Medesthetics

SEP 2014

MedEsthetics magazines offers business education and in-depth coverage of the latest noninvasive cosmetic procedures for physicians and practice managers working in the medical aesthetics industry.

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40 SEPTEMBER 2014 | Med Esthetics AUTOLOGOUS FAT TRANSFER For years plastic surgeons have used fat transfer to replace lost volume and fi ne-tune liposuction outcomes, but only in the last decade has it become part of the public's lexicon. In medical aesthetics practices, fat is be- ing used in place of injectables to replace lost volume and smooth wrinkles. There has been signifi cant debate about optimal harvesting techniques. Some doctors advocate centri- fuge, others prefer gravity separation or rolling the fat on cotton gauze to separate out oils and blood cells. Today, physicians are fi nding that harvesting technique takes a back seat to proper injection in achieving lasting results. "All of these harvesting methods have been studied, and there hasn't been anything consistent showing that one method is better than the other, which leads one to think that how you separate the fat isn't an essential mat- ter of importance," says cosmetic and reconstructive sur- geon Val Lambros, MD, FACS, who has been performing fat transfer for more than 20 years. The challenge with facial fat injection is that the patients who benefi t the most tend to be the patients who need volume least. "Fat is a great tool when used appropriately, but you have to have a high tolerance for ambiguity," says Dr. Lambros. "If you've got a chubby young face and you're putting fat in, it works great. If you've got an older, fat-depleted face, it's not as reliable and that's a major issue: the age of the patient." Some areas of the face that can benefi t from fat transfer include the brows, temples, cheeks and jaw line. "These are the prime targets for fat in my practice," says Dr. Lambros. One area he cautions against the use of fat is in the lower eyelid. "You have to be extraordinarily careful there," he says. "Even people who have lots of experi- ence with fat transfer see problems with lumps and bumps in the lower eyelid, and it's hard to get rid of. You can make it better, but you can't go back to where you were—at least not with current technologies." The best solutions for poor fat grafting outcomes include liposuction or surgery—neither of which is ideal for the undereye area, particularly because the fat is typically grafted into all the tissue planes. "A heat-based or ultrasound-based device might come along to help these patients," says Dr. Lambros. "But it is an issue— there are thousands of patients out there who've had fat grafting to the lower eyelid, and it's really hard to do much for them." Other concerns with fat grafting involve the risk of overcorrection and future weight gain. "Excess with anything isn't good," says Dr. Lambros. "If you're exces- sive with a facelift, the patient can look pulled. If you're excessive with liposuction, the patient looks irregular. If you're excessive with fat, you can turn a young, defi ned face into the Pillsbury Doughboy. The skin is smooth with no wrinkles, but it looks bizarre." In addition, young patients who receive fat transfer may struggle with changes in the appearance of the fat as they gain weight in later years. "I predict there's going to be a tidal wave of problems in a few years as patients who are getting a lot of fat in their faces now get a bit older and put on weight," says Dr. Lambros. Oculoplastic surgeon Frederic Stern, MD, FACS, who often uses fat transfer in place of dermal fi llers, notes that the key to avoiding poor outcomes is gradual enhance- ment. "The goal is to do a gradual buildup of the area," he says. "You do see an effect immediately, but you don't want to give 100% correction with just one injection of autologous fat, or it won't take. This is very different from dermal fi llers where you want to achieve the effect all at once." Aftercare also plays a role. "Immobilization is a good thing," says Dr. Lambros. "You try to keep the face as quiet as you can, because motion disrupts the tiny blood vessels that are growing into the fat." Dr. Lambros prefers to reserve facial fat transfer for his facelift patients. "Most of the patients are older, so the fat is less likely to grow with weight gain," he says. "Also, the patient is already anesthetized, and you can take out as much fat as you want." For his offi ce patients, Dr. Lambros recommends fi llers like Juvederm and Restylane for lines and wrinkles, and VOLUMA XC for volume. "Voluma has proven to be great for cheek bones; I love the stuff," he says. CRYOPRESERVATION OF FAT One advancement that may make fat transfer a more viable option for long-term fi ller patients who want AUTOLOGOUS MEDICINE

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