What You Need to Know About Stem Cells

plastic surgery dr paul howardResearchers and even medical students have known about stem cells for decades. They are the multi-potential cells in embryos that can become any cell in the body; brain, muscle, heart, etc. Years later an adult version of the stem cell was identified, not quite as basic as the embryonic stem cells, but able to become many other types of cells.

Once identified, we could grow them outside the body and stimulate them to become more advanced cells such as those composing cartilage, muscle, bone and even heart tissue.

More recently it was discovered that the bodies’ main repository of adult stem cells is in our fat (adipose) tissue. These adult stem cells can also be harvested from the bone marrow in much smaller quantities and with significantly greater pain.

This discovery was great for plastic surgeons as we are the primary surgeons who harvest fat for cosmetic reasons by suction-assisted lipectomy (liposuction). With this technique, liters of fat can be harvested at one time to be processed to release the adult adipose-derived stem cells from the fat.

There are methods that currently exist to multiply the number of stem cells from thousands to hundreds of millions, but this must be done in a laboratory and is controlled by the FDA.

These stem cells once multiplied and stimulated in the lab can become a medical treatment by replacing injured or worn out cells in the heart, joints and maybe even other organs such as the liver and kidney.

For the present, we can use a person’s own stem cells (not Aunt Thelma’s) to replace soft tissues if injured using your very own fat cells which already are charged with stem cells. Fat grafting to the face as part of a facial rejuvenation procedure has been around a decade or so in my practice. The addition of extra stem cells to the facial fat grafting we do with facelifts gives a remarkable improvement in skin tone and texture due to the rejuvenating qualities of stem cells.

The limit to stem cells is that they only work for you because you and your stem cells have the same DNA. Therefore, one can harvest and freeze your fat with your stem cells for future use but no one can “borrow” your stem cells.

Another limitation to stem cell medicine is that you cannot rub stem cells on your skin like sun block. The stem cells only work inside your body where they can interact with other cells. It naturally follows that if you cannot use Aunt Thelma’s stem cells, stem cells from other DNA sources like plants and trees have no effect on humans but are probably great for other plants and trees.

Just the words “stem cells” have become a cultural phenomenon. I’ve read recently where stem cells can reconstruct a breast and even make a small breast larger. Of course, none of that is true but fat grafting, with or without stem cells, is commonly used to reconstruct soft tissue defects of the face, breast and buttocks. The stem cells are there just to improve the amount of fat that survives with grafting and provide no volume on their own.

Advertisers who use the words “stem cells” to describe their latest, greatest fountain of youth product are taking advantage of the hyperbole of public perception which is totally different from the public facts regarding stem cells.

Aging & Fat Grafting for Facial Wrinkles

fat-grafting-for-wrinkles-and-lips

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).

On the Training of Horses, Linebackers, Pilots and Plastic Surgeons by Dr. Paul Howard

The critical reader may come to the opinion quickly that I am only a Plastic Surgeon and probably know little about training horses or football players.  While this is essentially true, I don’t believe it disqualifies me to comment on other fields of endeavor that require many of the same complex skills that are inherit to the plastic surgeon.

The training of surgeons is unlike any other field of endeavor.  One can read massive amounts of material, study diligently for four years of medical school, memorize the indications for an operation, actually study the pertinent anatomy and how to perform an operation and yet know virtually nothing without taking the final exam by incising the patient’s skin and performing an actual procedure where the stakes are as high as they can be.  This discipline is entirely different than any other medical specialty as the requisite study of disease is not the endpoint of training, it is the ante that allows one in the real game which is the application of knowledge to perform a mechanical skill (surgery) which is basically unnatural and requires skills that are not genetic but entirely learned.  Since surgery is learned behavior, there is no way to be graded except by the subjective appraisal of a competent surgeon.  As time evolves and the surgeon becomes independently proficient, the grading of results requires continuous, honest self-assessment of one’s results.  The built-in weakness of the surgical training paradigm is the quality of the “on-the-job” training.  This is the primary reason why surgical, and more specifically, Plastic Surgical training, can lead to widely diffuse results in the quality of the surgeon.  These facts became self-evident to me and led me to seek the most talented and well known surgeons of my era of medicine.  Since we learn surgery by watching and imitating others, it makes perfect sense to seek the best to emulate.  This quest is how I came to know John Kirklin, M.D, Ralph Millard, M.D, and Paul Tessier, M.D.  For those who are unfamiliar with the names, these are the best of the best in surgery.

Let me begin by admitting that I am a hero worshiper.  It happens that I have a small but unique set of personal heroes that I have accumulated over a lifetime.  These men have excelled in their respective fields which happen to include the thoroughbred racing business, the aircraft industry, the National Football League, and the field of plastic surgery.

Those who only know horse racing by watching the Kentucky Derby the first Saturday in May every year are not privy to the complexities of thoroughbred breeding, training, and racing.  You may notice the atmosphere in Louisville, KY at Churchill Downs includes beautiful hats and the unfettered consumption of Kentucky bourbon in the form of the ever present Mint Julep.  This pageantry belies the complexity of horse genetics and gene pools as well as the training of these extremely fragile animals.  Additionally, they are trained to race beginning as a two year old animal.  The three year olds that race the Derby are still adolescent animals and behave in many ways the same as our teenaged children.  Yet, the results of their early races can lead to a multi-million dollar horse, both as a racer and later as an addition to the thoroughbred gene pool.

Dr. Ruel Cowles is a veterinary physician/surgeon whose practice and life is dedicated to the healthcare of these majestic animals.  One of my mentors, John Kirklin, MD, was an established horseman and was convinced that race horses were essentially untrained whereas gaited, dressage, and jumpers were the only horses truly trained.  Dr. Kirklin also opined that a good jumper must be at least 10 years of age.  Racing 3 year-olds in packs of 10-20 over a mile long course against the best 3 year-olds in the world would probably be a daunting task for a 10 year-old thoroughbred.   It’s like training a 15 year-old to pitch in the major leagues – you can never be sure exactly what you will get.

Dr. Cowles embodies the best of clinical veterinary medicine as well as the intellect to excel as a horse breeder.  Dr. Ruel Cowles is one of my heroes.

I have more than a passing interest in the sport of American Football.  I was, as many of my colleagues were, a high school football player.  I managed to keep my NFL dreams alive through my first year of college where the physical and mental rigors of the game caused me to turn in my shoulder pads to pursue academics full-time.  As such I developed an almost unhealthy respect for those players who made it to the NFL.  I particularly liked linebackers as that was my chosen position.  The day I met Kevin Greene, at the time playing for the LA Rams, I realized who I would have become if I had the fortitude to continue playing.  Kevin was a walk-on at Auburn University in the early 1980’s under Coach Pat Dye.  He showed early on his pass rushing prowess, but only a few NFL scouts agreed and was chosen by LA in the sixth round of the draft. From his first training camp, Kevin’s coaches and teammates understood that going easy on the veterans was not part of his game.  All Pro offensive tackle Jackie Slater found out Kevin was a “maniac” on every play, pre-season or not.  Kevin was soon inserted in the line-up for the Rams and there he stayed.  After leaving the Rams for Pittsburgh, he truly found his identity, grew his hair to his shoulders, married a beautiful Alabama girl, and became a favorite in Pittsburgh because of his aggressive and relentless style of play.  He was known for sacking the quarterback but in fact was a complete linebacker in the 3-4 scheme.  I cannot remember a single time that a running-back or receiver managed to even fall forward after he got his hands on them.  I was privileged to be Kevin’s friend through the entirety of his 16 year NFL career including multiple Pro Bowls and defensive linebacker awards.  His intensity and dedication to his craft were unparalleled.   Ten years after his retirement from the NFL, he still holds the career sack total among linebackers.  Today, Kevin is imparting his knowledge to younger players as the outside linebacker coach for the Green Bay Packers.  Kevin is also one of my heroes.

I’ve known but a few fighter pilots and one submariner personally.  There are a few common traits these people have that separate them from the rest of us.  First, they all have very acute and agile minds that can assimilate knowledge quickly and apply it so that they are constantly evaluating their performance and improving by self-evaluating and reflection.  These traits are similar to those needed for plastic surgeons with the added immediacy of going Mach II or being thousands of feet under water.

As a first-year resident under Dr. Ralph Millard, I became acquainted with Dr. Gregory Lovaas senior resident under Millard.  Greg was like a xenon light in a room full of candles.  He shown brightly and was a wonderful teacher to me.  Knowing Greg as I did it was not easy to imagine the government putting him in a single seat F-104 fighter with nuclear weapons.  As I learned more about Greg, I realized he was the perfect personality for such a dangerous, in-your-face profession.  Greg, as most intelligent people do, had a wondrous sense of humor that may or may not have served him well over the years. My most vivid memory of Greg is the fighter pilot/Plastic Surgeon maniac.  He taught me the fighter pilot credo – “sometimes wrong, never in doubt.”  Greg Lovaas is one of my heroes.

A young boy and his twin brother grew up fatherless during the Great Depression in rural Griffin, Georgia.  Times were tough for everyone and the twins did the best they could for themselves and their family.  As they became teenagers, sports helped fill their days.  It was an accident playing baseball that knocked out the two front teeth on one of the boys causing a speech impediment and a lasting impression as he did not have enough money to receive the necessary dental care.  The twins with no prospects on the horizon lied about their age and enlisted in the Army and the Navy.  The story goes that the twins couldn’t understand why the new recruits were homesick and even cried at night while the twins were elevated from their Hell to three square meals a day and they weren’t worked very hard.  The addition of free dental care made WWII a life altering experience, all for the good.

New pair of shoes, one suit, two new teeth and training in electronics were enough to start a new life several years after the war with a new wife and further training in repair of the new-fangled American commodity – the television set.  The younger of the twins was desperately trying to live the American Dream.  Fixing the notoriously unreliable TVs and their vacuum tubes was a decent job.  Utilizing his military training and hands-on electronics experience, twin got a job with Lockheed Aircraft in Marietta, Georgia where he taught electronics to the new hires needed to build the C-130 “Hercules” and the new super airliner – the L-1011.  The younger twin learned he had a knack for teaching and especially training people to do a job.  He eventually parlayed this experience into industrial training programs for four Southern states eventually having a training facility posthumously named after him in Montgomery, Alabama.  Twin number two, and one of my heroes, was George L. Howard, my father.

The training of plastic surgeon is a long grueling process due to massive amounts of material to learn, but more importantly the aptitude, mental acuity, and complex decision making necessary.  Most students of plastic surgery realize that the training is so long (± 6 years) because the depth of knowledge necessary is vast and by necessity practicing plastic surgery requires a malleable mind to attack each challenge with freshness, intensity, and thoughtfulness. These attributes are not something one can read about, but can only be obtained by acquiring the knowledge from others who already have it.  This is why it is so important to ask the credentials of a plastic surgeon so one can surmise the quality of his/her education in plastic surgery.  In plastic surgery, it makes perfect sense that truly the best plastic surgeons are the best teachers.  My final heroes are two of my plastic surgery mentors that encompass the best that our field has ever created.  D. Ralph Millard, Jr., M.D., and Paul Tessier, M.D. are also my heroes.

Recent history has taught us the penalty to be paid by the consumer of plastic surgery who is swayed by the exquisite marketing of doctors who believe for financial reasons that the least amount of education in the intricacies of plastic surgery is somehow better than the full training program that has been in place for 30 years.  There is no other example of attenuated training in any of the surgical specialties.  Neurosurgeons are required to train in all aspects of neurosurgery and even take a year of basic neurology training even though few neurosurgeons practice all of the aspects of the specialty.  This is mainly because for the last 100 years it is clearly shown that almost all specialists benefit from a wide and diverse basis of knowledge leading to calmness under pressure and the ability to elicit a laser-focus required of the expert.  This is true for training many kinds of endeavors and one will never find a short-cut to the training of the best race horses, NFL linebackers nor in the making of aircraft or the training of plastic surgeons.  Hippocrates said it best in his aphorism “Life is short, and the art is long; opportunity fleeting; experience perilous, and decision difficult.”  The first time I heard this warning was from the great cardiac surgeon John Kirklin, M.D. in his famous surgical “blue-book” to help train young cardiovascular surgeons.

To learn more about Dr. Paul Howard, please visit his web sites:

www.paulhowardmd.com

www.TheHowardlift.com

Fibroblasts vs. Stem Cells by Dr. Paul Howard

The TV news media is reporting the latest “break-through” in cosmetic medicine science.  Evidently for a mere $4,000 one can take a punch biopsy of a patient’s skin, send it to a lab where fibroblasts are isolated, cultured and expanded.  This results in millions of fibroblasts which are then re-injected into the face to rejuvenate the tissues as fibroblasts are known to synthesize the protein collagen which is lost in the aging face.  This clearly is a break-through in cell biology albeit an expensive one and not a popular alternative since it doesn’t last longer than 6 months.

A different technology has been available for several years and achieves pretty much the same thing at a fraction of the cost, and it lasts forever.  Adipose derived stem cells are isolated from liposuction aspirate and then re-introduced into the areas requiring rejuvenation.  The stem cells are more basic precursor cells to fibroblasts thus are thought to transform into fibroblasts as well as other cell types that increase vascularity and provide many of the trophic growth factors that help rejuvenate skin.  Depending on their environment, stem cells can be encouraged to form cartilage, even re-create osteoblasts that form bones.  Therefore, stem cells have been used for a wide variety of clinical problems including skin rejuvenation, joint cartilage re-growth and healing, wound healing and even re-growth of cardiac muscle tissue.

All of these new technologies whether or not they are “FDA approved” need to be evaluated through the prism of overall scientific advances.  It seems that the imprimatur of the FDA allows the science to be exploited for marketing gain by the few.  Regardless, FDA involvement with these new scientific advances has not been well defined and tends to allow for marketing adulteration of the product  in question often misleading the consumer regarding other available options

Joggers and Runners: Beware

In our current healthy and image conscious environment many people choose to maintain fitness by running, jogging, or high impact aerobics.  While these exercises are great for cardiovascular fitness they are extremely bad for facial aging.  First and foremost facial aging is primarily a result of loss of skin elastic tissue due to sun damage, environmental factors and smoking.  Pounding the pavement has an adverse effect on facial aging in the face of poor skin elasticity.  Compression garments can be worn to hold firm abdominal, thigh, and buttock tissues as protection against the effects of running on these tissues.  No such garment can protect the face from the deleterious effects of extreme exercise.  Runners are usually thinner than others of the same age.  It is a well-known fact that while healthy, thin faces age quicker than faces with some fat content.  The opposite is true for necks – little fat in the neck is good whereas a fat neck is difficult to contour.  Many people who exercise heavily do not maintain adequate hydration.  Drinking large amounts of water help keeps skin hydrated and less likely to manifest dryness, fine wrinkles, and laxity of aging.  There are plenty of aerobic exercises and machines that provide a serious workout without the up and down pounding that can exacerbate the facial aging process.

Luscious Lips

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:

Read more about Dr. Paul Howard’s lip augmentation.

 

Lip Augmentation Before Picture

Lip augmentation before photo

Lip Augmentation After Picture

Lip Augmentation after picture

The Perfect Facial Filler by Dr. Paul Howard

Botox and Restylane have become the mantra for those seeking facial rejuvenation without the inconvenience of having a “surgical procedure.”  While these off-the-shelf products are enticing, they are expensive, temporary, and can be painful to inject, especially in the lips.  For more Plastic Surgeons, these artificial fillers (Restylane, Juvederm, Strattice) are appropriate only for temporary improvements where there are time constraints and the need to be in public within a couple of days.  Searching for the perfect facial filler had been elusive until recently.  The emergence of fat from your own body (autogenous) has paralleled the refinements in fat harvesting and injection techniques that have elevated the “take” of fat injections to the 80-90% range.  Coupled with improvements in local anesthesia and anesthetic agents make the overall experience with the new fat injection techniques less painful and more likely to give a permanent, elegant improvement in facial contours and rhytids (wrinkles).  Many non-surgical practitioners complain of the donor site for obtaining the fat.  While we must respect the donor site, offering the patient an improvement in body contour by harvesting fat for injection offers the patient the benefits of a liposuction (method of harvesting fat) procedure and cosmetic improvement of the donor site as well as the areas of the face injected with fat.

What does the future hold for facial fillers?  Ongoing research using stem cell and growth factor technology may lead to even further improvements in fat injection techniques while artificial filler research tries to make their artificial substances last longer and the cost with longer lasting substances is naturally higher and will continue to increase over time.

Fat injection techniques have proven to be a vast improvement over foreign-body injections for facial rejuvenation.  Fat is permanent, soft, cannot be rejected by the body, natural, and requires only small (3-4mm) stab wounds for injection.  The patient can request which body area is preferred as a liposuction donor site obtaining body contour improvement at no additional charge.  The well informed patient will usually choose the elegance of fat injection over the expediency of foreign material injected in the face.

As an extension of fat technology, we have begun fat injections in the back of hands for hand rejuvenation.  The injected fat decreases the appearance of prominent veins, knuckles, and tendons that become more pronounced as we age.  No one should let their hand reveal their age when we have the procedures to reduce the signs of the aging hand.

Read more about top fat grafting surgeon Dr. Paul Howard and view fat injection before and after photos.