Grafting and Fat Transfer: What is the real story?

For many years, liposuction was associated with body contouring and fat removal, and was mainly in the domain of plastic surgeons.  Although the technique has been refined in some ways, fundamentally it still involves the removal of fat using small, often insignificant incisions, to reduce areas that have accumulated fat deposits.  We use the term “cannula” to describe the metal tube that is passed to extract the fat.  While the details of each surgeon’s technique may vary, most agree that nowadays it is appropriate to place fluid (“tumescent fluid”) into the area first, in order to best prepare the site for fat extraction and to minimize blood loss and discomfort.  The ideal patient who is a candidate for liposuction has traditionally been the patient who is close to ideal body weight and has focal areas of excess or prominent fat.  Often, these patients note that, however hard they may work to keep their weight at their best, certain areas “just don’t go away.”

Some of the ways that liposuction has evolved include the development of new kinds of cannulas, the use of different ways of aspirating the fat, and the use of different forms of energy to break up the fat for removal.  Energy forms that have been applied to fat tissues include lasers, ultrasound and radiofrequency.  The use of radiofrequency has even been used without any incisions or cannulas, and has been passed directly through the skin with no incisions.  In my opinion, the results achieved with that technique have been minimal or disappointing.  It is always worth considering the fact that, whenever the surgeon delivers any thermal energy to the tissues, the risk of scarring or burning the tissues is a real potential danger.

Over time, interest has grown in using fat for valuable purposes rather than discarding it as medical waste.  Although fat has been harvested and reinjected for many years, the process has hardly been standardized and the results have been extremely variable.  Some of the best “minds” in plastic surgery have had legitimate disagreements on whether transfer of fat really works, and even more disagreement on the best method(s) to use for fat transfer.  Evidence increasingly shows that fat can be transferred by injection techniques and survive, and that fat can also be used as a source of delivering other cells, such as stem cells, to different regions of the body.  I have personally experienced very gratifying results with fat transfer, provided certain principles were followed.  Here are some guidelines that I follow in my own practice:

1)   The technique of harvesting the fat is very important, and this includes the selection of the instruments used, the pressure used to extract it, and the manner in which it is separated from unnecessary fluid.  This concept would suggest that the use of newer laser-assisted or thermal systems of fat removal may be very unappealing because they can destroy these valuable cells.

2)    The technique of delivery of the fat is equally critical, as the fat must be able to thrive in its new location and receive adequate blood flow and nutrition.

3)    Patients who are thin may be very good candidates for specific types of fat grafting; they do not have to be overweight or carrying pockets of donor fat.

4)    Areas that are prone to constant movement, such as the lips, are less likely to retain the volume injected when compared to areas that do not move as frequently.

5)    If you assume that some percent of the fat will be lost over time, while the rest has a good chance of retention, you are embracing a more realistic approach and will likely be pleased with the results.

6)    Fat grafting can be a great addition to other surgeries that you may already be considering, such as face or neck lifting.

7)    Fat has the possibility to provide long-term volume enhancement; off-the-shelf fillers usually do not.  For large areas of fat grafting, such as the buttock area, fillers are not even a reasonable option given those that are FDA approved in the U.S.

Fat grafting and transfer is a growing area of interest, and you will likely see more advances on the horizon.  I will keep you posted . . .

To your health!

Saul R. Berger, MD, FACS

www.drberger.com

Some Thoughts About Medical "Tourism"

A couple consulted with me some time ago about a number of cosmetic issues.  Both had traveled to a Central American country for cosmetic surgery.  Both individuals had multiple procedures to the face and body, including facelift, brow lift, breast surgery, tummy tuck and more.  Frankly, it was difficult for them to know where to begin describing the problems that resulted, including sutures that still needed to be removed more than one year after surgery, scars that left them looking “strange,” and residual cosmetic issues that were never corrected.  In actuality, they began the consultation acknowledging that they had made a “big mistake” in traveling for surgery, but were trying to maintain a positive attitude in moving forward.  What was their prime motivation for surgery in another country?  Cost.  They spent about 50% of the cost of similar surgery in the U.S.  Some of their problems were correctable, and some were not.  Ultimately, they never underwent additional surgery -- they were not able to budget for the corrective work.  How did they find and “screen” the cosmetic surgeon who treated them?  The internet.

The desire to look one’s best and the benefits of improved appearance on both a personal and professional level have been recognized for many years.  Interestingly, there are many studies in the field of sociology that have documented measurable advantages, on a societal level, to possessing beauty and attractiveness.  Studies have even documented this fact across cultures and geographical boundaries.  The wild popularity of such relatively “simple” procedures such as Botox Cosmetic and the billions of dollars spent on skin care attest to our desire to “look our best” as much as possible.  Despite the current state of the domestic and world economies, individuals are still seeking aesthetic treatments and surgeries.  In order to reduce costs, some people have traveled to other destinations for their treatments.  Is it worthwhile to travel abroad for cosmetic surgery, and what are the risks?  What is involved in “surgical tourism?”
 

Some years ago, medical tourism described upper social class individuals traveling to countries for specialized skin care, spa therapies, mineral baths, or other unique treatments in pampering settings such as cities in the Mediterranean.  In more recent times, it has become commonplace for foreigners to travel to the U.S. for treatments that were either unavailable or associated with major delays in their native country.  The escalation in health care costs in the U.S. along with advances in aviation travel have increased the volume of Americans seeking medical care outside the U.S. for everything from organ transplants to cardiac surgery.  Specifically in the area of cosmetic surgery, people have traveled for procedures such as liposuction, facial cosmetic surgery, tummy tucks and much more.  In almost all cases, the motivation for travel is a lower price.  The obvious question is: are those savings justified?

While there is no definitive answer to this question, and there are certainly skilled and competent surgeons practicing around the world, what risks do patients face when traveling abroad for surgery?  The risks fall into several general categories:

1. Competency risk – does the physician have the necessary training to perform the procedure(s) safely and to achieve desirable results?  It can be very difficult for Americans to ascertain the quality of training and certification outside of the U.S.  Satisfactory results in a friend or family member may not translate to your results.
2. Facility risk – does the facility follow the safest protocols to ensure sterilization of instruments and proper function of equipment?  Are there contingency plans for emergencies?  Do they have the latest equipment should something untoward occur?  As medical director for an ambulatory surgery center in Encino, California, I can tell you that we use many safety systems about which most patients are unaware.  Did you know that we confirm the reliability of every sterilization cycle by using a separate biological test?  Did you know that we maintain a completely autonomous power backup system that automatically activates in the case of regional power loss so that surgery is not interrupted?  Did you know that an independent technician performs regular site visits and checks every piece of electronic and anesthesia equipment for proper function and maintenance?  These are just a few examples of many.
3. Follow-up risk – how does a patient propose to get the follow up care and information that they may require?  Most surgeries require a full healing period of at least 12 months.  Once returning to the U.S., patients no longer have the chance for direct “hands on” evaluation of their surgery by the practitioner.  What if they experience a problem or require some minor adjustment, such as a scar revision?
4. Complication risk – how do patients handle complications, such as infections or keloid scars?  What if their medical insurance does not cover the complications of such elective cosmetic procedures?  Are complication risks higher because of travel itself?  For example, prolonged airplane travel could increase the risk of a clot in a leg vein, with the risk of a life-threatening clot moving to the lungs.

So, is it worthwhile to travel for surgery?  Of course, price has to be figured into any assessment for cosmetic surgery.  But I advise my patients to make sure that cost is not their prime motivating factor.  Remember, surgical tourism can result in medical problems, and any savings could be easily wiped out.  Caveat emptor!

To your health,

Saul R. Berger, MD, FACS