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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘stem cells’

Stem Cells and PRP in Plastic Surgery – Anti-Aging Hope or Hype?

Sunday, July 14th, 2013


Some have said that the power to slow down aging or to ‘heal thineself’ does not come from some external source such as potion or pills but from within. This has led to the popularity of two natural materials derived from blood and fat. Stem cells (in fat) and platelets are located throughout the body and can be relatively easily harvested and prepared into an injectable form. This permits them to delivered into almost any body site to create either improved healing or a tissue enhancement effect. This has enabled such autologous injections to be used for a wide variety of medical applications including aesthetic and anti-aging applications.

The use of embryonic stem cells in numerous medical diseases is controversial. But the use of adult stem cells for their potential cosmetic and anti-aging effects is not open to as much criticism as there does not seem currently to be much downside. The debate with their use is whether they can live up to the hype. Numerous anectodal claims are made about such injections as creating youthfulness, adding permanent tissue volume and improving the appearance of the skin. This has led to a number of procedures being touted, particularly on the internet, with such names as stem cell facelifts and stem cell-enriched fat grafts. The names suggests that they are better than the traditional procedures.

But stem cell injections in plastic surgery today are, most of the time, fat injections that undoubtably contain stem cells but in what quantity and what activity is completely unknown. Although not cleared by the FDA for this use, there are machines available that can process fat to get a stem cell concentrate which can be injected. The problem with fat-derived stem cells is no one knows for sure what happens when they are injected or if there are any significant adverse effects long-term from doing so. It is reasonably assured that fat injections are completely harmless and that stem cell injections are similarly so, but that is a long way from being shown to be absolutely so.

Conversely, evidence that stem cell injections have any positive anti-aging effects by themselves has not yet been forthcoming. There is no doubt that the promise of stem cells is great in terms of potential tissue regeneration and some observable anti-aging effects on the skin. But there is very little data from human clinical studies that currently support any of the hype or marketing claims some doctors make. Injecting stem cells under the skin has not been proven to improve the appearance of the overlying skin. (fat injections are more promising based on the volume addition) The clinical results to date are isolated case presentations and subjective observations and substantial research is still needed to figure out the potential of stem cells. Thus for now, stem cell injections like stem cell containing skin serums, must be viewed as suspect.

Unlike stem cells, the positive effects of platelets on healing is more established. Wound healing is known to be mediated by a complex array of cellular and protein and peptide interactions. Platelets play a major role in this process. Platelet-rich plasma (PRP) is blood plasma that has a high concentration of platelets due to processing techniques. During the procedure, about 60cc of blood is removed from the patient and and the PRP concentrate is then obtained by a centrifugation process. This creates a few ccs of concentrated platelets (platelet plug) that can be added to a variety of plastic surgery procedures to theoretically improve their results. Due to its platelet contents, PRP contains many different growth factors and cytokines that have potent cellular and tissue stimulation effects.

While PRP can be used alone as an injection, its small quantity (usually about 3ccs) lends itself to be mixed or combined with other materials as part of the injectate. These could include fat or, more commonly, synthetic injectable fillers. There are several commercial aesthetic products which do just that with marketed brand names such as Selphyl and the Vampire Facelift. These products create either a platelet-rich fibrin matrix or are mixed or done right after the placement of such well known fillers as Juvederm and Restylane. The benefits of PRP in these facial rejuvenation techniques, while appealing, has not been fully substantiated in widespread clinical use and ongoing patient treatments continue to evaluate what role concentrated platelets may provide for volume retention and any other anti-aging benefits.

Stem cells and PRP are naturally derived products but that does not necessarily confer that more of them in one spot will be better than what we have residing in our bodies now. Their appeal is undeniable but that has not proven just yet that their benefits are equally so.

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

Stem Cell-Enhanced Fat Injections for Breast Reconstruction and Augmentation

Friday, June 19th, 2009

While fat grafting has a long history in plastic surgery, its use as an injectable filling material is much more recent. Fat injections today are a well recognized technique for use in the face, hands, and buttock for soft tissue filling and augmentation. Fat injections into the breast have historically been much more controversial due to a higher rate of perceived complications and potential interference with breast diagnoses. However, improved fat purification and more refined injection techniques have eliminated most of these concerns.

Fat injections for the reconstruction of breast lumpectomy defects has been shown to improve the appearance of the breast and can help tissue damaged by radiation. In addition to filling out breast lumpectomy defects, plastic surgeons that I have talked to who are familiar with using it report that the breast can become softer and the overlying damaged skin can appear changed closer to normal. All of this occurs presumably to the fat and its contained stem cells which can promote the growth of a better blood supply in the radiated area of the breast and aids in reversing the effects of radiation damage.While the science awaits as to how fat injections work in detail, a revascularization effect is clearly a part of it.

Fat has been shown to contain stem cells, thought previously to be most prevalent in the bone marrow. Fat appears to contain at least as many stem cells per volume,  if not more, than bone marrow. Therefore, stem cell-enhanced fat injections may be a more accurate description of what we are doing. By harvesting and concentrating fat by centrifugation (or even sieve filtering), we are concentrating the stem cell/fat ratio which improves the potential interaction between the harvested fat cells and those cells of the tissues into which it is injected. Whether it is stimulatory chemical factors that are released from the stem cells or the creation of new cells from stem cell differentiation, or both, is not known and remains to be elucidated by further research.

One fear about this ‘natural’ use of stem cell therapy is that the stem cells themselves pose a risk to the breast by potentially turning into cancer cells. This result has never been shown and it is fair to say that stem cells injected into the breast are no more likely to turn cancerous than anywhere else in the body. A stem cell injected into breast (connective tissue) will follow local tissue signals and differentiate into new connective tissue.

While the optimal methods to concentrate or stimulate stem cells for fat injections into the breast (and elsewhere)is not precisely known, there are several methods that I currently use in my Indianapolis plastic surgery practice. Centrifuging liposuction-harvested fat is a standard technique. This is probably better than simple filtering and is only slightly more difficult to do. I also like to add platelet-rich plasma (PRP) concentrate (from 60cc of the patient’s blood) to the final fat aliquot to produce a ‘super-charged’ type of fat injection.While this is a bit of an alchemy or cocktail approach, there is pretty good science for fat concentration and PRP methods. It is only logical to assume that the combination is likely better than either one alone.

While fat injection in breast reconstruction is fairly accepted both for lumpectomy and around breast implants, cosmetic use of fat injections to the breast is just coming into vogue. At this time, there are numerous good clinical studies and experiences about the use of fat for breast augmentation . How to make it the most effective, however, needs further scientific and clinical study.

Dr. Barry Eppley

Indianapolis, Indiana

The Future of Injectable Filler Treatments

Wednesday, September 17th, 2008

The current popularity of injectable treatments is based on placing synthetically-derived compounds and drugs into and under our skin. At best, these are well tolerated agents that create their effect and then are gone after a relatively short period of time. The future of injectable cosmetic treatments will likely be somewhat different. And we are getting a glimpse of that potential paradigm shift right now.


Spurred by the discovery in the 1990s that fat contains a rich supply of cells similar to the stem cells found in bone marrow , developments and techniques to use stem cells from fat for injectable cosmetic and reconstructive procedures is being worked on around the world. A stem cell is a cell from which other types of cells develop and they lie in a resting state amidst many of our tissues. Fat has proven to be a rich source of stem cell populations. The theory behind this new injectable approach is that fat may be processed or handled in a way that allows the stem cells to create a blood supply for the transplant that helps the fat survive after injection. Or perhaps have the stem cells convert after injection into fat cells to replace those regular fat cells which did not survive the transfer process. During a single operation, fat is obtained by liposuction from the stomach or thigh for example and then processed using a special technique.. The ‘treated’ fat is then injected into the desired area. Because the patient is the donor, there is no risk of tissue rejection. This concept is being used in other parts of the world right now for breast augmentation and small breast reconstructions. I currently use a similar approach for my fat injections for cosmetic facial improvements and for those patients who desire buttock augmentation with fat grafts rather than a synthetic implant.


Botox® and synthetic injectable fillers are here to stay and will be the backbone of office and non-invasive cosmetic treatments of the face for years to come. The use of one’s own fat remains theoretically appealing, however, and current research suggests that it will ultimately have a slice in the injectable ‘pie’ in the near future. Because it involves more effort and costs, it role will always be more limited than off-the-shelf products. But its rich source of stem cells and its lack of any rejection issues makes fat a filler material worth working on.


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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