Q: Dr. Eppley, I had brow augmentation by injectable fat grafting done ten days ago. I had a quick question about after care from the procedure. Should I be avoiding going into a sauna? I figured the heat would increase blood flow to the fat graft, but I just heard about how Vanquish destroys fat cells by warming them to 110 degrees.
A: While high heat is a known detriment to fat cell survival, the actual temperature at which that would occur is around 140 degrees F….not just 110 degrees. Vanquish does help destroy fat cells but that is by causing an internal temperature of the fat in the treatment to reach and be sustained around 45 degrees C. Therefore, I don’t believe the heat from a sauna would make any difference in fat graft survival. While the heat from a sauna may reach 145 degrees, your internal body temperature never rises more than a degree or two. Vanquish specifically creates temperatures at the subcutaneous tissue level of 45 Centigrade plus with the specific purpose of destroying fat cells. External sauna temperatures do not create the same subcutaneous level temperature changes. If they did you would be ‘cooked’ just like the fat cells that were placed by an injectable fat grating technique.
Dr. Barry Eppley
Q: Dr. Eppley,I had cheek, infraorbital rim and paranasal implants placed last year. While they have helped the look of my flat midface significantly, the implants look a bit ‘skeletonized’ and need some additional volume around them to create an overall fuller facial look. I know that injectable fat grafting is the only long-term option available but I am concerned that I will spend a lot of money and it will not work. What are some insights to improving the success of fat grafting to the face?
A The take of injected fat is a multifactorial issue and includes where and how it is harvested, the technique of concentration, the method of injection and what facial area is being injected. (cheek and the midface have the highest average percent of take) Because of all of these variables, most of which are not understood how they influence the process, it is no surprise that fat grafting remains as much an art as a science. It is also fair to say that all surgeons who inject fat are not created equal.
The most important key in properly injecting your facial areas of concerns is to have enough fat volume to do it. The surgeon must harvest at least 60cc and concentrate it down to 15cc to 20cc. (it takes far more fat than one would think to really create the overall volumetric increase that it is needed) I personally prefer to add to facial fat injections a PRP solution to have a ‘booster’ effect. PRP (platelet-rich plasma) is an extract of your own blood that adds numerous growth factors and cytokines which theoretically improves fat cell survival and stem cell conversion.
Dr. Barry Eppley
Q: Dr. Eppley, In February 2012 I had a Mitrofanoff diversion done using small intestine. (appendicovesicostomy) Cathing thru the stoma has been a problem since day one. The hole keeps shrinking. Have to “punch thru” for each cath. Usually bleeds, plus painful. One stoma revision done last summer which lasted a few weeks. The urologist has suggested plastic surgery but I am skeptical and tired or surgeries. The total problem was radiation damage from prostate cancer treatment.
A: I think in the face of radiation, it is virtually impossible to keep a stoma open by any type of ‘simple’ scar revision around the stoma. As taking the same tissue that have been exposed to radiation and asking it to heal without shrinking by scar contracture will not work. These are not normal tissues. Any hope of sustained stoma enlargement must occur by altering the involved tissues to have improved vascularity. This could be done by injectable fat grafting around the stoma which adds healthy fat and stem cells and then secondarily performing an interpositional skin graft to the stoma opening. But this approach would be hard to get enthusiastic about when one has had repeated surgeries that did not work.
Dr. Barry Eppley
Q: Dr. Eppley, I am a freelance writer working on an assignment for a medical aesthetics magazine and I could use your input. The topic is fat transfer procedures; specifically, techniques and longevity. Here are the questions I’d like to ask:
 In general, how is fat harvested? What type of equipment is used?
 How is fat then prepared for injection? Which components of it are used? What type of equipment is used?
 What specific injection techniques are used? Do any of the techniques pose greater risks to the patient? Do any of them generally produce better results?
 How long can patients expect the results to last? Does that vary by patient? By technique used?
 Are certain patients more likely to experience bad results? Are some patients riskier than others? How important is patient selection in ensuring best results and least risk?
 Any other comments?
A: Injectable fat grafting is both a reconstructive and cosmetic technique in plastic surgery that is undergoing widespread acceptance and use. While fat grafting has been around for 75 years, the ability to place it with an injectable approach and the generous amounts that most people have and its easy accessibility has made it into a standard modern-day plastic surgery technique. Just because fat is natural and most everyone would love to give some up, however, does not necessarily make injectable fat grafting a completely reliable treatment method. It is important to understand that the biologic behavior of fat cells and the concomitant stem cells that accompany them is not well understood. Fat grafting is equal art as science in current practice and that should be borne in mind when its techniques are discussed. They are based on what we know today…that will likely change significantly a decade from now.
- Fat is harvested using liposuction techniques. Most believe that low pressure vacuum extraction preserves fat cell structures and improves their viability after transfer. Whether this is syringe extraction or a traditional machine that generates less than -20cc of water pressure depends on how much fat is needed.
- The preparation of lipoaspirated-fat grafts has seen the greatest number of techniques currently used, all of which strive to separate the liquid fractions (blood, free lipids, injectate) from the cellular component. This include straining and washing, free-standing decanting, machine centrifugation, hand-held separation using centripetal force and low pressure forced straining using low micron filters. Much debate surrounds which, if any, of these offers a superior number of viable fat cells for transfer.
- Fat grafts are injected using small-bore blunt cannulas ranging in size from 16 gauge to 26 gauge size (comparative injection needle sizes) connected to luer-lok syringes of 1 to 3cc sizes for the face and 10cc to 60cc size for body areas. Placing the fat grafts in small aliquots (0.1cc for the face and .5cc to 2ccs for the body) is well shown to allow their best survival. Retention is all about how quickly the fat cells can be nourished by blood vessel ingrowth and the delivery of oxygen. Big globs of fat are hard to get perfused while small droplets interspersed about the tissues allows the best opportunity for nutrient perfusion.
- The retention of fat grafts, both short and long-term, is not a completely well-known issue. It is believed and considerable experience shows that what survives by three months after injection treatment is what will be ‘permanent’. (retained) Whether this same fat survives 5 or 10 years later is not precisely known and depends on what specific condition is being treated. Aging-related treatments are believed to be less permanent than those of structural rebuilding.
- All other factors being equal, there are no ‘bad’ patients for fat injections. Some of the historic predisposing factors for plastic surgery treatments that bode poorly for healing, such as radiation and even diabetes, are exactly what some of the indications are for fat imjections. Age is an interesting potential issue because one would assume that older fat cells are less hardy, survive the transfer process with less viability and would take after transfer more poorly. This assumption, however, has yet to be shown to be true. This may more of a reflection that older patients (> 65 years old) make up a minority of the fat injected population.
- What was once thought to be a useless and unwanted tissue has ironically turned out to be a depot of regenerative material. Plastic surgery has just scratched the surface of what injection fat grafting has to offer and a whole new generation of research and clinical experience will take us much further than what we know today.
Dr. Barry Eppley
Q: I have read about using my own fat as an injectable filler. This seems like a perfectly natural, and if I must say, an obvious thing to do to build up certain body areas. Is it not widely done however and several plastic surgeons that I have talked to either don’t do it or seem uncomfortable or unfamiliar with it. Is this because it doesn’t work well or is there something unsafe about it?
A: The concept of injectable fat grafting is in a state of development or evolution. Liposuction makes for an easy way to harvest an injectable natural material but its survival or retention after injection has been the issue. Using the fat suctioned from the body, technologies exist and are being developed to process the fat and extract and concentrate either the fat and/or the stem cells which naturally occur there. The concentrated fat with or without stem cell concentrate is then injected into the desired areas of the body or face.
Currently, more marketing than science exists about injectable fat grafting. Unfortunately, some surgeons actually tout that they have developed such a procedure and have ‘proprietary or special’ methods of their own to prepare an injectable fat concentrate. Multiple uses are being done from to facial or hand fillers. I have even read from some surgeon’s websites that their procedure ‘not only removes fat you don’t want, but it replaces it and changes multiple areas of your body, making for a more full-body change.’
The good news is that injecting your fat poses no harmful effects other than it may not work well. The less than good news is that some are claiming benefits that have yet to scientifically substantiated or proven. Injectable fat grafts holds great promise and, for small volume areas like the face and hands, does seem to be significantly retained. Good success has also been seen in the buttocks although multiple grafting sessions may be needed to get the best size result. Other areas, such as the breast, are purely investigational for now and are far from a replacement for implant augmentation.
Dr. Barry Eppley