soft and comfortable.

Immediate fat grafting after breast implant removal offers a safe and effective method of subtotal volume replacement. It will not correct any breast sagging. If a lift is needed or desired, fat grafting will need to be deferred for three months afterwards.

Highlights:

1) Removal of breasts implants after decades of use will result in a significant loss of breast volume predominantly in the upper pole of the breasts.

2) Fat grafting at the time of breast implant removal can be done to prevent total collapse of the breast mound after implant removal if one has enough fat to harvest.

3) The focus of injectable fat grafting to the breast is in the central mound and upper pole of the breast which sits above the residual implant capsule.

Dr. Barry Eppley

Indianapolis, Indiana

Platelet-Rich Plasma (PRP) in Fat Grafting

Saturday, July 18th, 2015

 

Fat Injection Indianapolis Dr Barry EppleyFat grafting is one of the great innovations in plastic surgery of the past decade as a stand alone procedure or as a complement to many other plastic surgery procedures. As a natural graft material with usually good availability, it is an unrivaled aesthetic and reconstructive soft tissue reconstruction method. But despite its many attributes, fat grafting is not a completely reliable soft tissue creation method. Much investigation and study has gone into fat harvest and graft preparation and injection, but no universal method has been discovered that can consistently produce a consistently reliable graft take.

One fat graft preparation method that has been looked at over the years is the addition of a ‘priming’ or stimulating agent. The objective is to either improve how many of the intact transplanted fat cells will survive or increase conversion of the coincidental stem cells that are known to exist in fat to become new lipid-laden fat cells. Done years ago by mixing in insulin, today’s potential fat graft stimulator is platelet-rich plasma. (PRP) High concentrations of platelets would theoretically have a favorable effect on both adipocytes and stem cells.

Platelet Rich Plasma Injections Indianapolis Dr Barry EppleyPRP is a natural blood extract product that is rich in growth factors that have well documented effectiveness in wound healing. Through such growth factors as PDGF, TGF beta and VEGF, improved blood vessel ingrowth and deposition of extracellular matrix has been shown in many animal studies. Animal studies have also shown that PRP can improve fat graft take and reduce the formation of oil cysts most likely due to its revascularization effects. But despite the theory and animal research the use of PRP in fat grafting remains speculative with few clinical studies that have even investigated its potential effects.

Like any drug, the effects of PRP on fat would be expected to be dose dependent. Given that the average PRP volume extracted from a 20 to 60cc blood draw would be just a few ccs, its addition for example to a BBL (Brazilian Butt Lift) would be expected to have no effect on fat graft survival. In facial fat grafting, however, where graft volumes could be expected  to be between one and 50ccs, a few ccs of PRP would be more likely to be effective. Thus it likely all comes down to an expected concentration effect.

No one yet knows what the ratio of PRP to fat graft volume should be or would be expected to work. I currently operate on the theory that PRP should be used when the fat graft to PRP ratio is at least 10:1 or a 10% PRP composition volumetric ratio. Studies have shown that PRP may have its strongest effect on the differentiation of adipocyte-derived stem cells into fat cells. This may make the greatest contribution to final graft volume persistence. While vascular budding or endothelial sprouting may have a more minor effect.

The use of PRP in fat grafting (lipofilling) remains more theoretical than proven science. But the lack of any side effects with PRP allows for the its liberal clinical use and investigation.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Injection Fat Grafting for the Gynecomastia Crater Deformity

Saturday, June 27th, 2015

 

Background: Gynecomastia is a well known male chest abnormality that has a wide range of expression from puffy nipples to that of an actual breast mound.  It is treated by two basic approaches, liposuction and open excision. Which treatment method is sued depends on the size and tissue quality of the gynecomastia problem. Most commonly a combination of open excision through a lower areolar incision and more encompassing liposuction of the entire chest is done to get the optimal result.

The results of gynecomastia surgery is reflective of how much fat is removed and the evenness of its removal, regardless of the treatment method used. Both excision and liposuction are as much art as science as there is no way to know for sure as to how the tissue removal will ultimately look. While the plastic surgeon wants to get the most complete gynecomastia reduction, there is also the fear that too much tissue removed will cause the opposite problem. This would appear as an inward retraction of the nipple areolar complex known as the ‘gynecomastia crater deformity.’

While many early gynecomastia results may show a slight inward contour, these usually resolve on their own to a smoother appearance. But when excessive breast tissue is removed the inward retraction of the nipple-areolar complex becomes more obvious and pronounced as postoperative healing occurs. It is most manifest when one’s arms are raised as the adhesion between the underside the nipple-areolar complex and the pectoralis fascia causes a maximal retraction effect.

Case Study: This 38 year-old male had two prior gynecomastia reduction surgeries through an initial liposuction procedure followed by a secondary open excision procedure to get rid of some residual nipple puffiness. After the second procedure the nipples started to invert inward which became really evident with raising the arms. This continued to persist and did not change by six months after the second procedure.

Fat Injections for Gynecomastia Reduction Retractrion result front view Dr Barry Eppley IndianapolisUnder local anesthesia, fat was harvested from the lower abdominal area with small cannulas. It was concentrated by filtering and double washing into 40ccs. A small cannula was initially used to break up the scar and adhesions under the nipples and then fat was injected both under and around the nipple areolar complexes.

Fat Injections for Gynecomastia Reduction Retraction result oblique viewFat Injections for Gynecomastia Reduction Retraction result side viewAt three months after surgery his postoperative results showed improvement in the nipple areolar-chest contour and less nipple retraction. Fat take at this point would be assumed to be maximal. A second stage fat grafting is planned for further improvement.

When there is not an adequate buffer of tissue between the nipple and the pectoralis muscle, adhesion and scar contraction will occur. Correction of the gynecomastia crater deformity almost always requires release of the scar bands (adhesiolysis) and restoration of intervening tissue between the nipple and chest muscle. Injection fat grafting provides the easiest way to achieve both objectives. It could also be done through an open method using the lower areolar incision and placement of a dermal-fat graft. This approach poses more of a donor site harvest concern.

Highlights:

1) The gynecomastia crater deformity is caused by excessive breast tissue resection and scar contracture.

2) Gynecomastia defects can be successfully treated by injectable fat grafting which may require more than one session for optimal improvement of chest contour.

3) Injection fat grafting can be combined with PRP and Acell particles to optimize fat graft take.

Dr. Barry Eppley

Indianapolis, Indiana

The Safety of Injectable Fat Grafting

Monday, February 23rd, 2015

 

Fat grafting and its liposuction harvest has become mainstream in 2015 for both aesthetic and reconstructive plastic surgery needs. While ongoing clinical studies and experience will continue to evaluate its effectiveness, there is no debating that its use has become adopted by most plastic surgeons. Several of the reasons for its popularity is that most patients are adequate donors, it can be accessed by very familiar liposuction techniques, it is easy to process and inject, and can be injected just about anywhere on the body.

But one reason for its popularity is almost never discussed but is widely known amongst plastics…it is an injectable tissue graft that has few complications. No matter how well a graft or implant may work, it will never have widespread acceptance or use if it has a high rate of complications. While it has been acknowledged that human body is remarkably tolerant of processed fat loads, few studies have reported on it.

In the March 2015 issue of the Annal of Plastic Surgery journal, a paper was published entitled ‘ Autologous Fat Graft by Needle: Analysis of Complications After 1000 Patients’. The authors performed a retrospective study of 1000 consecutive fat transplantation at their hospital since 2005. Complications were determined and divided into either harvest site or recipient-site complications. Of the 1000 procedures, donor site complications were two hematomas (0.2%)  and eighty three contour deformities caused by liposuction. (8%) In the recipient sites, there were four infections. (0.4%) There was no skin necrosis in the grafted areas and no systemic complications from the harvest such as pulmonary embolism or deep venous thrombosis.

Liposuction Fat Aspirate Dr Barry Eppley IndianapolisIt can be seen that the overwhelming complications in injectable fat grafting is that from the liposuction harvest. These are contour deformities whose likelihood is based on how much fat is needed and how much needs to be injected. It is easy to see that large volume fat injections often require aggressive liposuction harvests and that is a setup for the creation of donor site irregularities. Often the liposuction harvest for fat grafting is viewed differently than the liposuction for aesthetic body contouring. It is important to not trade-off one aesthetic problem for another.

The very low complications in the recipient site show that injectable fat grafting has a very high safety level. I am surprised that using a needle to inject the fat did not have a few more minor complications due its sharp edges. I have long ago abandoned needles for injection and replaced them with blunt tipped cannula with side injection ports.

Dr. Barry Eppley

Indianapolis, Indiana

Dermal-Fat Grafts in Coccydynia

Monday, October 27th, 2014

 

Dermal Fat Grafts in Coccydynia Dr Barry Eppley IndianapolisThe tail bone is well known bony structure at the end of the spine. Known as the coccyx (Greek word for cuckoo), it gets its name due its beak-like appearance due to the bend in the fused vertebrae which make up its bony length. It usually is convex on the back side and concave on the stomach side. It does attach to the sacrum through muscular and fascial attachments and can be a fixed attachment or actually that of a true joint where it joins to the sacrum.

Pain in the tailbone (coccyx) is known as coccydynia. There are a wide variety of reasons  one can have coccygeal pain that is not due to trauma. (e.g., fractured coccyx or dislocation at an intercoccygeal joint) Chronic sitting is one reason which can put pressure on the coccyx causing a strain. One may be more prone to coccygeal strain if overweight causing a posterior subluxation of the coccyx. Conversely, if one is very thin with little subcutaneous fat to protect the bone it may develop bony spicules due to chronic pressure. Interestingly, coccydynia occurs much more frequently in women by a reported four to five times greater frequency than in men.

Treatments for coccydynia are usually non-surgical in nature including oral medications, protective cushioning and local anesthetic injections. When all else fails, surgical coccygectomy can be done but this is associated with significant after surgery discomfort and a prolonged recovery.

Dermal Fat Graft to Coccyx Indianapolis Dr Barry EppleyDermal Fat Graft to Coccyx Dr Barry Eppley IndianapolisAn alternative surgical option is a dermal-fat graft. Rather than removing the coccygeal bone, adding a protective tissue layer for additional cushioning is an option in very thin people. A dermal-fat graft can be harvested from any abdominal scar or from making a small low horizontal abdominal incision. (like that of a c-section) Using a small vertical incision (no greater than 3 cms) a subcutaneous tunnel is made right over the coccyx. The dermal-fat graft is placed into the tunnel and the skin closed over it.

Dermal-fat grafts have a great propensity for a high take rate if they are not unduly large. They quickly become revascularized and incorporated into the surrounding tissue. By adding an additional fat layer over the coccyx, a cushioning effect can be obtained. In the properly selected coccydynia patient who has a very thin soft tissue cover over the coccyx, adding a dermal-fat graft can help alleviate chronic discomfort.

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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