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 storage fee and a one time set-up fee by the storage facility (not including in-office surgical removal).
The use of complimentary or alternative medicines such as those found in herbal or homeopathic preparations has increased from 20% of our patient population to more than 60% of our patients. The fascination of herbals, teas, and homeopathic products exists because people believe these medicines to be “natural” and therefore perceived to be “safe.” Only recently have these products been scrutinized carefully by the medical community to determine how safe they actually are. In preparing for plastic surgery, safety issues are being addressed due to the fact that there are an increasing number of reports describing bleeding
complications due to herbal remedies. We now know the chemistry of most herbals so we can now identify the substances within each herbal preparation that are likely to cause bleeding problems. To date, the only documented sequelae of herbals that effects plastic surgery is the increased risk of peri-operative and post-operative bleeding which usually manifests as more swelling and bruising than one would normally see. In more severe cases, these homeopathic medications may even cause significant bleeding and hematomas.
A partial list of common herbal supplements that are known to cause bleeding problems is provided:
Oil of Wintergreen
Red Chili Pepper
Other dietary supplements known to effect healing or cause bleeding:
Chondroitin & Glucosamine
As a general rule of thumb, any herbal supplement which is known to cause or have any pharmaceutical activity should be discontinued 2 weeks prior to a general anesthetic or outpatient surgery under local or sedation. Since many herbal or homeopathic formulations contain numerous plant extracts, it is best to stop all homeopathic remedies including herbal teas a full 2 weeks before surgery. Patients may renew taking their supplements once uncomplicated healing has progressed for at least one week post-operatively. It is probably in the patient’s best interest to assume all homeopathic supplements have the potential to effect healing and should be discontinued 2 weeks prior to surgery.
Beautiful, full, pouty lips are considered youthful. One of the natural consequences of facial aging is the loss of normal lip volume causing a deflated appearance with wrinkling. There are many misconceptions regarding attractive lips that seem to have found their way into the social consciousness due to plastic surgery results that seem to have gone awry. Merely increasing the size or the amount of vermillion show (red portion of the lips) does not make lips youthful or attractive. In fact, exaggerated lips seem to invoke the opposite response much like the overdone rhinoplasty, facelift, or breast augmentation. It should be clear that exaggerated plastic surgery is a choice, not a necessity. Plastic surgery has progressed do the point where overdone is not mandatory and we Plastic Surgeons should question not what we can do but what we should do. Because a patient asks for bad plastic surgery doesn’t mean we are obliged to do it. Our role should be to educate those who ask for things we know are unattractive and if no common ground can be negotiated, no surgery should be performed.
There are details commonly associated with youthful lips that are easy to achieve as long as you know what you are trying to achieve. Full lips are youthful, grossly inflated lips are not attractive and reek of bad Plastic Surgery. Full lips require replacing the lost lip fullness with natural material such as fat. There are numerous off-the-shelf graft materials that seem easy to use, but as foreign materials they present a multitude of problems that make the result less than perfect. Autologous fat taken from the abdomen or hips, when properly processed, provides the best graft material for lip augmentation. Increasing lip volume causes some increased vermillion show (red portion of lips) seen from the front as well as increased “pout” as seen from the side. The increased volume must be apportioned so that they appear fuller and pouty. Other aspects of the beautiful lip include definition of the white roll, fully visible philtral columns, and important for a natural look, a lower lip that is slightly fuller than the upper lip. These nuances are not obtained by luck, but rather because of detailed surgical planning using the correct filler material. The results should be apparent immediately and should last a lifetime. Continued aging may lead to the need for touch-up grafting after several years even though the transferred fat, once healed, is permanent even though the lips are a highly mobile area of the face. Any perceived problems with graft “take” are generally due to poor harvesting of the fat and inadequate processing of the harvested fat. One should expect to have the fullness lost since the teenage years. It can be helpful for your Plastic Surgeon to see high school photos for reference.
Dr. Howard has been a world leader in fat grafting for over 25 years. Patients travel from all over the world for his fat grafting mastery to rejuvenate their appearance, or fat grafting for reconstructive procedures due to injury or birth defects. To learn more about fat grafting for lip enhancement, facial rejuvenation, or cosmetic hand rejuvenation please visit: