Upcycling Plastic Surgery
Upcycling might seem like an odd word choice when one thinks of Plastic Surgery, but it’s really quite apt when it comes to certain techniques used in everyday practice. Essentially, it refers to removing material from one area and finding a better use for it elsewhere. There are two opportunities that I am able to upcycle biologic material in my patients: during facelifts, (utilizing the Superficial Muscular Aponeurotic System or SMAS tissue) and when performing liposuction, taking unwanted fat from one area where it’s less-than-desirable and upcycling it to another where a bit more fat/volume is actually quite desirable.
To The Face
The SMAS layer in the face, consisting of muscle, fascia and fat is ideal for upcycling. When a facelift is performed, the SMAS layer is undermined, pulled taut, trimmed, and fastened to attachments. The skin then re-drapes over the tightened infrastructure with ease, avoiding an overly-done or ‘pulled’ appearance.
I had noticed that many of my older patients’ lips were quite thin, and in some cases, almost nonexistent. Lips tend to lose volume with age, so this wasn’t too surprising – but after they’d undergone a facelift, there was disconnect between the rest of the face and their lips. While fillers, including Juvederm and Restylane, are used to enhance lip volume, (and are sometimes over-used/abused),) they are a short-term solution for the problem. Studies have shown that the SMAS tissue could be utilized in the lips as a graft to offer a longer-lasting lip enhancement. The resected SMAS tissue can be fashioned into strips of varying thickness and inserted into ‘tunnels’ within the vermillion of the lips. Using SMAS tissue as an alternative to fillers works beautifully, follow-up results have shown persistent improvement lasting for up to 5 years.
SMAS grafts to other body parts such as the post-rhinoplasty nasal dorsum can also make a difference by smoothing and slightly elevating an irregular or over-resected dorsum.
In addition to SMAS, fat in and of itself is a remarkable substance, and most of us have ample supplies. The problem of course is that we have an excess amount in areas where it’s not exactly our friend and less in areas where we’d prefer a bit more (funny how that works). That being said, we owe a lot to fat. It provides us with warmth, energy and contour, and it has the unique ability of being able to survive when injected into the face, breast, and torso. It also boasts a plentiful supply of stem cells, which are the subjects of both research and legitimate procedures, but also, sadly, buzzwords creating a lot of commercial hype.
The “Stem Cell Facelift” is essentially the injection of fat into the face. It’s not clear to what extent the stem cells play a role in any improvement in the facelift itself, but that ambiguity doesn’t seem to stop the onslaught of hawkers and publicity hounds from claiming miraculous results.
Fat (regardless of the stem cell component) is a very promising resource for upcycling.
In any fat grafting procedure, fat is carefully extracted from the lower abdomen, the thighs, or any reasonably endowed location, and injected into the face, the breast, or wherever additional fullness/volume is desired. There are different techniques for treating or not treating the fat before injecting it, but usually there is some type of washing or concentrating of the extracted tissue.
The amount injected depends on the area. Small amounts can be utilized in the face to fill in nasolabial folds, the cheekbones, and temple-regions or on either side of the chin. Some physicians claim that simply injecting fat into these areas prevents the need for a surgical facelift, and occasionally that may be true. However, relying exclusively on fat injections may produce an overly-inflated fat face, in which the contours extend beyond the point of beauty or normalcy. By only incorporating fat grafting into a facelift when it’s indicated, carefully lifting the deep layer of the face, a plastic surgeon can reposition the existing fat that has dropped down from its original position to uplift into another area. This technique provides a more natural restoration of the original youthful shape.
To The Breasts
In the breast, larger amounts are needed for successful fat grafting and vary widely based on specific goals. For example, after a breast lift for drooping breasts, fat grafting may eliminate the need for an implant to fill the upper portion of the breast. After a post-mastectomy breast reconstruction procedure, fat grafting may be used to fill in the edges around the implant or to smooth out the contours after more elaborate tissue-flap methods. The time may come when fat grafting will completely replace implants for cosmetic augmentation, and several centers are working on this, but I don’t think that’s going to be in wide use any time soon. Fat grafting is not without its limitations.
Despite best efforts, not all of the grafted fat will survive. As a standard of practice, we transplant a bit more than we hope to have remain, anticipating a 25-30% loss in the weeks following a procedure. Another problem is that of “fat memory.” Fat seems to maintain its relationship to whatever source it came from. If fat is used to fill in facial contours and years later the patient gains a significant amount of weight, the transplanted fat will grow too. That can yield an odd, doughy appearance. The only remedy is continued weight control, which isn’t such a bad idea regardless.
Negatives aside, we can look to fat to be a major source of contour enhancement now and for the future.