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Early pioneer describes autologous fat transfers

San Antonio — After three decades, the cosmetic profession is finally starting to sit up and take notice of autologous fat transfers, according to plastic surgeon Tolbert Wilkinson, M.D., F.A.C.S.

"The topic is very popular right now," he tells Cosmetic Surgery Times. "In the last several years, we've had presentations at national meetings. Before that, proposals were always turned down."

According to Dr. Wilkinson, the sudden interest is due to a number of factors. Compared to commercial products, indigenous fat has a significant price advantage. If you run out, you can get more adipose from the midriff or thighs. And the immune system isn't likely to protest the transplant.

In short, fat grafting is convenient, quick, safe and cheap. It's also reversible. Because cells are fragile in the first month following transfer, physicians can crush and reverse the graft, if, for example, a patient decides she doesn't like the look of bee-stung lips.

Otherwise, the transfers are remarkably durable.

"I have grafts that are still working after 15 to 20 years," Dr. Wilkinson says.

Refining the procedure Dr. Wilkinson, a San Antonio-based plastic surgeon, has authored several books, including the Atlas of Liposuction, which includes a chapter on fat return surgery. His experience with the procedure dates back several decades.

"Initially," he says, "we couldn't make it work, because we were doing it incorrectly — forcing fat into spaces where it wouldn't fit. Around 1984, we had the first successful grafts, filling large dimples. They were done by Brazilians."

"We had the procedure pretty much nailed down by 1987, but people didn't get the idea. They thought fat grafts were an injection and forced damaged cells into areas where there wasn't enough space," he explains.

Dr. Wilkinson strives to keep the procedure simple. After removing fat from the midriff or jowl, he concentrates it by placing it on a pad to let it drain.

"In the past," he says, "we centrifuged. Now we just add 10 percent more fat."

Next, he places the adipose in a delivery gun, and, after undermining, makes three to four tunnels at different depths, injecting as he withdraws. He does not use the micro-droplet or threading technique. It takes much longer, without improving results.

The newest procedural improvement — dating to 1997 — is the use of exterior ultrasound. When directed at the jowl or body to improve extraction, melt fat or reduce swelling, it produces the incidental benefit of tightening.

"After five years' experience with the exterior ultrasound, we're not seeing the same problems of fat destruction caused by Thermage®. The energy delivery is deep to the dermis, not to the surface," he explains.

Expanding uses Dr. Wilkinson cites small ear lobes, crumpled chins, tear troughs, depressions under the cheekbone, nasolabial lines, wrinkles in the chin and between the nose and lip, and frown lines as problems cosmetic surgeons are correcting with fat grafts.

In correcting glabellar furrows, he inserts an instrument through a pinhole in the scalp to shred the muscles, weakening but not paralyzing them. He then elevates the furrows to better fill the area.

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