The History of Fat Grafting
Fat grafting has been part of the plastic surgeon’s armamentarium for more than 100 years. There are historical records of fat grafting going back quite a long ways. However, only recently have significant advances been made in fat grafting such that the fat grafts are reliable now and in the past year or two so that amazing transitions have occurred. When most people think of fat grafting they think of various movie actresses getting lips plumped up that look very very large. This is what happened in the 1980’s and early 1990’s when fat was harvested either as a piece of fat or as large chunks of fat and injected via a syringe of some type or a pump gun of some type into various parts of the body, most notably the lips. When we were doing fat grafting back then we told our patients that a certain amount of the fat would survive and live but a lot of it would melt away or resorb. About 15 or 20 years ago a plastic surgeon by the name of Sydney Coleman came along and revolutionized how we thought about fat grafting. What he said was we should think about fat grafting the way we think about grafting other tissues in the body. To understand this we have to understand what a graft is. A graft is defined as a piece of tissue that is moved from one location to another location without its own blood supply. It has to acquire a blood supply. i.e. blood vessels grow into it over a period of days or weeks. The most recognizable graft that most people know about is skin grafts. Plastic surgeons have various tools we use to take thin layers of skin and transpose them to other spots on the body usually for burn victims or perhaps for reconstruction after excision of skin cancers of the face. Very thin skin grafts usually have 95% or greater chance of surviving. However, their quality is not very good. Thicker skin grafts were we take the full thickness of the skin is a little bit harder to deal with but the quality is much better. The reason why a thin skin graft takes better than a full thickness skin graft is because in the first 5-6 days the grafted material, be it skin or fat or muscle or bone has to live on diffusion of oxygen in the local tissues. Therefore grafts are dependent upon the quality of bed that they lay in. It can be thought of as a framer putting seeds in a field – if the field is no good the seeds will not survive. So what Sydney Coleman figured out was that we were putting in grafts that were way too large. They were not able to acquire enough oxygen to survive because the oxygen couldn’t get into the depths of these globs of fat. So what he started doing was putting thin strips or thin rivulets of fat into the tissues and they were able to acquire a blood supply from their surrounding tissues, provided they were put in healthy tissue, and then they survived at a much higher rate. So nowadays most plastic surgeons put thin streams of fat when they are fat grafting to allow the tissue to have a much higher rate of survival.
Current Techniques of Fat Grafting
Today fat grafting is done either under local anesthesia or regional or general anesthesia depending upon the extent of the case and the magnitude of the case. We harvest the fat by injecting some solution much like we would do liposuction. We inject this solution within the tissues of the abdomen or the inner knee or the thigh. We make a small incision and we use a canula with small holes in it. The canula is attached to a syringe with gentle suction on it. This is compared to the higher pressure suction we use typically with traditional liposuction. As the tissue is withdrawn into the syringe it is withdrawn as small tiny little specs of fat. This differs remarkably with what was done even 3-4 years ago when we used a canula with larger holes in them. Essentially, the same canula we performed liposuction with but just the smaller gauge canula. Now, we use a very small canula with lots of small holes that withdraw fine little specs of fat. The idea being that when this fat is transposed to other parts of the body it will be a much smoother effect. The fat is then gathered and managed in a few different ways. Surgeons manage or handle their fat in different ways depending on personal preference. The research on this is still evolving. Typically in my practice I place the fat into test tubes and spin it in a centrifuge for a certain amount of time. The test tubes are then removed from the centrifuge, the oily layer and the plasma is separated to the top, the saline to the bottom and the fat is in the middle. We decant the top and bottom layer and just use the pure fat particles which are then loaded into 1cc syringes for fat grafting to the face or lips etc.. 10cc or even 30cc syringes are used for fat grafting to larger areas like the breast or the buttocks. Sometimes when we are doing fat grafting it is impractical to centrifuge 200cc’s – 400cc’s of fat. In those cases we allow the fat to settle in larger syringes and gently spin them by hand and then separate out the same components and inject it. This is typically used for the larger cases of buttocks and breasts.
Uses of Fat Grafts
Fat Grafting – The Face
The aging process causes a loss of turgor or firmness and plumpness to the face in men and women alike. When people come in with complaints that they just look old or haggard in the face we as plastic surgeons look at the quality of the skin, the elasticity of the skin, the texture of the skin, and perhaps the loss of volume in the face. Typically we think of plump as youthful. If you look at magazines or pictures of people when they are younger their tissues are plumper, firmer and fuller and as they get old they get a bit droopier and less full and lose volume. Adding micro fat grafting to the face or lips in conjunction with facelifts or by itself or in conjunction with laser resurfacing has become a fairly routine part of my practice. So for example it is very common to perform a fractional laser resurfacing to the face and then add some micro fat grafting to the eyebrows or the area just underneath the eyebrow laterally. Sometimes we fat graft the malar area or the lower orbital area and then often times we fat graft in the perioral area particularly in women who seem to lose a lot of fat in this area. Finally, fat grafting to the lips is a wonderful technique to plump up the lips without over doing it. Still, we occasionally get some re-sorption. They are a bit unpredictable but they are getting better and better. The results are quite gratifying and often very long lasting, as in “permanent”.
Fat Grafting Hands
One of the tell-tale signs of aging is the appearance of hands. Some people don’t really care about the appearance of their hands or their face for that matter. In a lot of people who seek out cosmetic surgery the appearance of their hands can become somewhat distressing as they age. A wonderful technique for making the hands looking more youthful is micro fat grafting to the dorsum of the hand. We use a tiny 1mm canula and inject fat in the subcutaneous space over the dorsum at the top of the hand were the veins and tendons and thin. Skin that was once problematic are, within one week, usually looking camouflaged and look very good. Dr. Coleman showed pictures at our recent meeting in Boston of patients 15 years out from fat grafting to the back of the hands and not only are the fat grafts still in place and look wonderful, the hands look like the hands of a lady 30-40 years younger than her stated age. In addition, there are some unbelievable side effects to the skin that we will talk about later on in this blog. This procedure is generally done under anesthesia as we are going to graft the whole back of the hand and it is a little bit uncomfortable to do with someone awake. So I prefer to do it when the patient is asleep. The operation usually takes total about 1 hour.
Fat Grafting Buttocks
The so called Brazilian Butt Lift is nothing more than fat graft to the buttocks. Fat may be taken from the abdomen or the hips during a typical liposuction procedure and then the fat is washed as we mentioned above. and settles. It is then placed in syringes and it is injected into the buttocks. We plan preoperatively where in the buttocks we would like to put it. We try and put these fat grafts deep into the buttocks in streams of fat so again it can gain an oxygen supply and ultimately a blood supply. Results can be very gratifying. For fat grafting to the buttocks you have to have enough fat someplace else for liposuction and often that is something that is not the case in a women who has a small or flattened buttock because they are often low body fat anyway. However, certain body types are amenable to fat grafting to the buttocks and it can be very gratifying. By the way, fat grafting injections are done through tiny little stab incisions that are totally un-noticeable after the wounds heal.
Fat Grafting Breasts
In the past year or two there have been quite a few articles coming out about fat grafting to the breasts. Years ago it was considered verging on malpractice to do fat grafting to the breasts. The reason for this was that fat grafting causes micro calcification in the fat grafts. Some pieces of fat die and calcium deposits form around these dead fat cells. The fear was that on future mammography it would be very difficult for the radiologist to determine what is a micro calcification from potential breast cancer vs. some fat that has turned into a small piece of calcium deposits. Many people today feel that the radiologists are quite confident that they can read one vs. the other. In addition, it is now routine to do the fat grafting in the subcutaneous space and underneath the breast gland and to avoid anything within the breast tissue. I think that there is still room for debate within this area because it is sometimes very difficult to fat graft and be sure you’re outside the plane of the breast tissue. In some women the breast tissue is very fat and it is frankly very difficult to tell whether you’re within the breast tissue or in the subcutaneous space. There are however some very unique areas within fat grafting for the breasts which I personally feel are conducive to consideration of fat grafting. I have used fat grafting for some patients with rippling medially despite having a silicone gel implants which usually produces minimal rippling. So the very slender lady that has a breast augmentation but still has a bit of rippling medially might be a good candidate to harvest the fat off of her tummy or buttock and fat graft perhaps 15-20cc’s to each breast through a small stab incision increasing the layer of subcutaneous fat just in that medial lateral breast to hide some rippling. I think this can be a very nice area for fat grafting rather than going into the pocket and replacing the implant or changing the architecture of the pocket or putting acellular dermis in these areas which is our typical techniques at this time.
The most amazing revelation in the past year or so in the area of fat grafting to the breasts has come in the area of total breast reconstruction with fat grafting. Dr. Khouri presented some amazing cases in Boston a few weeks ago at the American Society of Aesthetic Plastic Surgery meeting. He showed cases of patients who had mastectomies with a transverse scar across their breast and no excess skin who, over the course of the 3 treatments and perhaps 6 months to a year develop a fully reconstructed c-cup breast with no expanders, no implants, no flaps from the abdomen or back and no micro surgery. The results were soft and natural and simply unbelievable. The audience was astounded as he showed numerous cases like this. I think this is absolutely the future of breast reconstruction at least for a small segment of women who had enough adequate body fatty tissue to transpose to the breast. This technique of breast augmentation that some doctors are doing with fat tissue and breast re-construction with fat tissue require, in most cases, the use of an external suction device called the BRAVA device that is like a giant cup that fits over the breast. Suction is applied via machine for 10 hours a day for a few weeks to stretch out the skin envelope at which time the patient comes to surgery for fat grafting. This is probably the only downside of it. However, when one considers that we can do breast reconstruction without an implant and without an expander etc. this might turn out to be quite a useful technology to add to our tools for breast reconstruction.
Stem Cell Enriched Fat Grafts
Advertisements have been popping up around the country. One such advertisement that a friend showed me was from Miami, FL. A plastic surgeon was advertising ‘stem cell enriched face lifts’. So what is this all about? Well, it turns out that in the study of fat grafting we have discovered that the aspirated or the fat removed during liposuction has a very high content of stem cells. These stem cells can be concentrated and used in stem cell experimentation. About 5-6 years ago I was doing research with a scientist at NASA. She would come to my office immediately after liposuction to take my liposuction material for her stem cell research. Recently, our articles have shown that when we take the lipo aspirate or the material removed during liposuction and place it in a centrifuge, that the bottom ½ of that section of fat that I talked about earlier in this article is very high in stem cell concentration. It is this fat graft that is quite remarkable and has great promise but also potential unintended consequences in the future. Let me expound. First of all the plastic surgeon in Florida that I told you all about that is using stem cell enriched tissue that advertised a stem cell enriched facelift is doing Micro fat grafting of the face like many of us do but is aware of the extra stem cells in the fat grafting material and that is what he is advertising as a marketing device. The second interesting thing about stem cells is perhaps the effect it had on Dr. Sydney Coleman’s patients hands. What he showed was a close up of the quality of the skin and how it changed over 15 years. Remember, this patient was probably a mature patient when she first had the fat grafting to the back of her hands. Over the ensuing 15 years his close up photography showed remarkable transformation of that skin to that of a very young woman. Now this is not a randomized multi person study – this is just one patient and it could be in fact that she was using other agents on her hands to make them look more youthful. However, there is also speculation that these stem cells change the local nature of the skin and that is what we are studying further these days. Further, there is quite a bit of concern out there about what the effects of stem cells might be on breast tissue. Remember, breast tissue has a higher metabolic rate, a higher turnover rate and of course has the incidence of breast cancer. The question among some plastic surgeons out there is what’s going to happen in 10-15 years with breast tissue and can this increase breast cancer or some other malignancy within the breast tissue or at the surface of the subcutaneous tissue and the breast tissue were the fat grafts were placed? One might just say that the subcutaneous tissue is nothing more than a bunch of fat and we are just putting more fat in it so it’s difficult to know the exact answer.
Long Term Consequences of Fat Grafting
In addition to the possibility of stem cell induced malignancies, which we think is very small, there are other issues that one might consider when thinking about fat grafting. At this same meeting another surgeon presented pictures of several ladies that had undergone fat grafting some several years before and then proceeded to go through a cyclical weight change which they had a history of doing. These women gained between 20-50 pounds and suddenly their faces assumed a somewhat grotesque appearance with large bulging eyebrows and cheek and lip areas. We are unsure whether fat harvested from the knees or the abdomen behave differently, but certainly when a person gains weight all fat cells that survive will gain weight. Whether they gain weight differentially will depend upon were they come from – this is a question that we are still researching. Suffice it to say that these patients that this surgeon showed definitely had an unusual growth to these fat cells in the face. They were out of proportion with their local tissues of the face. In other words, their face didn’t just look a little bit chubbier. It was obvious areas where they had the fat grafting looked out of proportion with the rest of their face. In my own personal practice I think I will only do fat grafting to the face lips etc. in women that I am quite confident do not have this propensity for significant weight gain even though that might be unknown in some women.
Conclusions of Fat Grafting
Fat grafting is a very interesting area of plastic surgery that has been utilized for years and is being refined each and every day with newer and newer techniques and some remarkable research. I don’t think the final story has been written but it certainly is a nice adjunct in many patients for facial cosmetic surgery and for making the back of the hands look more youthful. In a limited number of patients we can use it for the buttocks and occasionally in small areas of the breast in my hands. I don’t think I will be doing wide spread breast augmentation with fat grafts unless there is looser tissue and a modest amount of subcutaneous fat and we are just going subcutaneously to augment the breast moderately.