Natural Facial Rejuvenation depends on selecting the best techniques to correct the natural signs of aging. The Neck Lift is usually combined with the Face Lift to maintain facial harmony, as is shown in the before and after pictures shown above.
Plastic Surgeons and Facial Plastic Surgeons alike have for decades debated the benefits of opened and closed approaches for Facial Rejuvenation. Most often, open vs. closed is debated for Rhinoplasty (Cosmetic Nasal Surgery), but at the most recent American Society for Aesthetic Plastic Surgery meeting in Las Vegas, the open vs. closed debate centered around Neck Lifts.
The Annual Aesthetic Meeting attracts thousands of Cosmetic Plastic Surgeons from around the world.
The American Society for Aesthetic Plastic Surgery
The American Society for Aesthetic Plastic Surgery (ASAPS) is over 2600 Plastic Surgeons strong. Most members are from the United States and Canada, but many countries are represented. Only about one-quarter of all American Board of Plastic Surgery certified surgeons have been accepted as ASAPS members. The ASAPS is the largest plastic surgery society dedicated exclusively to the Cosmetic side of Plastic Surgery. Most members, like myself, are also members of the American Society of Plastic Surgeons (ASPS). The ASPS represents both cosmetic and reconstructive plastic surgeons and has over 8000 members. The ASPS represents about 94% of all Board Certified Plastic Surgeons in the United States.
The Las Vegas Plastic Surgery Debates
The nice thing about a society dedicated to just the aesthetic aspects of plastic surgery is that we can focus on Cosmetic Surgery. There are many scientific sessions, expert panels and instructional courses offered over the week long meeting, each dedicated to a specific aspect of what Plastic Surgeons do. Every procedure is covered, often with multiple sessions exploring every aspect of every technique. Since there is often more than one way to do each procedure, lively debates are common, and some of these debates have been going on since long before I started my San Francisco Bay Area Plastic Surgery practice.
The Neck Debate – Open Vs. Closed
One such on going debate explores the various approaches to Neck Rejuvenation. Neck Lifts seem easy enough, but they are one of the more challenging areas to correct. Just about everyone over 40 has tried lifting their neck at least once or twice in the mirror, but making the change long lasting, without distortion, is the challenge. Several Neck Lift techniques exists, but they are usually divided into two main groupings – Closed Neck Lifts and Open Neck Lifts.
Closed Neck Lifts
There is a tremendous amount of crossover between Neck Lifts and Face Lifts, and since the face and neck age together, the Neck Lift and Face Lift are usually combined to maintain facial proportions and harmony. The term Rhytidectomy (literally wrinkle removal) is used for Neck Lifts, Face Lifts and even Brow Lifts.
When the neck has loose skin without platysmal bands, a Closed Neck Lift may be the best option. If disproportionate fat is present, Liposuction can be used to sculpt an even smoother contour.
Closed Neck Lifts are similar to what we do in the mirror. The skin is tightened in the direction of the jaw line, and the excess is removed to hold the smoothed skin in place. This reduces the loose skin under the chin (the waddle or turkey gobbler), reduces jowls and better defines the junction between the face and neck. For closed neck lifts, the skin is opened around the ears like for a Facelift, but the neck is left closed.
Open Neck Lifts
The platysma is a flat muscle that supports the neck skin. Often it is separated in the midline. As we age, we see this separation as Platysmal Bands, the two cords running down the front of the neck. One goal of the Neck Lift is to diminish to appearance of these bands.
Open Neck Lifts do everything a closed neck lift does, but also include an incision under the chin. The opening allows for direct adjustment of the superficial fat and muscles under the chin and down the front of the neck. When platysmal bands are present, the two cords of skin that run from under the chin down the front of the neck, they can be “repaired” through an open technique. Excess fat can also be removed, and we Plastic Surgeons debate how much and from which levels fat removal is most effective, yet still safe and predictable.
Minimally Open Neck Lifts
I add a third class of Neck Lift to my treatment algorithm: the Open-But-Just-A-Little-Bit Neck Lift. This is a combination of a Closed Neck Lift with Liposuction of the neck. It can accomplish much of the fat removal of the open technique through a much smaller incision. When disproportionate fat is present beneath the chin, Liposuction can be a useful adjunct to tightening up the skin. In this case a small incision is made under the chin to allow the fat to be suctioned, but not big enough to look through or repair the platysma muscle.
Most Plastic Surgeons Use Multiple Approaches
In our yearly ASAPS debates, Plastic Surgeons choose techniques and debate the pros and cons, but in reality most of us use multiple techniques. The choice depends on what our patients need. This month I have used techniques from all three categories of Neck Lifts listed above. I choose different techniques for different patients depending on what is broken, and what I have to fix.
How To Choose The Best Neck Lift For Your Neck
If you are considering a Neck Lift, it is helpful to have an idea of what your options are. Some problems respond better to specific techniques. If loose skin is the main problem, a closed technique may be the best. Platysmal bands may respond better to an open technique, while disproportionate fat may respond to liposuction.
The Internet provides lots of information, but trying to choose your own technique is a bit like trying to pick the wrench your plumber is going to use. Get a working knowledge of what is possible and get the help of a professional. Choosing the best Board Certified Plastic Surgeon is much more important than choosing the best technique. Getting multiple opinions can help, but you will likely learn that multiple approaches are possible. Having multiple choices can be a source of confusion, and this is why you need the best Plastic Surgeon.
Neck Lift Consultation
If you are in the greater San Francisco Bay Area, and would like to come into my Walnut Creek, CA, office for a Neck Lift evaluation, give me a call at (925) 943-6353. During your private consultation we will review your expectations and explore your options, so that the best Neck Lift for you can be selected.
When a patient asks me, “Do you think I need a Breast Lift or could I obtain good results with just large Breast Implants?”, I know I have some explaining to do. It’s a common misconception that larger breast implants can lift the breasts. The reality is that Breast Augmentation and Mastopexy (Breast Lift) are two completely different, but complementary procedures.
How To Evaluate Your Breast Enhancement
Optimal Breast Enhancement pays attention to both the size and the shape of the breasts. Above Breast Augmentation with Breast Implants is performed to enhance the size of the breasts and even out the asymmetry (the uncensored before and after pictures are below under “What Is Breast Pseudoptosis?”.
I separate Breast Enhancement into two areas for optimization: the best size and the best shape. Breast Implants are the safest and most predictable means we have to significantly increase breast size, but they do not lift the breasts, ever. Breast Lifts can change the shape of the breast, but they do not change the size of the breasts. Let’s go over each procedure separately, and then talk about the combination of Mastopexy Augmentation.
Breast Augmentation With Breast Implants
Choosing the best size for your breasts is the most subjective, and challenging, aspect of Breast Augmentation. I could spend an entire blog post on How To Chose the Best Breast Implant Size. Clicking on the link under Categories: Breast Implant Options gives you a quick series of San Francisco Plastic Surgery Blog posts that go over the most common options available for Breast Augmentation. The best advice I can give you is to do your homework. Stuff your bra. Try on different clothes. Look at pictures. Review online before and after photos. Whatever it takes for you to know what size is right, do it.
The Ideal Breast Size
Once you have your Ideal Breast Size in mind, you need to explain it to your chosen Board Certified Plastic Surgeon. If you desire smaller breasts, Breast Reduction Surgery is used. Because the volume of the breast is reduced during the Reduction Mammoplasty operation, the breast naturally deflates. A Breast Lift is incorporated into the Breast Reduction to enhance the shape.
Breast Implants enlarge the shape you already have. The Breast Augmentation before and after pictures above show Breast Augmentation without a Breast Lift.
If you desire larger breasts, Breast Augmentation is safest and most predictable option. Breast Implants provide the appropriate boost in volume to enhance your breasts. If you already have a pretty shape, Breast Augmentation is all that is required. Breast Implants provide a proportionate increase in breast dimensions.
The Ideal Breast Shape
When the breast volume is good, but the breast needs a lift, Breast Lifts can help. The Breast Lift (Mastopexy) before and after pictures above show how the breast can be reshaped without adding volume.
The Ideal Breast Shape is independent of size. The ideal breast has the nipple at the front of the breast; the nipple is located on the most forward projecting part of the breast (or slightly higher), and most of the breast tissue is located above the inframammary fold (IMF). The IMF is the junction between the bottom of the breast and the chest wall. When the nipple is located below the level of the IMF this is termed ptosis (true sagging).
Ptosis does not improve with Breast Implants. In fact, large breast implants increase the chance of developing ptosis due to their weight. Implants over 350 cc’s are more likely to require future surgery. Additionally, when the nipple is lower than the IMF, adding more volume to the breast tends to push the nipple down lower on the breast mound. The bigger the Breast Implant, the more weight, and the more the nipple gets pushed down. Not ideal. The best procedure in this case is a Mastopexy Augmentation, or Breast Lift with a Breast Implant.
What Is Breast Pseudoptosis?
Breast Augmentation can help with pseudoptosis and asymmetry. The breasts appear bottomed out before surgery, with most the breast volume located below the nipple and mild pseudoptosis. The Breast Augmentation before and after pictures above show how Asymmetrical Breast Augmentation can correct the shape of the breasts and the size discrepancy. In this case, the right breast was smaller than the left before surgery, so a larger Breast Implants was used on the right.
There is a specific type of Breast Deflation that can occur with weight loss, or after pregnancy, called Pseudoptosis (fake sagging) that responds well to Breast Augmentation alone. Pseudoptosis is likely the source of confusion about Breast Implants fixing sagging breasts. I review the difference between pseudoptosis and true sagging (ptosis) in the post: Do I Need A Breast Lift? (The Pencil Vs. The Pinch Test). With pseudoptosis, the nipple is above the IMF, while the breast tissue is below the IMF. Pseudoptosis is not the same as breast sagging, so it does not require a Breast Lift when Breast Augmentation is performed.
Breast Lift or Big Breast Implants?
The Breast Augmentation Mastopexy before and after pictures above show what is possible when Breast Implants are used with a Breast Lift. Correction of both size and shape is possible.
So, to answer the question, “Breast Lift or Big Breast Implants?” If you are happy with the shape of your breast, and desire a larger cup size, Breast Augmentation with a Breast Implant is likely the best option. On the other hand, if most of your breast is located below the IMF and your nipple is headed south, a Breast Lift is needed to enhance your breast’s shape. A Breast Lift can be used along with a Breast Implant (Mastopexy Augmentation) if the breast needs to be lifted, and additional volume is desired.
Breast Enhancement Consultations
Above, I have tried to simplify the decision tree for Breast Enhancement, but as more details are considered, the plan may need to be customized. If you are unhappy with your breasts’ shape, or you would like to make them a little larger, give me a call at (925) 943-6353, and make a personalized consultation appointment. We can go over all the details and formulate a plan that works best for your specific situation. Need information in Spanish? Click here: Aumento de Senos.
Liposuction has been one of the most popular Cosmetic Plastic Surgery procedures since the development of Tumescent Liposuction. The American Society for Aesthetic Plastic Surgery (ASAPS) ranks Liposuction number one, with almost 400,000 Liposculptures performed last year. The second most commonly performed procedure, with over 300,000, is covered in last week’s video blog: Breast Augmentation.
The San Francisco Bay Area’s KRON 4 Body Beautiful
More information on Liposuction, also known as Liposculpture, is available right here on the San Francisco Plastic Surgery Blog. Below is a video segment from a recent appearance on Body Beautiful. Host Janelle Marie and I discuss Liposuction, its indications and recovery. Like any elective surgery, safety and predictability are number one. This is why it is important to seek an experienced Board Certified Plastic Surgeon when exploring your Body Shaping options. Only a Plastic Surgeon can offer you all the currently available options.
Liposuction Video (Liposculpture)
More Liposuction for More People
Liposuction procedures increased over 15% compared to the previous year. This is despite the marketing of many minimally invasive and non-invasive disruptive technologies. The fact that more Liposuction was done last year than ever before means it still works, and works better.
The ASAPS Liposuction Page gives Liposuction a 91.6% patient satisfaction rating, based on over 1000 patient reviews. On the ASAPS site, Liposuction gets 4.58 out of 5 stars, with 90.6% of patients giving the procedure 4 or 5 stars. Only 1.6% of patients rate it 1 star. This is consistent with the popular plastic surgery social site RealSelf, which also gives Liposuction a 92% “worth it” rating.
How Do CoolSculpting and Kybella Rate?
The hottest Non-surgical and minimally invasive alternatives to Liposuction are Cool-Sculpting and Kybella. So how do they stack up to Liposuction? Both are less expensive for a single treatment, but a series of treatments are usually recommended, which means additional cost and downtime with each treatment.
CoolSculpting uses cold pads to chill your fat away. CoolSculpting gets a 77% rating on RealSelf, but there is an asterisk *Worth It ratings [on RealSelf] only factor in “Worth It” and “Not worth it” ratings. They do not include “Not sure.” When the not sure votes are added in, the “worth it” rating drops to 50.6%.
Kybella in an injection of bile acid that dissolves fat. It has a very misleading 97% “worth it” rating when comparing only the “worth it” to “not worth it” votes. When the “not sure” votes are considered, the “worth it” rating drops to 48.7%. Although Kybella injections seem less invasive that Liposuction one of the more dramatic complications, temporary paralysis of the lower lip, is five times greater. It turns out that bile acid also dissolves the fat that protects and insulates the nerves. In most cases the nerve heals and returns to normal function in about three weeks. To be fair, Liposuction’s RealSelf “worth it” rating also drops when the “not sure” votes are tallied, from 92% to 65.2%.
What Does Liposuction Do?
Liposuction removes localized and disproportionate fat. Bulges around the waist (muffin tops, love handles, lower bely fat), neck or thighs (saddle bags, inner thigh) can all be effectively removed by vacuuming away the excess fat. Liposuction is not a weight loss tool. Unlike weight loss, however, Liposuction has the advantage of being able to spot remove disproportionate fat directly from the areas in which it is causing problems. Even the most meticulously performed Liposuction cannot tighten skin that is inelastic. Not everyone I evaluate is a good candidate for the procedure. Some patients will choose more effective, alternative treatments other may choose to leave well enough alone. It is an individual decision, but since most Plastic Surgeons offer many different types of cosmetic plastic surgery, they are uniquely qualified to inform you about all your options.
To review all your options, and maximize your knowledge of Liposuction and the alternatives, nothing can substitute for an in-person consultation appointment. If you are in the San Francisco Bay Area, give me a call at (925) 943-6353 and get the information you need to make an informed decision.
Breast Implants are used both to provide a larger bust and to augment the natural contours of the breast. The primary goal is to improve body proportions and the fit of clothing and bathing suits. Breast Implants can help when the breasts have always been small; however, the loss of breast volume after childbirth is another common reason for Breast Augmentation.
Breast Augmentation On Television
Below is a Breast Augmentation Video. It contains Before and After Pictures of Breast Augmentation with narration. Breast Implants and Breast Enhancement, including primary Breast Augmentation, Breast Augmentation Revision and the treatment of Capsular Contracture are illustrated and discussed on KRON 4, the San Francisco Bay Area’s New Station. The show is Body Beautiful, and many video segments are available here on the San Francisco Plastic Surgery Blog and Dr. Mele’s YouTube Channel. Just click on Videos under categories in the margin or the YouTube logo.
Breast Augmentation Video (Breast Implants)
Breast Augmentation Consultations
Breast Augmentation is a very personal decision. If you have always had small breasts, or your breasts have shrunk due to pregnancy, weight loss or even age, Breast Implants may be an option. To learn more, schedule a private consultation appointment with a Board Certified Plastic Surgeon in your area. If you are near the San Francisco Bay Area, give me a call at (925) 943-6353 to get all your questions answered.
Blepharoplasty is the plastic surgery term for an Eyelid Lift. It literally means eyelid changing. For upper eyelids, the change is most often the removal of excess skin, which can make you look tired or block your vision. For the lower eyelid, the most common change is the removal of lower eyelid bags. Since the eyelids normally swell when we are overtired, the fullness caused by the fat under the eyes makes us look like we need a nap.
Eyelid Surgery on KRON 4’s Body Beautiful
Over the years, I have appeared on television many times to answer the frequently asked questions about cosmetic plastic surgery. Most recently, I had the opportunity to discuss Eyelid Rejuvenation on the San Francisco Bay Area’s News Station, KRON 4. The show is Body Beautiful, and over a hundred video segments covering many types of cosmetic plastic surgery can be found here on the San Francisco Plastic Surgery Blog. Just click on “videos” under the heading “Categories” in the column for a complete listing. Below is the most recent Blepharoplasty Video. You can also find them on my YouTube channel.
Blepharoplasty Video (Eyelid Lift)
Eyelid Surgery Consultations
An in-person consultation is the best way to get accurate medical advice about your eyelids. A brief exam and medical history are needed to be sure the procedure is right for you. Safety and predictability are the most important aspects of any surgery, but this is especially true of elective plastic surgery. If you would like to schedule a personalized consultation appointment, give me a call at (925) 943-6353.
Otoplasty continues to be a popular procedure. It is one of the few cosmetic plastic surgery procedures that is done for children, but Otoplasty is an ear shaping procedure that is performed every day for people of all ages.
Dr. Mele Discusses Otoplasty on KRON 4’s Body Beautiful
This month, I appeared on the Bay Area’s News Station, KRON 4, to discuss Otoplasty on Body Beautiful. Below is the video segment, which includes a brief description of the procedure and a narrative of several Otoplasty Before and After Pictures.
Otoplasty Video (Ear Pinning for Prominent Ears)
How Often is Otoplasty Performed?
Yesterday, I performed two Otoplasties. It is a common procedure here in the San Francisco Bay Area, especially Ear Pinning for prominent ears. Last year, the American Society for Aesthetic Plastic Surgery reported that 36,727 Otoplasties were performed. Otoplasty missed being a top ten procedure by one slot. If earlobe repairs for torn earlobes were included, it would likely be in the top three.
Types of Otoplasty
There are many reasons for having otoplasty. The most common by far is the correction of ears that stick out with an Ear Pinning procedure. However, many other ear deformities can also be addressed.
Microtia (Absence of the Ear)
The ultimate Otoplasty is the creation of an ear for someone born absent one. It is a very complicated, specialized procedure most commonly begun early in life and under the guidance of a multidisciplinary team at Children’s Hospitals like UCSF Benioff Children’s Hospital in San Francisco, UCSF Benioff Children’s Hospital in Oakland (formerly Oakland Children’s Hospital) and Stanford’s Lucile Packard Children’s Hospital. In fact, one of the world’s pioneers in Microtia Reconstruction is the San Francisco Bay Area’s now retired plastic surgeon and sculptor Burt Brent. The combination of Plastic Surgery and Sculpting is a necessity of today’s total ear reconstruction. In the future, however, with the advent of digital scanners and 3-D printing, future reconstruction may become less dependent on sculpting skills.
Other Ear Deformities
Prominent ears and microtia are at opposite ends of the Ear Deformity spectrum. A Prominent Ear is essentially a normal ear that sticks out. Microtia is the nearly complete absence of the ear. Otoplasty can be used to improve both these extremes as well as the range of ear deformities that exist between them including: losses, redundancies or injuries of ear structure either from trauma or tumor removal.
Restrictions in ear growth can manifest as Cup Ear or Lop Ear. Excess growth can result in Darwin’s Tubercle, Stahl’s Ear or Spock Ears. Injuries to the ear result in missing parts, Cauliflower Ear, Torn Earlobes and Keloids.
If you are considering cosmetic ear surgery, give my San Francisco Bay Area Plastic Surgery Practice a call at (925) 943-6353. The type of procedure best suited to your ears will be selected and discussed, giving you the information you need to make an informed decision about what the next step can do for you.
When I started my San Francisco Bay Area Plastic Surgery practice in 1997, cosmetic procedures were performed one eighth as often as they are today.
In 1997, over 1.6 million cosmetic plastic surgery procedures were performed, and most of them were surgical. The breakdown was 55% (900,933) surgical and 45% (740,751) non-surgical.
In 2015, almost 13 million cosmetic plastic surgery procedures were performed. The number of surgical procedure performed more than doubled, from 900,933 to 1,912,468. Percentage-wise, however, surgery slipped to only 15% of all cosmetic procedures. There was a tremendous surge in the number of non-surgical procedures performed driven by new technology and expanded FDA approval. In 2015 10,879,909 non-surgical procedures were performed, a 1400% increase.
Non-surgical Plastic Surgery Procedures Then and Now
The nonsurgical procedures of 1997 were not the same as today’s. The sole filler was collagen, which only lasted a few weeks, sometimes months. Botox was available, but the use of Botox for wrinkles was not FDA approved. In 1997, using Botox for frown lines and wrinkles was strictly an off label, use confined to selective Dermatology and Plastic Surgery practices (like mine).
In 2016, there are a variety of FDA approved fillers are available, each lasting months, sometimes years. The most commonly used dermal fillers are Hyaluronic Acid based including: Restylane, Juvederm, Restylane Lift (Perlane), but Radiesse (Calcium Hydroxyapatite spheres) has also emerged for boney augmentation (Cheeks and Chins) and the nasolabial folds. Botox is FDA approved for wrinkles, and is now found in just about every spa in the San Francisco Bay Area.
Surgical Plastic Surgery Procedures Then and Now
Unlike their non-surgical counterparts, the majority of the surgical procedures performed today are largely the same. New techniques and material (sutures and implants), have developed, but the most popular procedures of 1997 are the most popular procedure of 2015 too. To date, they have not been replaced by non-invasive procedures because non-invasive procedures cannot accomplish the same results. Women continue to dominate men in numbers, so let’s break down the procedures desired by each sex.
Plastic Surgery for Women
The headlines read that Buttocks Augmentation is the fastest growing cosmetic surgery. The 30% increase is statistically true, but is magnified by the fact that not as many Buttocks Augmentation are done as Breast Augmentation. Looking at the number of cases performed in 2015 reveals the popularity of the procedures:
Buttocks Implants – 5678
Buttocks Lifts – 5008
Brazilian Butt Lifts (Fat Grafting to the Buttocks) – 15,705
Breast Implants – 305,856
Comparing Buttocks to Breast Augmentation, if 3000 more Brazilian Butt Lifts are performed this year, that will almost be a 20% increase. On the other hand, if 3000 more Breast Augmentations are performed, that will be an increase of less than 1%. It’s all relative to how many procedures are performed.
The most popular Cosmetic Plastic Surgeries for women are Liposuction, Breast Augmentation, Tummy Tuck, Breast Lift and Eyelid Lift.
The most popular Cosmetic Plastic Surgery procedures from women have been pretty consistent over the last 18 years:
Comparing the male and female procedures, Rhinoplasty, Facelifts and Breast Reduction are pushed out of the top five by Mommy Makeovers; however, they are next. Cosmetic nasal surgery was number 6; Facelifts was number 7, and breast reduction was number 8 for women. When it comes to Cosmetic Plastic Surgery, men and women seem to want the same things.
Cosmetic Plastic Surgery Consultation
If you are considering Cosmetic Plastic Surgery in the San Francisco Bay Area, call (925) 943-6353 today, and schedule a private consultation appointment. Every consultation is tailored to your specific needs. The decision to proceed, or even to explore, cosmetic surgery is personal. My goal is to provide you the information you need to make your own informed decision.
Fat Grafting has been around for at least 125 years, so it is not an experimental surgery. However, the amount and quality of long term data is not great in the areas of:
the volume of fat used
the percentage of fat take
the techniques that improve fat take
how fat grafts stand up over time
how many procedures are required to get to the desired endpoint
To better answer these questions, I encourage all Plastic Surgeons performing fat grafting, especially fat grafting for Breast Augmentation and Breast Reconstruction, and those with large numbers of patients, to voluntarily participate in collaborative fat grafting research and encourage their patients to have long term (10 year) follow-up to see how good fat grafting is.
Why More Research Is Need For Fat Grafting
The aim of Fat Grafting Research to be certain that what we are doing as Plastic Surgeons is as safe and effective as it seems. Fat Grafting has been around a long time, so it is unlikely that any new dangers will be identified; however, the current literature is lacking in large, prospective fat grafting studies. There is no standardization of how fat is harvested, processed and re-injected, and even less information is available on head to head trials of Fat Grafting outcomes compared to Breast Implant outcomes.
Breast implants replaced Fat Grafting over 50 years ago as a safe and effective means of providing or restoring breast volume during Breast Augmentation surgery.
How Research Helps
Both Fat Grafting and Breast Implants have proven track records. There is plenty of evidence about how well they work, and documentation of the problems each have. For breast implants we have good data out to ten years and beyond. Having ten year data for Fat Grafting would provide additional objective evidence of the safety and efficacy of fat grafting. This means more accurate percentages to help you make an even more informed decision. More data about various methods used for fat grafting can show if one method is superior to another and help us achieve more reliable results with fewer touch-ups.
The FDA Does Not Regulate Fat Grating … At Least Not Yet
For medications and medical devices the FDA requires proof of safety and effectiveness prior to approval. Moreover, it is becoming more common that long term studies showing on-going safety and effectiveness are required even after FDA approval. For example, all FDA approved Breast Implant manufacturers were required to sponsor 10-year, prospective studies on their products, to be certain they continue to be safe and effective. We are nearly at the end of theses studies, and no new, unexpected problems have been identified. Many plastic surgeons feel that Fat Grafting should be held to the same standard.
Recently, there have been rumors that to crack down on quacks, the FDA wants to regulate the transfer of stem cells. Stem Cell Transfer does not currently fall under FDA regulation because it is neither a drug nor a medical device, but that may change. Since fat cells contain more stem cells pound for pound than even bone marrow, it is conceivable that if stem cells become regulated, fat transfer may too become regulated. Having long term follow-up studies in hand, before the FDA requires it, will be very helpful to show regulators how Fat Grafting fits into the cosmetic and reconstructive aspects of Plastic Surgery. If you were around Plastic Surgery in 1994, you know how the lack of good data crippled the availability of breast implants for the ensuing fourteen years.
Fat Transfer is New and Natural
I am always suspicious when a salesperson tries to sell me on product buy saying that it is new or natural. If you think about it, new and natural are opposites. New products, for the most part, are man made, while natural products have been around thousands, if not millions, of years.
New and Cosmetic Plastic Surgery usually do not pair well. Most new products are gone in a year. Why? Because they don’t live up to the hype. Procedures and products that have been around a long time continue to be used because they are safe, and they work. If you are being sold Fat Grafting because it is the latest thing, you know from the information above, and the last few posts, that Fat Grafting is not new. But what about natural?
The nice thing about substances found in nature is that we have generational experience with them. As a species, we know if they are good or bad. Arsenic is natural and usually bad. Here is an example of good that continues with the fat theme of this post.
Natural Fats – Cis-Fatty Acids
Over millennia, our bodies have evolved to digest fat. Whether it is animal or vegetable, fats found in nature are easily digested and stored for energy, at times too efficiently. Fats found in nature are Cis-Fats. The “cis” designates the shape of the molecule as illustrated below.
Unsaturated fatty acids have double bonds, which cannot spin. This means there are two possible orientations. The healthy “Cis-” orientation has both hydrogen atoms on the same side causing a bend in the chain. This bend fits the shape of our natural enzymes and is easy to digest.
Unnatural Fats – Trans-Fatty Acids
Trans-fats, on the other hand, are not found in nature. When these fats are manufactured in a lab half of the fatty acid’s double bonds are the natural cis-orientation and the other half are the never seen in nature trans-orientation. Europe has banned the use of trans-fats in foods, but trans-fats, also known as partially hydrogenated fats, continue to be used in US food products despite growing evidence that digesting it is not something our bodies can do well. Think of the enzymes we use to digest fat as fitting the cis-fats like a key fitting a specific lock. Trans-fats are the wrong shape, and don’t fit well.
Trans-fats have the hydrogen atoms on opposite sides of the double bond. The result is a straighter molecule that tends to plug up our natural enzymes causing health problems. Since this shape is not found in nature, our bodies are not equipped to digest them.
Natural is Good
In the case of fatty acids, the naturally occurring cis-fats are good, while the unnatural trans-fats are bad. In chemical reactions not guided by enzymes, there is a 50/50 chance of a mono-unsaturated fatty acid, a fatty acid with a single double bond, being cis or trans. It is amazing that every animal and plant on Earth manufactures almost exclusively cis-fatty acids.
Like all good rules in nature, there are a few exceptions. Trans vaccenic acid (t-VA), found in ruminants and dairy products, may be an exception to the rule. Unlike the manmade trans fatty acids, t-VA, may lower LDL cholesterol and triglycerides. On the other hand, t-VA is also found in the orbitofrontal cortex in patients with bipolar disorder and schizophrenia. Nature, like beauty, is sometimes hard to pin down.
Natural, New, Good and Bad
So, while new is usually bad for Cosmetic Surgery, this is not a rule. All old, tried and true treatments were new at one time, but old treatments have withstood the test of time. Natural also sounds good, but natural aging, stretching, laxity or smallness are the exact problems that Cosmetic Surgery strives to correct. I worry about doctors hiding behind the words new and natural without providing good head-to-head controlled research demonstrating the advantages and problems with the procedure. Fat may be natural, but there is nothing natural about taking fat from one area of the body and stuffing it into another body part. Of course, the same can be said of Breast Implants, and that is why Breast Implants are the most studied medical device in use today.
Breast Fat Grafting – An Historical Note
When I started my practice in 1997, fat grafting to the breast was specifically listed as not covered by malpractice insurance. That is to say, if there was a problem, malpractice insurance would not cover any injuries to my patients. It was the only procedure prohibited, and its restriction was based on the past record of fat grafting, specifically with liposuction used to harvest the fat. The early results were not good.
With improving results, and appropriate informed consent, in 2008 the American Society of Plastic Surgeons removed their 20 year moratorium on fat grafting to the breasts. However, I am still very selective about who I offer to do Breast Fat Grafting. I draw a line between smaller breast defects causing indentations and complete breast reconstruction without grafting.
Smaller Breast Defects respond the best the Fat Grafting. Smaller defects are very difficult, if not impossible, to fix with other available techniques. Fat grafting can be tailored the the exact size and shape the defect, providing a better cosmetic result.
Complete Breast Reconstruction with Fat Grafting is an exciting area of treatment that is being pursued with some success. Completely reconstructing a breast with fat is difficult, and often requires multiple procedure upfront. It is not as predictable, stable and for thin patients available as we would like it to be. At this time, fat transplantation is more an adjunct to current methods of breast reconstruction, rather than a replacement. Getting sufficient fat to take reliably, requires more research, and an improvement in current techniques. Hopefully, we can get there.
Fat Grafting Consultations
I am very excited about how Fat Grafting is literally shaping cosmetic surgery. It is an important procedure, and there are aspects of fat grafting that make it very appealing for selective patients and selective procedure. We don’t know yet everything Fat Grafting can offer. On the other hand, it is not a panacea, and more research is needed for large volume fat grafting, especially to the breasts. Some proponents of fat grafting may read this post as negative, because I do list many of the problems with Fat Grafting. I am a fan of the cautious use of Fat Grafting, but overall, I have tried to keep objective.
Fat Grafting can be used for Facial Augmentation, a Brazilian Butt Lift or to fill a portion of your breast that is indented. To enlarge a normal, but small breast, breast implants are still the best option in most cases. Our San Francisco Bay Area Plastic Surgery office is open weekdays 9 AM to 5 PM. If you would like to schedule a consultation appointment for Fat Grafting, Breast Augmentation or any of the other Cosmetic Plastic Surgery procedure we offer the San Francisco Bay Area, please give me a call at (925) 943-6353.
Fat is the hot topic this year. Plastic surgery statistics show that fat grafting to the buttocks, the Brazilian Butt Lift, is the fasting growing cosmetic plastic surgery procedure.
Fat Grafting Today
Like most Board Certified Plastic Surgeons, I perform fat grafting for selected patients. Facial Augmentation, Brazilian Butt Lifts and to help with contour deformities (indentations) are the most frequent reasons. Dents left after surgery, like a large breast biopsy, do not respond well to Breast Implants, but Fat Grafting can fill in the area nicely. On the other hand, for normal breasts that need significant enlarging, Breast Implants remain the safest and most reliable choice. Fat transplantation, or Lipofilling, for Facial Augmentation, the Brazilian Butt Lift and Breast Enhancement are discussed below.
Fat For Facial Augmentation
Fat is still used most commonly for Facial Augmentation, especially dents or wrinkles caused by aging, injury or disease. Fat has been replaced by Dermal Fillers for most routine facial age management. Restylane, Juvederm, Perlane, Voluma, Radiesse and others provide clean, convenient, readily available stuffing for lips, cheeks and facial wrinkles. Plus, for the HA based fillers, bad results will go away with time, or can be reversed more quickly by injecting hyaluronidase. For selective patients, fat grafting may provide longer lasting results. However, poor results from fat grafting is also more permanent, so choose your procedure and your plastic surgeon wisely.
The Brazilian Butt Lift
In experienced hands, Fat Grafting to the buttocks often gives better results than butt implants. This is especially true when the goal of a Brazilian Butt Lift (BBL) is more than just to increase the size of the bum. BBL fat grafting can be contoured to change the shape of the buttocks, rather than just to enlarge them. Other fillers have been tried, but none are FDA approved. Off-the-shelf products, like PMMA and silicone, have lead to many disastrous results and should be avoided.
Breast Augmentation With Fat
For routine Breast Augmentation, Breast Implants are still superior to fat grafting. Fat grafting has been an option since long before Breast Implants were invented early in the 1960’s.
Did you know that the poor results achieved with previous methods of Breast Enhancement is why breast implants were invented? Over 50 years ago, breast implants quickly replaced all other techniques, including fat grafting, because of the implant’s enhanced safety and predictability. I am not saying Breast Implants are perfect. Even with the latest advancements in silicone technology and manufacturing they are not, but they remain the best method for Cosmetic Breast Augmentation.
Limitations of Fat Transfer to the Breasts
The limitations of fat grafting are well documented, but here some of my concerns with fat grafting to the breast:
You need some fat to graft. Many of my patients with small breast also have very little fat. Often, there is not a large enough volume of spare fat available for Breast Augmentation. On the other hand, there is almost always an appropriately sized breast implant available.
The amount of fat that can be transferred is limited by the available blood supply. Even with unlimited fat, the breast augmentation that is reliably achieved with fat is often smaller than the augmentation that can be provided with breast implants. I have done breast augmentation for women who were disappointed by the amount of augmentation provided by fat grafting. Breast Implants were able to provide them with a more desirable breast size.
Fat is unpredictable. Sometimes, 100% of the graft takes, sometimes only 50% takes. As a result, fat grafting does not always fill uniformly. This often leads to irregular contours and the need for additional fat grafting. Breast Implants come in predictable sizes with specific dimensions.
When fat grafts fail, cells die. Sometimes, after a period of inflammation, the dead cells just go away. Sometimes, they form hard lumps which can be felt, and calcifications which can be seen on a mammogram. The calcifications from dead fat are usually larger than the calcifications seen from cancer, but occasionally the calcified areas need to be biopsied to be certain they are not cancer. If there are many calcifications, this may interfere with the screening for breast cancer. Breast implants can fail too, but they can be removed and replaced with a new one.
When fat grafts fail, cells live. Now I know this is the desired result. It is important to realize that the fat cells that survive the transplantation procedure do not know that they are in a new place. They will continue to shrink and enlarge as your weight changes. If you lose weight, you will also loose fat graft volume. Alternatively, if you gain weight, your grafts will enlarge and not always evenly. Breast implants do not change volume.
Donor sites need to heal, too. Fat grafting requires fat harvesting. With the advent of Liposuction, fat harvesting has become much simpler and efficient. On the other hand, removing the fat for grafting has all the risks associated with Liposuction. The donor site will be sore. It needs to heal, and just as importantly, needs to have an aesthetic contour. Breast Implants do not have a donor site.
Plastic Surgery Consultations
There are many more specifics to discuss. I will continue the discussion next week. If you would like to get the specifics that apply to you, schedule a consultation appointment by calling (925) 943-6353. Our San Francisco Bay Area Plastic Surgery office is open weekdays 9 AM to 5 PM, and we offer a wide variety of Cosmetic Plastic Surgery procedures.
Many of my San Francisco Plastic Surgery Blog posts are inspired by the questions I get from patients. Inquires come from patients in my Walnut Creek Plastic Surgery Office during in-person consultations and also from the Internet, via the contact forms available in the margin of this blog and my other Plastic Surgery Web Sites. The question of fat grafting for Breast Augmentation comes up with some regularity, so I will share both the pros and cons of fat grafting, specifically, How Fat Grafting Compares to Breast Implants for Breast Augmentation.
The Medical Use of Fat
Fat cells are incredibly efficient at storing fat. While most cells look like a fried egg with a nucleus the size and proportion of the yolk, fat cells are so full of fat that the nucleus looks more like the gondola of a blimp. In the picture, the nuclei are the small purple dots along the edges of the giant fat-filled adipocytes.
Fat and medicine have long been associated. Anthropologists have discovered that Australian Aborigines used fat, bandaged with animal skins or bark, to treat open wounds. The Aboriginal folklore is some of the oldest and most accurate oral history on the planet. Their stories date back 300 generations, and include not only medical care, but the rise in sea level 10,000 years ago as the ice age ended, the great barrier reef forming the coastline of Australia and fertile hunting grounds where today’s Australian bays exist.
European medical history also documents the use of fat for treating opens wounds. While this was usually animal fat, human fat was also used. Descriptions of the Siege of Ostend, circa 1601, include stories of Dutch surgeons bringing “great bags of human fat” to the battlefield to treat the wounded. Since Liposuction had not yet been invented, I will leave to your imagination the source.
The Surgical Use of Fat
Fat is harvested with liposuction, and the cells are processed to remove oils, fluid and broken cells from the healthy fat cells (adipocytes) for grafting.
As early as 1889, Fat Transfer procedures are documented. In an attempt to cure a patient suffering from cirrhosis of the liver, Van der Meulen transplanted the patient’s omentum, a collection of fat and blood vessels found in our abdomen, to the patient’s liver, in an attempt to revascularize the failing organ. The omentum was disconnected from its blood supply, and additional fat autograft was placed with the omentum between the liver and the diaphragm. While this first attempt resulted in the patient’s death, in 1895, Rutherford Morison tried again with a similar operation.
Morison’s patient also had advanced cirrhosis. After the procedure, this patient lived for two years. He may have lived longer; however, he died two days after a much more trivial operation for a ventral hernia repair. Even with today, cirrhotic patients do not do well with surgery. They have trouble with nutrition, clotting and controlling infections. Remarkably, the post mortem autopsy revealed that the omentum and Fat Transfer resulted in the formation of numerous new blood vessels, which helped to decompress the dangerous portal hypertension seen in cirrhosis. Portal decompression in more reliable forms is still used to treat portal hypertension caused by cirrhosis.
Who Invented Fat Grafting?
Fat Grafting is an old technique. In 1893, Gustav Adolf Neuber reported the use of small fat grafts to fill in a soft tissue depression on a 20-year-old man’s face. Neuber mentioned he had less success when he tried to use larger grafts, saying that “grafts larger than an almond would not give good results”. This is still true today, as larger fat grafts cannot establish a blood supply fast enough to survive the transplantation.
Fat Grafting in the Breast
There are many examples for fat transfer in the medical literature beginning early in the 1900’s. In 1895, Vincenz Czerny performed Breast Enhancement with the transplantation of a lumbar lipoma removed from a woman’s back and placed into her breast. Early pioneers like, Holander, Lexer and Pennisi published the first articles and books devoted to autologous fat grafting before 1920. Characteristics of Fat Grafting noted then, are just as true today:
Smaller grafts are more reliable.
Younger patient’s fat survives better.
A healthy recipient blood supply is needed for the fat graft to survive.
Fat that survives continues to behave like it did in the donor area.
This last point is important for the predicability of the fat grafting results. If you lose weight, the donor area gets thinner and the volume for the fat grafting is reduced. On the other hand, if you gain weight, your fat graft will enlarge. The problem with reliability of Fat Grafting for Breast Augmentation, both with initial take and long term stability, is one of the main reasons that Breast Implants rapidly replaced fat grafting and all other previous Breast Enhancing methods in the early 1960’s.
Fat Grafting Today
I perform fat grafting for selected Facial Augmentation, Brazilian Butt Lifts and to the breast for localized volume loss. Problem areas, like the dents left after a large breast biopsy, do not respond well to Breast Implants, and fat grafting can be tailored to selectively fill concavities. Although some progress has been made, for significantly enlarging an otherwise normal breast, breast implants remain the safest, most reliable and least traumatic choice.
The Brazilian Butt Lift has been on the rise in the US for the last ten years. The technique allows not only for buttocks enlargement, but for reshaping the buttocks. The before image on the left shows square buttocks which are asymmetrical, too full up top and yet empty laterally, especially on the left. The after image on the right shows more shapely female buttocks with a rounder fullness, smooth contours and better symmetry. The end result is an hourglass figure.
There is much more to discuss about Fat Grafting. Other ways that Fat Transfer is used, and the common areas treated will be discussed in the next two posts. Also, coming next week, I illuminate some problems often left out of the discussion. Understanding the downsides and the limitations of Fat Transplantation is an important part of making an informed decision.
Fat Grafting Consultations
If you would like to schedule a consultation appointment for Fat Grafting or Breast Augmentation, please give me a call at (925) 943-6353. Our San Francisco Bay Area Plastic Surgery office is open weekdays 9 AM to 5 PM.