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The future of fat

The most recent American Society of Plastic Surgery (ASPS) statistics suggest fat grafting is a plastic surgery trend. In 2016, minimally invasive cosmetic fat injections went up by 13%; buttock augmentation using fat grafting rose 26% and breast augmentation using fat grafting shot up 72%, compared to 2015, according to ASPS.

Dr. Johnson“[Fat Transfer] has become part and parcel of many plastic surgeons' practices,” says ASPS President and Sacramento, Calif., plastic surgeon Debra Johnson, M.D. “It is incredibly useful as a filler for contour irregularities after breast reconstruction, under depressed scars and as an augmenter in the face.”

But the fat grafting picture is far from rosy. Irresponsible uses and horrendous results, from death to disfigurement, threaten future uses of fat grafting — even by responsible cosmetic physicians and surgeons.

NEXT: Fat and The Face

 

Fat and The Face

Dr. Johnson says she performs fat transfer in almost every facelift.

“… replacement of lost facial fat is truly rejuvenating, as it not only adds volume but appears to improve skin quality and texture,” Dr. Johnson says.

Dr. Johnson also uses fat transfer in her cleft patients, to fill in lips that are asymmetric after lip repairs and to augment the posterior pharynx to reduce velopharyngeal incompetence, or hyper-nasal speech, after palate repair.

Dr. TaleiBeverly Hills facial plastic surgeon Ben Talei, M.D., says that he uses fat transfer, judiciously — especially when using it as a primary modality for cosmetic rejuvenation.

“The reason I am so cautious is because of the poor predictability in survival of fat and how it will act once transplanted. Fat has a survival rate of zero to 100%, in my opinion, when you look at each person as an individual. The fact that it has an overall survival of 60 to 70% in a cohort of patients means nothing to me when I treat an individual patient who should expect nothing less than 100% predictability for a cosmetic intervention.”

When he uses fat for cosmetic rejuvenation, Dr. Talei says he’s conservative. Rather than injecting 10 mL of fat all over each side of the upper and lower face, he tends to use a smaller volume, of 4mL to 5mL. And he’ll likely inject it in the mid face and upper mid face in a deep location, where irregularities would have no effect if they were to occur. He tells patients that more than one treatment might be necessary to achieve the intended goal.

“Most of the time I am using fat as an ancillary procedure rather than a primary procedure. It's a very nice adjunct to many facelifts, as long as it is done conservatively,” Dr. Talei says. “Overall, I avoid fat grafting into the lower face and superficially under the skin for many, many reasons.”

Female patient shown before and after AuraLyft and eyelid rejuvenation with a small amount of conservative fat grafting for added cheek accents. She received an upper eyelid lift and lower eyelid tightening with fat repositioning and canthopexy to tighten the rounded lower eyelid. Photos courtesy Dr. Ben Talei.

NEXT: Promises and Precautions

 

Promises and Precautions

There are lots of ways to harvest fat, from simple syringe or cannula systems to fancy in-line depots that keep the fat sterile but remove serum and blood, according to Dr. Johnson. Some doctors centrifuge the fat; some don't, she says.

“Everyone appears to get similar results, so there's no absolute ‘right way’ to harvest and concentrate the fat,” Dr. Johnson says.

According to Dr. Talei, emulsified fat, or Autologous Micronized Lipocyte Injection (ALMI), is a method for breaking down fat particles into a creamy smooth substance, so surgeons can inject it where they want.

“The risks are dramatically minimized with this method. The survival of the grafting is reduced as well we believe, but that's ok,” Dr. Talei says. “This method can now safely be used to treat difficult areas like the temples, marionette lines and nasolabial folds.”

“I'm still hesitant to place fat directly under the eyes because of the complications,” Dr. Talei says. “And we should always be cautious of injecting the lower face.  If you cause the face to weigh down or produce irregularities like peau du orange, how will you fix this? I can't most of the time.”

Fat transfer, according to Dr. Talei, is much safer and easier to use in the body.

“It has become extremely popular to perform liposuction and reinject the fat into the buttocks and waist for sexier curves. Men are also doing this now for larger pecs, shoulders, arms and even manipulating these procedures to get six-pack in the abs,” Dr. Talei says.

Another promising area for fat or emulsified fat is hair restoration, he says.

“So far, we have seen that Platelet Rich Plasma (PRP) can have a positive effect in many but not all patients with androgenic alopecia,” he says. “The results from a combination of PRP mixed with ALMI or A cell matrix have been promising, although nothing has been proven yet.”

There is a new option in the pipeline, which could have promise. It’s an off-the-shelf fat graft that will be available soon, according to Dr. Johnson. 

“It is denatured fat, so, there is apparently no allergic response,” she says. “This might be a nice option in patients who need more volume than a typical hyaluronic acid syringe, those who metabolize other fillers quickly, or very thin patients who don't have adequate donor areas for standard fat grafting. It remains to be seen how long this fat filler will last.”

NEXT: Fat Future At Risk?

 

Fat Future At Risk?

Despite fat grafting’s apparent traction, this approach to face and body augmentation could soon be out of favor.

There are concerns with some practitioners touting the stem cell aspect of transferred fat and offering snake-oil type cures for various ailments, according to Dr. Johnson.

“I had a patient who spent $50,000 for a ‘stem cell’ cure for his liver cancer. To me, that's criminal,” she says.

The FDA is concerned with the strip mall stem cell facelifts and other such cosmetic options and has issued draft guidelines that, if enacted, would severely restrict fat grafting, according to Dr. Johnson.

“The American Society of Plastic Surgeons responded vigorously to these draft guidelines with a 16-page, 198-reference, forcefully spelling out the value of fat grafting. Our Plastic Surgery Foundation created the GRAFT registry which encourages our members to enter data on all their fat grafting cases, so we can demonstrate to the FDA how and where we are utilizing fat grafting, and what our complications are,” Dr. Johnson says. “We feel that with robust data we can make better decisions as to techniques and uses of fat grafting for the benefit of our patients.”

Major plastic surgery societies are gravely concerned, she says, with several incidences of death after buttock fat grafting in young, healthy patients.

ASPS has joined with the American Society for Aesthetic Plastic Surgery (ASAPS) and several international societies in a task force to try to understand and prevent the horrendous complication, according to Dr. Johnson.

“As plastic surgeons, we must be exceedingly careful in our technique of buttock fat grafting to prevent inadvertent embolization,” she says. “We hope to develop best practices for buttock fat grafting that our members can rely on for safety.”

Disclosures: Drs. Johnson and Talei report no relevant disclosures.

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