What is old often becomes new again as techniques improve and better science comes to focus on a treatment; fat injections are an excellent example of this. Close to 100 years ago surgeons came up with the idea of taking fat from one area of the body and moving it as a graft to fill a defect somewhere else. These procedures typically failed for larger lumps of fat couldn’t heal in well to the new area leading to fat cell death, cysts, firmness, or infections. Still a creative approach for after the turn of the century. The advent of liposuction techniques in the 1980’s led to Plastic surgeons revisiting the ideas of injecting fat into areas of the body to correct trauma defects and for cosmetic purposes. While there were occasional successes there were still many failures and unreliable survival of the fat grafts that led to patient and surgeon disappointments. Still given the potential of fat grafting for breast augmentation, buttock augmentation, facial filling, cancer reconstruction, and traumatic contour correction has made us continue to push the envelope to make it a more reproducible technique. Many studies have now been done to look at the physiology of fat cell so we better understand how much trauma the cells can tolerate when harvested by liposuction. Studies continue to look at whether cells survive better if cleansed, or centrifuged at low speeds, or if growth factors or other agents can be added to them to make them healthier and survive in the new site they are placed. In short, we keep learning, keep refining the techniques, and keep looking for new ways to do this better.
Stem Cells and Fat Injections
More recently the science of stem cell research has been focused on fat cells as a good stem cell line. It turns out that fat has a higher number of stem cells than some other tissue types of the body. Stem cell is a fancy term for a cell that has the potential to turn into different types of cells. So a fat cell that is a stem cell might be able to turn into a muscle cell or a bone cell if the right chemical triggers direct it to change. Also stem cells have the potential to release more growth factors or other cellular chemicals that might be advantageous for tissue growth. Now I’m simplifying this in a huge way; this is very high level scientific stuff that involves DNA triggering, cell life cycles, complex growth factor chemistry, and the mechanisms of how cells “speak” to each other. Just taking a stem cell and sticking it somewhere in the body doesn’t mean it will do anything special, that stem cell needs all the right chemical triggers to behave like the “magical cell” that it can be. My own research background when I was studying General Surgery and also later with Plastic Surgery was growth factor research, collagen research, and the science of wound healing, and I still have a hard time understanding all the science of stem cells and I was in the field back in the day. Still this is very exciting stuff even though we are just beginning to crack the egg of stem cell potential. So what has this meant for fat grafting for breast, buttock, and body contouring?
First, fat grafting has been shown to be much more reliable now with correct handling of the fat and good patient selection. Second is there may be some stem cell interactions that go with fat transfer that helps with the results. This second point is still to be worked out, we must remember that the stem cells in a fat graft is an extremely low number of cells compared to the regular fat cells, and again without the right chemistry in the area those cells likely aren’t doing anything special. The jury is still out on the exact involvement of stem cells in the graft, but there is some loose evidence that it’s a good thing to have them there. So let’s revisit body contouring.
Fat Grafting and Breast Procedures
There is great interest in breast augmentation and breast reconstruction with fat grafts from liposuction. It’s critical for patients to understand that the hype is always greater than the reality, but this is still a very promising area. Breast augmentation or reconstruction with fat injections is still viewed as an “experimental” technique, but it is becoming more accepted as we study it closer. The most obvious concern is can fat grafts to the breast lead to increase risks of breast cancer or can the grafting procedures make it harder to detect breast cancer later in life. If some breast fat grafts for cysts or scar tissue in the breast it might make it very difficult for a radiologist to tell cancer from scar. As more cases have been preformed and more radiologist have evaluated patients over time post fat grafting they have not found this to be a problem. The experienced radiologist can most always tell “non-cancerous” scar tissue in the breast from the signs of cancer on a mammogram. Also as our grafting techniques get better there is better “take” of the grafts and less scar tissue to worry about. To date there has been no indication that fat grafting increases the risk of cancer occurring in those grafts, but of course it will take many thousands of patients followed for many years to get solid data on that type of topic. We have to remember that the incidence of breast cancer in the regular female population is around 10%. If someone gets fat grafts and has a breast cancer 20 years later we really have no way of knowing that she wasn’t going to get breast cancer anyhow. One thing that remains very clear in my experience is that younger patients have better graft take than older patients and so fat grafting has greater promise in augmentation of younger patients than perhaps patients over 40 years of age. Of course other health issues come into play also for the patient with diabetes, a smoking history, cardiac or vascular disease will have less success with fat grafting than the patient without any medical issues. Physiologic age is more important than chronologic age. Some 50 year old are physiologically in better shape than some 35 year olds.
Fat Grafting Success Rates
In my plastic surgery practice in Tucson Arizona, I have had some young patients take fat grafts so well that I had to go back and remove some later, and I’ve had some older patients look like none of the fat stayed after 6 months or more. It’s a very mixed bag of success rates, but it keeps getting better in my hands. Patients have to be realistic and surgeons have to avoid making grandiose promises about results. Don’t let anyone tell you it works all the time, but also don’t let anyone tell you it’s not a valid technique for fat grafting works very well often.
One issue for patients considering fat grafting for breast augmentation or buttock augmentation is that tiny patients might not have enough fat to accomplish much augmentation. A very slim patient that wants very little buttock or breast augmentation might get away with it, but these patients typically need standard techniques of breast or gluteal augmentation to accomplish their desired look. A little more heavy set patient may have more fat to harvest to accomplish filling with fat alone. Another key issue to remember though is the more fat we put in the more chance it might not take as well. Fat grafts do best as small threads of filling at many different levels and directions so the fat has the best chance of getting blood vessels to grow to them and provide nutrition and oxygen and all the good stuff that keeps a cell alive and happy. The more fat that gets layered in next to other fat grafts the more difficult it is to get good healthy fat as the final result. This is one of the reasons fat grafting can take a long time to do. First we have to suction the fat to be reinjected, and the technique of harvest can’t be too traumatic to the cells, then we clean the fat and “purify” to cells so the graft is more likely to have more healthy viable cells, then we have to reinject the cells into multiple spots and planes so they have the best chance of making it on the long term. Rough rapid traumatic technique might kill more cells, it’s a delicate balance of efficiency to cell survival. We’re very excited about the current use of fat grafting and the promise of better things to come as the science is worked out better and better every year.
If you have any questions about fat grafting for the breast, the buttock region, or body contours please don’t hesitate to make an appointment for a consult with Tucson Plastic Surgeon Dr. Jeffrey Nelson at (520) 575-8400
Like many things in cosmetic surgery, you can do a “little” or you can do “a lot”. When a patient comes in for body contouring consults the first issue is, can this patient get away with just liposculpting and avoid incisions for skin excision or muscle tightening? Liposuction is a marvelous procedure that can accomplish surprising results, but we must also remain realistic and guide patients to the right procedures to accomplish logical goals. Avoiding skin excision is more likely if the patient hasn’t had major weight changes, or pregnancies that can lead to skin laxity. In the case of pregnancies the internal connective tissue that gives support to the abdominal muscles can be stretched significantly, and all the sit-ups or exercise in the world won’t bring those supportive structures back to normal; it requires internal suturing to reef the tissues back to a more youthful position.
Liposuction and Laser Liposuction
While liposculpting and laser liposuction can provide some skin tightening, often the patient’s hopes and desires are beyond the reality of what skin tightening will occur from the healing process; just sometimes you have to accept that a tummy tuck type procedure is needed. A younger patient with good skin quality may get terrific skin contraction following liposuction procedures while the patient with thinner skin, many stretch marks, loose hanging skin will likely be underwhelmed by the skin contraction and disappointed. This is why an honest discussion with the Plastic surgeon and realistic assessment or photos of typical results leads to the right decisions being made on your behalf. Be wary of overselling of skin contraction; our job is to give you clear realistic impressions of what surgery can do for you. Sometimes that’s liposuction alone, sometimes liposuction with tummy tuck or occasionally abdominoplasty alone with no liposuction. Different strokes for different folks and different body types.
Tummy Tuck Variations
We’d all love to get away with liposuction only, but since bodies come in all sizes the Plastic surgeon has an armamentarium of tummy tucks to address the given situation. The common names for the types of tummy tucks are, the mini-abdominoplasty, abdominoplasty, panniculectomy, extended-abdominoplasty, and the circumferential-abdominoplasty or belt lipectomy. Each of these types of tummy tucks may or may not have some affiliated liposuction used with them. Let’s walk through these surgeries one at a time.
The typical mini-abdominoplasty is an incision of six to 10 inches in length that removes excess skin just above the mons pubis well below the belly button. The final incision is in a similar position to a C-section scar. This is well suited to the thinner patient with only a bit of loose skin lower on the abdomen. Modifications of the mini-abdominoplasty may have some degree of dissection to lift the skin and fat off the muscles and structures of the abdominal wall so some suturing of the muscles back closer together can be done. Occasionally we might disconnect the belly button at it’s internal connection on the belly wall and reconnect it a little lower allowing a bit more skin excision. This is called an “umbilical float” for we leave the belly button (umbilicus) attached to the normal outer skin and let it float down a touch as the mini-tummy tuck is done.
Regular Tummy Tuck
A regular tummy tuck or abdominoplasty will involve a cut around the belly button where it attaches to the outer skin and we leave it attached on the inside. A new belly button hole is cosmetically shaped and the original umbilical skin stalk is sewn into this new skin hole. Almost always when we do a regular tummy tuck we tighten up the stretched out internal structures. The midline tissue stretch is called Diastasis Recti, which is a fancy Latin way to say the six pack abs muscles have stretched apart. We suture them back closer together where they were when we were young. Also some patients benefit from reefing in some of the lateral muscles to make a better contour. These standard Abdominoplasties have longer incisions than mimi-abdominoplasties and remove all the skin and fat below the belly button to the pubis area. As I mentioned in the first line, you can do a little or you can do a lot so it’s easy to see that as patients have more loose skin going around their side or on their backs than we can extend these incisions as needed.
When the incision is taken well around the flanks and a bit onto the back the operation is called an extended abdominoplasty. If the procedure goes completely around the trunk front and back we call it a circumferential abdominoplasty. Both the extended and circumferential abdominoplasties require repositioning the patients so you can get the back and the front done. Different Plastic surgeons have different ways they may position or start the surgery, but either way it requires more time and repositioning to get all the areas we are after. The extended and circumferential surgeries take longer and are a bit more involved so frequently the surgeon will want you to stay a day in the hospital or a recovery center. The extended and circumferential operations are well suited for the major weight loss patient or patients a year or more after Bariatric (weight loss) surgery. While these types of tummy tucks are bigger operations than a standard tummy tuck they allow for more buttock contouring and provide lateral thigh lifting at the same operation so can be very powerful options in body contouring.
Belt Lipectomies and Panniculectomies
Panniculectomies and belt lipectomies are very similar to the standard abdominoplasty and circumfertial abdominoplasty, but are terms used more often when we only are cutting out the redundant skin and not doing techniques of muscle tightening, undermining and removing extra to make a cosmetic result. Some patinets can have panniculectomy type procedures covered under their insurance plan, but this almost always requires strong documentation of chronic skin infections under the hanging skin, many bouts of rashes and other problems. This occurs more often in diabetic or other patients more prone to infections and therefore they also are at more risk of infection from the surgery. The patient has to check with their insurance provider to see if panniculectomy is a covered benefit, and than they also need to realize this is just a skin removal and closure type procedure not a true abdominplasty which is a much more cosmetic and tailored procedure.
Hopefully this gives a nice overview of the surgical excisional options for body contouring. Of course there are further refinements and modifications of these main categories that are beyond these introductory remarks, only by being assessed by a board certified Plastic surgeon can you get a good heads up about what is right for you and your expections.
What is Xeomin® (incobotulinum toxin A) botulinum product?
Agents to weaken muscles have blossomed over the last few years. Botox® was the original agent we all became very familiar with and its original indications related to treating problematic eye muscle spasms, neck muscle spasms and the like. As physicians noted people’s wrinkles improved Allergan, the producer of Botox® started marketing Botox Cosmetic® to manage certain facial wrinkles and than doctors expanded the areas of use to broaden the cosmetic use of the product.
The next kid on the block was Dysport® (abobotulinum toxin A). Dysport®, like Allergan’s Botox® is a variation of the outline toxins type A that interfere with the mechanisms of muscle contraction. Dysport® is a smaller molecule than Botox Cosmetic® so it might spread over a slightly larger area, and it is dosed differently to achieve a similar effect as Botox®.
The most recent outline toxin A product approved by the FDA is Xeomin (incobotulinum toxin A). As with other outline products the primary indications have been for cervical dystonia (neck spasms) and for glabellar lines. Glabellar lines are those verticle “elevens” between your brows above your nose. Again plastic surgeons may often use the agents to address wrinkles in other areas of the face, but these are “off label” usages.
Each of these outline toxin A products will have their different dosing to obtain results. Each company, Allergan with Botox Cosmetic®, Medicis with Dysport® and now Merz Aesthetics will have their own approach to marketing their cosmetic product. Your plastic surgeon will guide you in deciding which product might be best for you and what your specific dosing and areas of utilization are best to soften the signs of muscle activity with wrinkles.
Botox Cosmetic® and Dysport® are two trade names for injectable medications that paralyze muscles. Botox has been around for ages and initially was used for stopping unpleasant facial muscle “ticks”, neck muscle spasms or other abnormal muscle tightness.
With time it was realized that by weakening specific facial muscles, we could improve wrinkles around the eyes, in the forehead and the space between the brows. Even more recently these muscle weakening agents have been found to benefit some patients’ migraine and tension headaches. Another interesting use of Botulinum toxins is to stop excessive sweating. The toxin works very well at controlling severe sweating which is called hyperhidrosis. Excessive sweating can be very embarrassing and patients are greatly relieved when this can be controlled with Botox or Dysport®.
Botox Cosmetic® and Dysport® fit under a category of medications called Neurotoxins. Neurotoxin is a fancy name for any drug that interferes with normal nerve function. The Botox type toxins, of which Dysport® and Botox Cosmetic® are both types, interfere with motor nerve interaction with muscles. The original Botox Cosmetic® approval was for use between the eye brows to improve those vertical lines, the “elevens”. Physicians may often choose to use Botox Cosmetic® or Dysport® in other areas to treat forehead wrinkles, crowsfeet, lines around the mouth, or muscle bands in the neck. Usage in these areas are what we call “off label” use of the medication. If some neurotoxins are placed in the “crowsfeet” area lateral to the eyes the muscles are temporarily weakened and less wrinkles show. When neurotoxins are used in the vertical neck bands, these can contract less and make the neck look more youthful.
Botox Cosmetic® and Dysport® are trade names for types of Botulinum toxin; these two agents are called Type A toxins. There is also a Type B Botulinum toxin that has a quicker onset of action but much shorter period of effectiveness. Type B is called a Myoblock, but has had much less use in the cosmetic and wrinkle control environment.
Botox Cosmetic® and Dysport® are terrific non invasive injectables to help decrease animation lines of the face and to get a fresher, relaxed look. Research is on going to find better and longer lasting forms of neurotoxins to decrease facial lines, stop headaches, and decrease embarrassing sweating.
Liposuction has rapidly marched into the 21st century since the first case I performed in 1984. The French get credit for getting the liposuction snowball moving forward. Liposuction was first performed with fairly large suction cannulas (blunt metal tubes with side holes) to suction out fat. Once it was clear how worthwhile this technique was for body contouring better developments in suction devices, smaller cannulas with specific pruposes and aesthetic refinements were rapidly brought forward.
Today, terms like Tumescent technique, Liposculpture, Power Assisted Liposuction, Ultrasonic Liposuction and Laser Liposuction are tossed out there left and right so it’s tough to tell what is real, what is hype and what is marketing. My personal bias is it’s not the individual device type that is so important, it is the surgeon’s attention to detail and aesthetic judgment that is going to make the most impact. That being said, some of our technical refinements have their advantages.
Tumescent liposuction essentially means we fill the tissues with fluid, numbing drugs and medication to shrink down blood vessels to decrease bruising and blood loss. This may permit surgery under local anesthesia or full sleep. Most surgeons “tumesce” the tissues these days. While as plastic surgeons we may give different formal names to how much we “tumesce”, the bottom line is most surgeons will always tumesce to some degree. While the term liposculpting has a nice ring to it all liposuction is a form of liposculpting and experienced surgeons really liposculpt on every case. Ther term really focuses more on good technique, attention to detail, occasional reinjection of fat if appropriate and the use of varying plans of treatment and finer (smaller) cannulas.
Ultrasonic liposuction was very popular in the ‘90’s but never had full broad appeal. This special instrumentation can be helpful in denser tissue or reoperative areas, but has some more specific risks and expenses that make it uncommonly used today.
Laser liposuction is the current media craze in body contouring. Perhaps “Smart Lipo” is the name the public has heard the most but there is also “Cool Lipo”, “Slim Lipo” and others. The science behind these techniques is to use an internal small laser cannula that allows the surgeon to heat and rupture fat cells internally and then use standard suction to remove the fat and material or in small zones let the body reabsorb the cellular debris. The different competing devices use different laser wavelengths and energy levels to accomplish similar goals. Care must be taken to avoid over heating or burning patients and the technique is inherently slower than conventional liposuction. Of course the lasers represent a significant expense and possibly a higher cost to the patient, but in the right hands there is solid science behind the technique. Many surgeons are not convinced that final results are superior to standard liposculpting and therefore not worth the expense. Every meeting in plastic surgery, different sides still argue about which is the best option so the jury is still out on the internal laser question vs. just good technique.
Power Assisted Liposuction
Power Assisted Liposuction (PAL) uses mechanically driven oscillating cannulas during liposuction. This mostly is transferring the work load to a handle that oscillates rather than the surgeon using his or her arm and wrist to do the work. Some surgeons don’t like the bulk of the handles or the vibration to the arm, yet some like not having to exercise too much during a case. The PAL technique, like ultrasonic can be beneficial in denser tissues.
Zerona body contouring is a form of external low energy laser treatment that decreases body contour in a completely non-invasive way. This very low level of laser energy doesn’t heat or injure fatty tissues but makes fat cells decompress free fatty acids into the extra cellular areas that the body clears, uses as energy and possibly redistributes diffusely throughout the body. The Zerona is perhaps most beneficial when smaller contour correction is needed and the patient desires no surgical down time. Tucson plastic surgeon Dr. Nelson has also found this type of low level laser therapy beneficial in the recovery phase of standard liposuction.
Hopefully this has been a nice primer on current techniques in liposuction body contouring. Please go to www.jnelsonmd.com or call us to schedule your Free consultation! (520-575-8400)
Rhinoplasty and Nasal Surgeries
Plastic Surgery has all these fancy terms like Blepharoplasty, Abdominoplasty, Platysmaplasty and, yes, Rhinoplasty. “Plasty” essentially meant to change and rhino means nose, but more frequently we are making the nose smaller.
Rhinoplasty is performed either by the endonasal approach with all incisions inside the nose, or the open approach with most of the incision inside but a small portion on the outer skin. The open approach allows the skin and soft tissue to be lifted off the cartilage and bone of the nose making it possible to tailor the structures directly. The plastic surgeon can then move tissues around, suture them directly or place grafts very precisely. The patient’s anatomy and the surgeon’s comfort level with different techniques may determine the use of the open or endonasal approach.
Septoplasty and Turbinates
Often during Rhinoplasty we may also perform a septoplasty. The septum is the stiff vertical support in the middle of the nose that separates the left from the right nostril and airway. If the septum is deviated removing part may help the airway and breathing. The septum can also be used to get graft material to help shape the tip of the nose or add volume to the dorsum.
Another structure in the nose that occasionally needs to be addressed is the turbinate. The turbinates are inside the nose and moisturize the air we breathe. Occasionally turbinates are enlarged and the patient’s breathing can improve by reducing the turbinates’ size.
Reconstructive Rhinoplasty is a specific subset of nasal surgeries to correct defects caused by trauma or cancer. The focus of reconstructive procedures is to move local nasal or facial tissues around to fill the defects from cancer removals. This brief introduction to nasal surgery does not permit me to cover the depth and breadth of Rhinoplasty and reconstruction. Whole books are written about these individual topics. In fact, many books have been written about Rhinoplasty alone.
Choosing a Rhinoplasty Surgeon
During your Rhinoplasty consult try to get a good sense of your Plastic Surgeon’s aesthetic judgment and clinical plan. As a Tucson Plastic Surgeon I frequently utilize computer imaging for these surgeries, though not all surgeons like that approach. Take time to go through pre and post op photos to be sure you are comfortable with the surgeon’s results and approach to specific cases.
To Schedule a complimentary consultation please call 520-575-8400 or visit www.jnelsonmd.com
So Many fillers, lasers, peels and Surgeries….
“What is best for me?”
The science and technology of Plastic Surgery has made it much more difficult for patients to try to figure out what is their best option. While the internet can help present information on the myriad of options out there, nothing beats a well informed discussion with your plastic surgeon. The very fact that there are so many options mandates the educated and experienced eye of a trained specialist.
There are more than 10 different types of injectable fillers alone for deep furrows and facial wrinkles. Dr. Nelson has experience with essentially all of these products and some are better for one type of problem or wrinkle, and some better for others. Experience, common sense, and a good understanding of the patient’s expectation guides Dr. Nelson in choosing one product or another as “your best filler”.
Similarly, patients can get lost when reading marketing ploys that say one laser or one type of peel or one type of procedure is best for them. In the right hands and for the right reasons any one procedure may prove to be best or interchangeable for different patients. Everything we do as surgeons has different risks and benefits as well as different recoveries and expenses. Only by talking face to face with a patient can any plastic surgeon determine which is best for that individual patient.
One major advantage of doing a consult with a board certified plastic surgeon, such as Tucson plastic surgeon Dr. Nelson, is that because he is experienced with non-invasive procedures as well as lasers, peels and the full spectrum of surgical options he can decide with you what option or options are best for you. Some procedures might provide the best cosmetic result but the down time and recovery might guide the patient to a smaller, less invasive procedure. Dr. Nelson’s more than 20 years of plastic surgical experience allows him to tailor the best procedure or procedures to meet your cosmetic goals.