It was about ten years ago that I first met Dr. Sidney Coleman. He had just published a text called Structural Fat Grafting and was showing his results which were superior to others I had seen. I had been studying fat grafting since 1991 when I did my first case. I immediately saw the genius behind his methods backed up by beautiful photographic documentation; I purchased his book, had him sign it, bought all of the recommended equipment and was on my way.
It was about this time that it became obvious that adipose tissue was special in ways we had never figured. Our own fat turns out to be the bodies’ primary depository of mesenchymal stem cells, rather than from bone marrow, explaining adipose tissue’s ability to rejuvenate our faces when injected into the face.
After a number of years and hundreds of cases I began to notice a pattern in our results. It became clear that our older (>60 years old) patients seemed to have much less than the 80-90% graft survival that we had become accustomed to. Others had noticed the same phenomenon (PRS 2014 August; 134(z), 227-232) but placed the cut-off at 45 years of age.
Empirically we studied the gross appearance of the suctioned and centrifuged fat noticing there tended to be a demarcation within the fat layer itself. Approximately 30-50% of the fat looked somehow different, less “cellular or robust” if you will. The location of the donor fat areas also seemed to appear different with the entire specimen seeming more cellular. Donor locations have been studied and our observations confirm that flank and upper buttock fat seem more vital than abdominal or thigh fat. For younger patients the opposite seems true.
We also believe, as do others, that stem cells from older individuals seem to lose some of their “potency” in regards to being multi-potential mesenchymal cells. The rejuvenating ability of adipose derived stem cells may age and become less potent over the lifetime of the organism. This observation has practical implications as many people are choosing to donate their adipose stem cells for possible future use as a treatment for certain diseases and possibly even cancer. It makes sense to donate one’s stem cells as early- as young- as possible to have maximum effectiveness. The cryopreservation of adipose tissue is now a growing industry requiring only standard liposuction techniques to obtain the fat which is cryopreserved indefinitely for a small yearly fee.
In the year 1923 Fanny Brice was the talk of the town. She was the star and main attraction of Florenz Ziegfeld’s Follies, the most attended vaudeville act of tis time with the most famous attraction. Ziegfeld’s Follies was where Fanny Brice became a celebrity. Not bad for a Jewish girl who evidently suffered from image problems due to her very ethnic and large proboscis. As a comedienne on stage her nose was a perfect prop for her comic routine. At what point in her seemingly glorious life did she decide to “bob” her Jewish nose is unknown.
Barbra Streisand, a half century later, faced the same critical audiences that had persuaded the young Fanny Brice to change her Jewish appearance, but could not persuade Streisand to do the same. It was after Streisand’s brilliant performance in Funny Girl, a play about the life of Fanny Brice, that the questions about her looks began.
Fanny Brice was a prolific self-marketer and realized the national publicity her nose job would have. How she found her plastic surgeon, Dr. Henry Junius Schireson, a man of forty-two with a dubious past, questionable educational background as a doctor, and a reputation that he would operate on anything for money, remains a mystery.
For the event the media were notified and Fanny Brice had her nose bobbed in her hotel room by a quack surgeon. Her nose job was the medical event of the day and generated press attention until the birth of the Dionne quintuplets in Canada in 1934. Henry Schireson was an overnight sensation and probably the first celebrity plastic surgeon. It wasn’t too many years later that Schireson lost his medical license under a barrage of lawsuits and retired a disgraced man.
As far as Brice, she continued to be the gold standard for female comediennes, continued her ethnic Yiddish humor on stage until 1934 when she changed to radio and had an illustrious career on air where no one could see her new and improved nose.
In the race from body to petri dish Bone Marrow Stem Cells (BMSC) has been the standard bearer among research scientists since their discovery in the 1960’s. They have the advantage of being well-known and easily understood by researchers. The primary downside to BMSCs from the beginning has been the clinical difficulty harvesting the cells from bone marrow derived from the pelvis of the donor. This bone marrow harvesting procedure generally requires general anesthesia and is painfully difficult for the patient.
Embryonic Stem Cells, when available, were the preferred choice of many doctors until the philosophical question of the beginning of life was raised and left unanswered. The utilization of human fetuses and umbilical cords for the purpose of research has been banned in the U.S. for several years.
Adipose Stem Cells (ASC), a more recent discovery, have been shown to be easily harvested by modern techniques of liposuction with very little pain or discomfort. Liposuction is a simple office procedure without the need for general anesthesia and provides the donor with a cosmetic improvement as a secondary consequence to the attainment of large quantities of ASCs.
ASCs, besides being easy to harvest, have been shown to have 100-500 times more stem cells than an equal volume of bone marrow. When intended for immediate use, the Stromal Vascular Fraction (SVF) of the centrifuged fat contains all of the stem cells and can be used interchangeably with the isolated, cultured adipose stem cell product.
There is an increasing amount of research in the field of restorative medicine, so we are working with the Adicyte Company to harvest and make available to our patients at a future date their own adipose stem cells harvested today by liposuction. In the near future when research has become sophisticated enough to offer treatments based on autologous stem cells, your stem cells can be retrieved, thawed out and used for stem cell therapy as if they were brand new. Current therapies currently under protocol include re-growing cardiac muscle after heart attack, treating autoimmune and immunological diseases and re-growth of cartilage in damaged knees and shoulders. There is even some preliminary work in a treatment for certain cancers also.
Dr. Paul Howard now offers stem cell storage with your adipose tissue (fat) – learn more
The Wrinkle in Botox
Why you can still expect to have a Facelift
Wikipedia’s definition for wrinkle “is a fold, ridge or crease in the skin.” Botox is a wonderful medical break-through that has altered how some women smile, or lack thereof. Just like many medical breakthrough products, Botox is often over-sold to the general public giving them an unrealistic expectation of results and, often, misconceptions about turning back the clock or stopping the aging process altogether. Medical technology has yet to advance enough to alter our DNA and stop the aging process, but has given us products such as Botox that can help prevent wrinkles from occurring to some degree.
Botox is a product that paralyzes the muscles in the injected area. Since most wrinkles are created from the stress of the underlying muscles, paralyzing those muscles helps to prevent the muscles from contracting thus it prevents skin folds from occurring. When used prior to the appearance of wrinkles, then Botox is preventing those folds from occurring, thus the signs of aging. When used after the signs of aging are present, then Botox assists those muscles from contracting thus relaxing the fold, or wrinkle. Most patients can see visible improvement over time after consistent use. However, the “wrinkle” in Botox is that is does not erase those deep wrinkles once they are formed, but can help minimize their appearance.
Deep wrinkles are the manifestations of muscle contractions over a period of time. Wrinkles are more than just folds, they are the visible signs of soft tissue having been broken down from the stress of the muscle contracting. A tissue replacement, such as artificial fillers or fat grafting, is often recommended to achieve the desired result of minimizing the appearance of wrinkles beyond the capabilities of Botox.
Common areas for Botox Cosmetic are the forehead, glabella (between the eyebrows), and the crow’s feet area around the eyes. Injecting Botox to frown lines is not advisable unless you wish to paralyze your smile for about 4-6 months. Even if you could obtain some benefit from Botox injections to the frown lines (laugh lines – or the parentheses lines that extend from our nose down to the corners of our mouth), then the manifestations of aging would still exist as gravity is a proven cosmetic disadvantage to our facial structure. Botox injections cannot prevent gravity from pulling down the soft tissues of our cheeks contributing to those laugh lines and creating those jowls which in turn help create marionette lines from the corner of the mouth extending down the sides of the chin.
Since it is clear no one would want to Botox those frown lines, the aging process in that area will continue thus leading to a more traditional procedure such as a facelift. Other factors that can help minimize the appearance of wrinkles are skin care, using sun-block protection, drinking plenty of water to keep the skin hydrated, and maintaining a healthy weight. Botox is a great product for the prevention of forehead wrinkles, but one should understand it isn’t a magic potion for all areas of the face.
Read more about botox.
By its very nature, Rhinoplasty is one of the most personal of Plastic Surgical procedures. Many people define the way they look and reflect their ethnicity on their noses and any changes anticipated must be fully discussed pre-operatively. To do this the patient must have a firm and unwavering commitment to facial change as well as an honest and realistic expectation about the nose they wish to have. This may start with a look through today’s fashion magazines to see what the “beautiful people” look like. While it is rarely possible to recreate another’s nose, it does provide a starting point and does give the Plastic Surgeon a general idea of what the patient wants. The process can then begin to alter the patient’s expectations to something nearer to reality. Every patient should expect to have a more attractive nose that also breathes well, but not every patient can have the perfect little turned-up nose seen in so many of our current movie actresses. Once the Plastic Surgeon gets a general idea of what the patient desires, then he/she can begin discussion of the details of the operation and what may or may not be possible. During this part of the consultation, drawing expected results on the pre-operative photos or utilizing computer imaging is essential. The only caveat regarding computer imaging is that it is always better if the operating surgeon does the imaging so that the imaged results are as close to realistic as possible.
Explaining the details of the procedure is important as the possibility of complications is hidden in these details. For instance, describing a dorsal hump reduction should lead to the possibility of a small elevation at the bone-cartilage junction and in large reductions leads to a discussion of osteotomies and supra-tip problems. We usually perform a septoplasty as straightening the outside of the nose can incur septal deviations that cause breathing difficulties if no septoplasty is performed. Additionally, the sub-mucous resection of the septal cartilage can be replaced (banked) for possible future use or used to help define a nasal tip or to open an internal valve or straighten the cartilaginous dorsal septum.
The thickness or thinness of the skin needs to be addressed as each can affect the visualized result; thick skin will camouflage tip contouring while thin skin may show the tip architecture created in the finest detail. Therefore, in a thin skinned patient more discussion of tip detail is crucial. Explaining planes, cartilage breaks, and light reflexes may then become important.
The most important pre-operative information that must be understood clearly by the patient is that it takes at least 6 months and usually up to a year before the final result is realized and that any necessary revisions should wait at least 6 months in most circumstances. It is important to not over-sale the cosmetic rhinoplasty.
From the Plastic Surgeon’s point-of-view, reconstructive and even cosmetic rhinoplasty is challenging and has a “steep learning curve” which means it takes a lot of cases to become facile with the instruments and the operation. I personally was trained by one the best rhinoplasty surgeons ever (see: Rhinoplasty Tetralogy by D. Ralph Millard, Jr., MD). My early practice encompassed a lot of broken noses due to automobile or physical trauma. Then I gained a reputation for cleft lip and palate as well as the most difficult rhinoplasties on infants and children. After 20 years of experience I now only concentrate on teenage and adult cleft lip rhinoplasties, complex rhinoplasty due to trauma and most cosmetic rhinoplasty. After an extensive 26 year experience, I still find rhinoplasty to be the most taxing and the most rewarding operation that I perform.
Read more about Rhinoplasty by top plastic surgeon Dr. Paul Howard..
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