Fat Grafting & Fat Transfer

Fat transfer and Fat Grafting

This has become one of the more popular things people want. Obviously you cannot mention this trend without mentioning the Kardashian's and the BBL. The Brazilian butt lifts are what most people know them by. But there are so many more places on the body that patients have asked us to use fat and that I've started to learn you can use fat. I think maybe it's a good idea to start out a little bit of detail about what that procedure involves for people.

What is a fat transfer?

A fat transfer, quite literally means you're taking fat from one part of the body and moving it to another part of the body. The procedure really is called fat grafting because it is a graft. Graft means you're taking a piece of tissue off the body. It no longer has any direct blood flow from where it came from and you're putting it somewhere else that it wasn't before. The important distinction in that is it has to grow a new blood supply and get new blood vessels going to it for it to survive. When we take fat and liposuction it from somewhere and put it somewhere else, it takes a couple of weeks for that fat really to kind of grow into that area and become permanent. It really isn't even permanent. It's definitely much longer lasting than fillers. Just like everything in our body changes over time, over 20 years you will lose a lot of fat in your face, in your legs, in your buttocks, you usually gain in other places. That's true of the transferred fat as well. It will gradually go away over time to some degree.

Safety 

Let's talk a little bit about a couple things. Safety of it, exactly what are you doing when you're doing it? Let people know. We're doing liposuction and then what are we doing with the fat once we get it and how are we injecting it? 

Fat transfer can vary from a 30 minute procedure under local where we numb up a small area of fat by the hip or the thigh or the tummy, take a little bit of fat out maybe 20 or 30 milliliters like a shot glass and then we use it in small amounts for say the under eye area or cheek bones or something where there's a small volume. Sometimes procedures like that can even be done under local anesthetic. I find people are more comfortable with a little bit of sedation on board though. The other extreme end of that is full body liposuction where you're taking all the fat you suction from the whole body and putting it back in. Now, legally unless you're in an actual hospital and staying overnight you are not allowed to suction more than 5,000 milliliters.

I work with a group of anesthetists that go to multiple cosmetic offices. They've been around for 20, 30 years. I know for a fact there are surgeons who break those rules, fudge the numbers on the reports and they take six, seven, eight, nine liters of fat and they put a lot of it back in.

It may give the look someone wants but it's not safe. There's a reason they have those laws in place.

Where can you transfer fat to?

I do a lot of fat transfer to the face, to the breasts for cleavage and to the bottoms. I've also done fat transfer for people who've had liposuction where it's indented and a little uneven and we've done some things to the back of the hands but the common ones are face, breast and butt.

Breast

From breast cancer patients, to really constructing breasts. I began doing fat grafting for some of those patients where the problem is, even with an implant in, it doesn't look like an actual breast. There's no tissue in the cleavage or upper pull where people really want it. I got a lot of experience taking fat, nobody's ever sad to get rid of some of their fat and putting it where people wanted a little enhancement.

To me that is really still how I prefer to do fat transfer to the breasts. I like it for contouring, for shaping, for improving cleavage. I don't like it for volume.

There is a certain amount of fat capacity wise that your tissue and your skin can hold before the pressure becomes so much that it kind of cuts off the blood flow, the same way wearing a super tight pair of pants would cut off blood flow. There's also only so much healthy tissue to put the fat in between. If you put big huge globs of fat in, it's not going to be able to grow blood flow. They've shown in studies that is has to be a centimeter or less in size for blood flow to really be able to get to that whole piece of fat. If your surgeon is shoving 1200 milliliters of fat in each buttock, there's not always a lot of space for that to go.

It looks great for a couple months and then all of a sudden some of the volume starts to go away. Either your body metabolizes it and digests it like it's an infection or it can turn into hard lumps and start draining. To minimize the risks of that, if you really do want to go crazy with volume you just need to stage it. Do one surgery where you kind of can get that volume, know how things are, how much fat takes, etc.

I wish I could give people a number but everybody's body's different. Everybody has a different amount of tissue in each area. If you've got a lot of buttock muscle and a lot of stretchy skin you certainly can fit more fat than if somebody's really thin and they've got a really tight skin envelope already. It's very individual per patient but I really rarely like to transfer more than 500 or 600 cc's of fat to one particular area.

Labia

Is the only place I forgot to mention so far. Probably 'cause ... No matter how much we do it, it's still weird to kind of talk about.

We do a ton of vaginal rejuvenation in our practice and we will dive into that and we will discuss it because it is one of those hush-hush topics a lot of people don't want to talk about but you would be mind blown to know how many people walk in our door. It's one of the highest procedures in our practice that happens and it is not because people want to look like a playmate or they want to look like something they saw on TV, it is a legitimate concern and it's a legitimate issue that people have. One of the things that they have is deflation of the majora area down there and people can say it's saggy, it looks deflated, It looks wrinkled. It doesn't cover the minora anymore.

There are lots of different things I hear from patients. I'll be honest, it's not as popular as a lot of other procedures because so many women wear tight bathing suits and yoga pants that they'll take a wrinkled labia over a full labia that might look obvious through clothing.

Yeah. That's not the biggest part of our vaginal rejuvenation surgeries.

But it is possible and I have done just small amounts for women with just a little bit of fat loss where they feel like if it just looked a little more plump it'd look a little more youthful.

Hands & Nanofat

Renuva is a fat injection that is related to some of the allografts and slings and products that we've used for breast reconstruction. They're basically tissue based products meaning they get a later of tissue from a pig, a cow, usually human but they process it in a way that there's no more living cells. There's no living particulate matter of that product. When it comes to us it is a powder in a syringe. It's essentially a mixture of growth factors and remnants of stem cells that will once mixed with liquid and 

Injected in the body, stimulate your body to grow new fat cells in that area. That's wonderful for patients who really don't want to undergo the liposuction part of it. Or don't have enough fat. The problem with it is, it is expensive. It's tissue, it is about $2,000 for a three milliliter syringe. For someone who has a very small deficiency in fat in their face or somewhere else, it's very upsetting to them, or the breast, where a small volume is going to fix it, it may be a better choice than undergoing surgery.

The results are essentially permanent. The FDA studies aren't long enough to say that anything is permanent but they're a couple of years in and by that point it's about the same thing.

Nanofat is a pretty new concept in fat transfer. It means that we are breaking down the fat into basically its molecular components. It's not a live fat cell anymore that's going to go into your tissue and grow and just be there. It's more like the Renuva product where we're injecting growth factors and things that will stimulate your body. Places where we wouldn't traditionally put fat, scar tissue, eyelids, I mentioned fat for the under eye. Very specifically it's safe to put fat over the boney part, not real safe to put fat right in the eyelid. But if you're using the Nanofat it's processed in a way where it's broken down so much it's much more liquid.

Basically what you do, you take the fat out of the body, you put it in a syringe, you connect it with a lure lock, it's a little connector to another syringe and you squish it back and forth a bunch of times. Then you put a little filter in there and you push it back and forth a bunch of times. Then you put a smaller filter in there until it's down to 400 micrometers. That's Nanofat.

It is a liquid. It looks kind of gold in color and you inject it with a syringe just like you would inject filler into the skin and into superficial areas. It's a real breakthrough for us because we didn't use to put fat in superficial areas. It would feel lumpy, bumpy, and it might not take. This is kind of a new thing. The only problem with it is, it is not instant gratification like fat transfer. It's a stimulator and it can leave things a little bruised and a little inflamed looking for a couple of months while that process is happening. These procedures are not without risk and without trade-offs and I really just hope to impress upon people if your surgeon is sugar coating this and making it sound like it's going to be a walk in the park, just ask more questions. Especially with full body lipo and BBL, there's a chance you could have a pretty tough recovery. For two to four weeks.

Even for me, as a procedure I think oh, we'll just go in and we'll suck out the fat and we'll be out and oh, it took me an hour but then it takes me two and a half hours and then patients are sore and stiff for three, four weeks afterwards where they kind of pictured three, four days. There are some people who sail through surgery and do great but you can't known that you're that person ahead of time and it's a very small part of the bell curve that's way at the top.

We had a patient today who wanted to do full thigh lipo and she was in management and retail on her feet all the time and we explained she would need time off, at least a week, maybe two weeks if we're doing full thighs. She's like, I can't. I can't fit that into my lifestyle. She'll end up doing what we call sculpsure. A non invasive fat removal here in the office and it doesn't have any of the downtime so you definitely want to ask the questions of what's going to be fitting into your life with all these fat procedures. I think that's one of the big things is know that there are multiple options. Some may not give you as powerful a result, but if they're less risky and they fit your downtime better it might be a better option.

Longevity & Shape 

Let's talk about the longevity of these really big Brazilian butt lifts and what can happen. Really ultimately because within the practice you I prefer to do it for contouring. I like to make beautiful heart shaped, round, get rid of the square and just really more of an aesthetic of it, just make it really pretty, versus really enlarged.

Most of our patients don't really want big butts, they just want one that's more shapely or a little higher or looks a little better in a bathing suit. Or fits in jeans better. When you're talking about BBL, believe it or not about 70% of the shaping comes just from doing the liposuction.

If you're lipo-ing those love handles and the triangle above the buttocks you really get a nice sway in the back, you can lipo around the thighs and really create more of a shape. Then to me I only like to put fat back in and only in an amount that kind of completes the roundness or creates the shape that that particular person's looking for. Using the flanks on the body to bring in the waistline and then use a little fat to bring out the curve.

Some people want their butt to be more curvy than it is. Other people just look at their butt and see well there's a nice curve here but there's almost this divot at the top or a dimple and they only want fat in those areas. It's a really big distinction. They're all the same procedure but they're really different.

The narrow waist and large butt look is very popular with some patients but many people have to realize you can't always get a super narrow waist and a round bottom just from liposuction.

If your fat is within or under the muscle layer in your abdomen, visceral fat, we can't take that out with liposuction. Also, to get that really pinched in curve, many of the girls you see on Instagram and posts are using waist cinchers, waist trainers, for months at a time in combination with their surgery. It's really not just the surgery that's doing it.

Some people love that shape where it's as narrow as it can get and it's fuller. That's not what bodies usually look like so many times there's more than one step to get to that place.

Now, we've already talked about some of the complications. If there's too much fat it can get infected and drain out, it can turn into hard lumps but even if everything goes smoothly if you've put in enough fat to not just fill out the looseness of the skin that's existing but to stretch the skin even more, if you get later reabsorption of that fat or in time when you just get kind of saggy in your tissues 'cause you get old, I am really interested to see how many dimpled cellulite really saggy down to the mid-thigh butts we're going to see in Hollywood.

In about 20 years, I mean, I don't want to call anybody out specifically but I saw a picture of Amber Rose and Black China on treadmill and as a surgeon I just kind of thought what's that going to look like in 25 years? I mean, they might like the way it looks now but it's unknown because this is a newish procedure. If you kind of want to go down that road you just have to realize we don't really know all the implications of this.

Small volume fat transfer has been done for a very long time. It's been studied extensively. There's a guy Sidney Coleman in New York and Roger Khouri in Miami, they've written a lot of research about it and they know if you're looking for just a breast augmentation with fat transfer there are people who do it like them but they tend to take eight to nine hours doing a surgery.

Sidney Coleman who kind of pioneered these techniques puts in about a milliliter of fat at a time, in any one given location. He does mainly breasts. Well, a lot of breasts. It will take him eight hours to get somebody a cup size or two larger because he's very fastidiously ... he's processing his fat to get out all of the impurities and the blood and all the extra liquid. Then he's putting it in very small syringes and being very careful about where he injects it in the tissues to make sure that it's all spread out evenly and that it's going to get good blood flow. Because remember we said, anything bigger than about a marble sized or a centimeter, the center of that's not going to get blood flow if it's put in a bigger chunk or injection than that. 

Speed of Fat Transfer

How long surgery should take? These guys that are putting in fat in very small increments take hours and hours to do fat transfer. A lot of the places that are offering these at really discounted rates are cutting corners and they will suction fat out at a very rapid pace and they use a very large canula to literally just reverse it on the liposuction machine and what I call plow the fat back in at 300 milliliters a minute.

Normally once the fat is suctioned it's a good idea to keep it in a closed system so it's not exposed to a lot of air. Reversing things through the tubing and having it come from the lipo tube, the lip canula into the tube into a canister and then straight back through that, that's not a bad idea but when you're doing it at 300 to 500 milliliters a minute you're not able to as easily control where that fat is going.

I remember sitting at the Baker Gordon Conference last year and there was a surgeon, a very prominent surgeon, demonstrating BBL using this technique and about half the audience was literally gasping saying I would never feel safe doing that. He just kept saying well I know I'm at the right angle, I'm not going to do anything.

The rate of death from BBL is higher than any other procedure in plastic surgery and it's not the procedure itself. It's cowboy's doing the procedure like that. Trying to maximize their revenue by sucking it out, cranking it back in instead of taking the proper time to do it safely.

A lot of people get very sticker shocked especially ours, our BBL's tend to be a lot more because our time under anesthesia and OR is really what calculates a lot of the price but that's the way it should be done. That's the only way I'm going to do it.

You know, we had a patient a couple of years ago who was considering getting BBL with us, went somewhere else and unfortunately she passed away of a complication. All I remember her saying is well, I would love to go with you guys but their price is just so much better. There's a reason if the price is that much better. This is one of those procedures you definitely don't want to take a gamble with and can have a pretty high complication rate if it's not done right.
 

Rejection

Because there's no living matter in it there's nothing for our immune system to react to. It's not a living thing so our body can't reject it. Now, does that mean all of it's going to survive? No. Again, it all depends on how your body reacts to something being injected.

Some people when they have surgery get very swollen. A lot of people don't know this but the blood vessels only go so far in our tissue. For oxygen and nutrients to actually get to our cells they have to basically diffuse out of the blood vessels across our tissue into the actual cells. Even a small amount of surgical swelling can interfere with that process. Smoking interferes with that process. Sitting on pressure interferes with that process. We can never promise or guarantee how much volume someone's going to retain from fat grafting 'cause it's just too individual.

Post care is extremely important. In general, about 50% to 70% of fat stays but it's really body part dependent. I would say for breasts honestly unfortunately it's probably less than that. Probably 30% to 50%.

Just out of my experience with patients and what kind of volume, and not even just my patients. I'm fascinated with fat transfer to the breasts as a procedure because honestly, every woman would rather avoid implant complications and not have an implant.

But time and time again when I look at the results they look fabulous at three months and then by a year or two. It's not that different than it was pre-op. For small areas, the rate of take is higher because you're asking less of the body.

For small areas like cleavage you do see a persistent difference. But for global size in the breasts especially, it's just not been as impressive as I want it to be before I'm going to talk to patients about doing that.

Contouring Previous Liposuction

Another thing I was just thinking of also when you were going down that, it was we've had a lot of patients who have come in who have had prior liposuction from other surgeons and you mentioned it briefly at the beginning of it but it was like contour irregularities that fat grafting is really good for that and that people think that's crazy, like, I lipo'd all this fat out and now you're going to put fat back in for those areas where you have a little assymetry on the thighs or in the abdomen where there might be a little contour on this side, but those are times where we have used it to help contour that area.

For kind of, I don't want to say botched lipo 'cause it can happen even with talented surgeons and compliant patients but for lipo that just doesn't turn out the way you want and there's skin puckering and unevenness, a lot of times just going through and doing some liposuction and laser technique can kind of break that up and kind of even things out. But if there's a true divot or kind of a volume hole and I've seen some patients, I had one patient who had one in her buttock from a shot that she got a hematoma around it and then it went to a divot.

For little things like that, yeah it can be really helpful.