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Dr. Barry Eppley

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Posts Tagged ‘stem cell injections’

Nanofat Grafting for Skin Rejuvenation

Saturday, October 26th, 2013


Fat grafting has been around for over fifty years but has reached present day popularity due to the introduction of liposuction for harvest, droplet injection techniques and the discovery of adipose-derived stem cells. Fat injection grafting is mainly used to create more volume in the face and body for a variety of aesthetic and reconstructive conditions.

As fat injection therapies have evolved, the techniques for injections have gotten more refined using smaller injection cannulas and the placement of smaller fat particles. This is called microfat grafting and is useful for small structures like the eyelids, lips and even large wrinkles or folds. But fat grafting can be taken down to even a smaller level which has been called nanofat grafting. With this method, the fat must first be emulsifed into a pure liquid and then injected with needles or cannulas as small as 27 gauge.

While nanofat grafting is possible, what actually is in the liquid fat and how well does it work? In the October 2013 issue of Plastic and Reconstructive Surgery, the article entitled ‘Nanofat Grafting: Basic Research and Clinical Applications’ provided insights into these questions. In comparing typical lipoaspirate (macrofat), microfat and nanofat, no viable fat cells were seen in the nanograft. Nanografts had a high level of stem cells in which culturing them showed proliferation and differentiation capabilities. Nanofat grafting was performed in 67 cases of facial wrinkles, scars and dark lower eyelids. The clinical results showed good improvement in skin quality without any side effects or complications.

Nanofat grafting is a new concept that takes injections down to small structures and with an injectate which contains few intact fat cells. With a reduced number of viable fat cells, it would have limited use as a volumizing treatment. But as this paper has shown, its use appears to be a treatment option to improve skin quality. (skin rejuvenation) Improvement in skin quality is a well known by product of fat injections and is presumed to occur through increased collagen production and remodeling triggered by the grafted stem cells. Since nanografts have few fat cells in it due to the mechanical preparation process, its cellular component is the stromal vascular fraction of the graft which includes      a substantial number of mesenchymal stem cells.

The location for nanofat grafting is placement into the intradermal level of the skin to improve its quality. The effects of these injections appear to take months to see. Because its effects are probably due to stem cell activity, it may not really be appropriate to call it a fat graft at all. It appears to be more of a poor man’s tissue engineered treatment that is made without expensive and time-consuming equipment. How effective it is can not be completely determined from this one paper, but the concept has merit for more widespread clinical use.

Dr. Barry Eppley

Indianapolis, Indiana

Stem Cell and Fat Concentrates For Plastic Surgery and Anti-Aging Therapies

Saturday, October 15th, 2011

The use of stem cells in medicine has garnered much media and public attention. Because it is a natural component of human tissues and it is a pluripotent cell that has the capability of converting to many different adult cell types, it holds much promise for numerous medical therapies. While the quest for which medical diseases stem cells offers the best benefit is being investigated with much fervor, there is no question that anti-aging conditions are one logical application.

While not a disease in the truest sense, aging is a natural medical condition  that is degenerative of both cells and the substrates in which they exist. The use of stem cells and the factors that they may excrete would seem like they could offer some regenerative effects on one’s external appearance. Thinning and wrinkled skin, atrophy of fat and supportive connective tissues, and restoration of face and body contours have the potential to be enhanced with adjunctive stem cell techniques.

The promulgation of stem cells to the forefront of anti-aging treatments has been driven by the realization of their easy access. While stem cells have traditionally been thought of as existing largely in bone marrow, it is now known that fat is the richest source of adult stem cells. Estimates are that fat has 300 to 500 times more stem cells than bone marrow. Given that fat can be quickly harvested through liposuction, the acquisition of stem cells is now easy.

While plastic surgeons have trued numerous methods of isolating stem cells at the time of their harvest, the present reality is that it is not easy to obtain really true concentrates of them. Most so-called stem-cell therapies today in plastic surgery are nothing more than concentrated fat injections. While these fat injections do contain some stem cells, calling them stem cell injections or stem-cell enhanced fat injections is a stretch and more of a marketing concept that it is a true stem cell therapy.

To obtain stem cell in sufficient numbers from fat, it requires that they be isolated, grown and processed in laboratory conditions. It was only a question of time before a commercial laboratory became available to provide this service for plastic surgery and anti-aging applications. Cryo-Lip, a bio-tech startup laboratory based in Indianapolis, is now offering the service of cryopreservation of adipose-derived stem cells, fat, or both. It is now possible that patients and plastic surgeons can not only obtain viable stem cell concentrates but can have them stored and grown for future use.

While liposuction surgery is an obvious source of fat to be processed, it can also be done when one is not desiring body contour changes. The amount of fat needed for processing is in the range of between 25 to 50ml which can be obtained using a patented syringe system under local anesthesia in the office if desired. The sample is then sent to Cryo-Lip for processing and storage. The average turnaround time to obtain injectable materials is two weeks. The samples can be sent as either a fat or concentrated mesenchymal stem cell mixture. The existence of viable stem cells is confirmed by testing and analysis before being sent. If not an adequate number of viable stem cells is present in the sample, the provider is informed and the tissue is discarded at no charge to the patient.

The now easy access to stem cell concentrates allows them to be used for numerous potential cosmetic and regenerative medicine uses. Some of the well known current applications include their adjunctive use with fat for lipofilling for facial volume restoration and breast and buttock augmentation. When used as isolated stem cell concentrate injections, they have potential use for facial skin rejuvenation, wrinkle reduction and fold and crease filling.     

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 and Stem Cell Injections for Breast Lumpectomy Defects

Tuesday, April 21st, 2009
Lumpectomies for the treatment of breast cancer is an increasing method of therapy that spares much of the breast. With earlier detection of breast cancer today, less invasive and better breast conservation is now commonplace. Lumpectomies, however, leave indentations and crater-like dents after the cancerous tissue has been removed. Because of the size and location of lumpectomy defects, the traditional use of breast implants for reconstruction may not always result in a satisfactory solution. Other autologous methods of breast reconstruction such as  muscle and skin-fat flaps may be too big of an operation for the problem with donor scars that are undesired. Recent work around the world  has led to a new and less invasive method of breast reconstruction for lumpectomy defects. Provided adequate breast skin is present, filling the space where the breast tissue was removed can restore areas of indentations and collapse. Using cosmetic liposuction techniques, fat cells are harvested , stem cells extracted from the fat, and a combination of stem cells and purified fat is injected into the breast defect.

This innovative, but not completely proven, treatment is based on the awareness that subcutaneous fat is a rich source of stem cells. Stems cells are pluripotent cells that can be theoretically stimulated to turn into new fat cells. (perhaps this is what happens from crash dieting and then rebound weight gain?) Fat is suctioned, usually from the abdomen or hips, and the stem cells are then isolated through a centrifugation method. The extracted stem cells are then mixed in with the remaining fat and injected it into the breast lumpectomy defect.site. The hope is that the use of stem cells will help keep the transplanted fat alive…or become fat cells themselves. Either way, the volume of injected material remains because it becomes living tissue.

The American Society of Plastic Surgery has issued a specific position paper on the use of injected fat into the breast. In summary, they state the its use and the final results are affected by a lot of different factors, particularly the technique used to harvest, concentrate, mix, and ultimately inject into the breast. The procedure is highly operator dependent. It use in the breast is lacking sufficient scientific studies to determine long-term effectiveness. The decision to use fat injections in the breast is one to be decided between patient and their plastic surgeon.

The use of fat injections, with or without stem cells, has a lot of use and recent history for facial and buttock augmentation. In my Indianapolis plastic surgery practice, my experience with stem cell concentrates is limited but I have often used platelet-rich plasma (PRP) with fat to enhance survival. The combination of cleaned and purified fat, stem cells, and PRP would be the ultimate therapeutic cocktail. This may be a bit of an alchemist’s approach, but all the components are autologous and would cause no harm. The goal is how to optimize fat graft survival and maintain volume. I am confident that both PRP and stem cell additions are useful but the question is which one of the two is better. At present, this is unknown.


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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