Fat Grafting

One of the most exciting and promising areas in plastic surgery today is the use of a patient’s own fat to replace lost volume resulting from facial aging, for increasing breast volume and to correct other deficient areas of the body. Recently, there has been an increased awareness of the potential of using fat over facial fillers. Currently available fillers for the most part are artificial, have limited life expectancy and in some cases may result in increased scar formation. A patient’s own fat, however, is completely natural, and the portion that takes after grafting is believed to last for years – perhaps for the rest of the patient’s life.

This also makes fat a very appealing choice for increasing breast volume, both in reconstruction and cosmetic enlargement. Fat is being used to correct soft tissue deformities resulting from trauma and poorly performed liposuction. Fat can also be used to restore the thin, wrinkled appearance of aging hands. In addition to the benefit of restoring volume, it turns out that our fat is one of the richest sources of stem cells in the body – in fact, fat has been shown to contain 500 times more stem cells than bone marrow. The benefits of these stem cells are rapidly being revealed through ongoing research. Each area of potential use of fat will be explored in detail.    

Fat As a Facial Filler

Over the past few years, plastic surgeons have become aware of the fact that aging is much more than loss of elasticity of the skin of the face and neck. It turns out that as we age, our faces lose volume from changes in our facial bones, but perhaps more importantly, from an actual loss of volume of the fat in our faces. Youthful faces are full, and as we age we begin to see hollowing around the eyes, loss of volume of the cheeks and temples. In the past, surgeons seeing the laxity resulting from this deflation sought to correct the resulting aged appearance by lifting and tightening the skin through brow and facelifts. This resulted in unnatural appearing surgical results – the drawn, too tight and unnatural appearance of many facelift surgeries. As a result of the appreciation of the need for restoring volume, I am finding that I need to do less surgical “tightening” and am doing more restoring of volume with fat and achieving much more natural results.  Another benefit of fat grafting in the face is that we see improved quality of the skin overlying the grafted areas. This most likely is due to a “stem cell effect” but more research needs to be done to verify this.

The future for fat grafting for the face is exciting, and I truly believe we will see more and more restoring of facial volume with fat in the near future. It is critically important, however, that the facial fat grafting be done with the best known practices of harvesting, processing and most importantly, precise, artistic delivery of the fat to achieve the most natural appearance. It is important that patients be sure the person doing their surgery is board certified by the American Board of Plastic Surgery or the American Board of Facial Plastic and Reconstructive Surgery. Also, it is important that the surgeon they are considering has significant experience in fat grafting and should be willing and able to show before and after pictures of their own patients to demonstrate their expertise in this very challenging area of cosmetic surgery.

Fat Grafting of the Breast

I am very excited about the use of fat to restore volume to the breast both for cosmetic augmentation or enlargement and for breast reconstruction as well. My initial experience was to use fat for salvage cases of breast reconstruction resulting from cancer surgery as well as from bad results from cosmetic breast surgery. The use of a patient’s own fat has proven invaluable to restore soft tissue volume and to correct deformities of the breast resulting from mastectomy, radiation or complications of cosmetic breast surgery. Amazingly, when autologous (from the patient) fat is used we see not only a restoration of soft-tissue volume, but an improvement in the quality and texture of the overlying skin as well.

Incredibly, the injection of autologous fat grafts into irradiated breast tissue has consistently been shown to improve not only the appearance of the irradiated skin, but has led to improved sensation in the skin flaps of the reconstructed breast as well. This is most likely due to the effect of the stem cells contained within the fat tissue that is injected. Some of the stem cells have been shown to secrete a variety of growth factors, including ones that increase the development of new blood vessels.

Breast Augmentation From Fat

We are now able to do cosmetic breast enlargement using a patient’s own fat rather than a saline or silicone filled breast implant. Initially, we needed to do two or maybe even three surgical procedures to achieve a reasonable increase in volume. Now, through the use of the Brava device, we are able to achieve a 1- 1 ½ cup-size increase for many patents in a single surgical procedure. The Brava device currently has FDA approval for non-surgical breast enlargement. A few individual surgeons led by the inventor of the device, Dr. Roger Khouri, are using the Brava device as a pre-conditioning tool to expand the amount of tissue available to place fat grafts into. This allows more total fat to be placed in a single session, hopefully obviating the need for a second procedure. Typically the Brava device must be worn for six hours per day for three weeks before the fat grafting surgery. We anticipate that two-thirds of the volume of fat that is grafted will remain. Thus, for example, if we place 450cc of grafted fat we would anticipate a retained volume of 300cc’s of fat.

Having Lipoaugmentation of the breast to increase breast volume offers many advantages over conventional implant augmentation. There is no concern about implant failure and the need for additional surgery and expense in future years to replace an implant. The breast feels completely soft and natural when fat is used to provide volume and in addition, more volume can be placed in the exact areas where volume is desired, say at the top of the breast or in the cleavage area. Radiologists who have looked at the mammograms of patients who have fat grafting are not having any problem reading them, which is an important safety issue. The final important advantage of lipoaugmentation is that the patient gets liposuction of a problem area in addition to enlarging her breast – a win-win. Lipoaugmentation is the ultimate “green” plastic surgery – we are recycling your fat!

Here are links to two Brava videos on YouTube. Part II explains how to start and put on the Brava device. Part III illustrates removal of the Brava.

Video Part II          

Video Part III             

Fat Grafting To Other Areas

In addition to the face and breast, we have used fat grafting to correct volume loss in many other areas such as the abdomen and thighs, arms and hands. We unfortunately have patients come to us who have had poorly done liposuction where too much fat was removed – leaving depressions. Also, we see patients who have had traumas or surgical procedures that resulted in soft tissue defects or deformities. Fat is often the only good cosmetic answer to correct these problems.

Lipofilling of the back of the hands gives excellent correction of the crepey, thin skin that occurs with aging, revealing prominent veins. This aged appearance of the hands often gives away the real age of someone who has had excellent surgical correction of the aging face. The quality of the skin actually improves as well.

Stem Cells and Fat

In addition to the many benefits fat offers from a simple volume replacement, it turns out that fat is an incredibly rich source of stem cells. In fact, many of the benefits we see after fat grafting such as improved appearance of the skin quality, correction of radiation effects, improved sensation in areas that had lost some or all sensation is likely attributable to the effects of stem cells and the growth factors they secrete. Much research is currently being conducted, and I am actively participating in research with Dr. Keith March at the Indiana University School of Medicine, who is one of the world’s leading experts on adipose derived stem cells. Much more can be learned about the potential benefits of these cell based therapies at http://www.celltherapyfoundation.org/