The Future is Fat

The role of fat in our bodies is complex. There are several types of fat but in its various forms it acts as an energy store, a shock absorber and it is essential for many of the core metabolic pathways of life. Its anatomical distribution also has a profound impact on the way we look and feel. Certainly without fat there would be no life. The distribution and volume of fat changes in our bodies as we age or if we are stressed and also with certain diseases. Emaciation and obesity are strange cousins but we have all seen the visual effects of too much or too little fat. The amount under our skin can be a clue to our health, wealth, genetic makeup and perhaps on occasions our minds! Eating too much or too little in a world of plenty can be driven by imbalances in our psychology well being.

Sometimes the fat distribution is anatomically abnormal. Drugs such as steroids can redistribute fat in characteristic ways.

Romberg fat grafting

Patient with Romberg Syndrome Before Lipo-filling

Romberg fat grafting patient

Patient with Romberg Syndrome After Lipo-filling

The term Cushinoid refers to the physical appearance of a patient with too much steroid. In cases of extreme exposure to this drug, they develop chubby moon-type facial features with fat migrating to the back of the neck causing a “buffalo hump”. Rare conditions, such as Cherubism, mimics this in babies who are born with extremely chubby faces due to too much fat making them look abnormally round. In even rarer cases of Cherubim only one side of the face can be affected or even parts of the body.

Conversely, too much thyroid hormone burns up fat, making the face gaunt and causing abnormal fatty-type material to accumulate around the eyes, causing them to bulge. Fat wasting is also seen in the cruel and rare condition known as Romberg’s disease (see Shauna’s story). Usually starting in childhood or early adolescence, one half of the face wastes away. In severe cases the underlying facial bones are also affected accentuating the asymmetry. Patients look normal on one side but skeletal on the other. The hair of the scalp can drop out on the affected side or turn white and the same can happen to the eyelashes.

It was the treatment of this disease in children and young adults that gave me a lot of experience with lipo filling. By using fat to plump up the affected side the asymmetry can be improved. Fat can be harvested by gentle liposuction techniques and injected into areas of where tissue volume is deficient. This is known as lipofillingFat Separation

The principle is to take fat from where there is enough to spare such as the abdomen, love handles or the thighs. The harvested fat is usually briefly centrifuged so that it is possible to inject pure fat without any of the infiltration fluid or cellular debris. The actual harvesting and injection technique is very important. It is easy to damage fat. Injecting it also requires care. The area needing treatment is lipo-filled in several directions. The fat is injected in small amounts with a fine metal cannula (thin tube). The fat is gradually built up in layers as a lattice and is deposited in multiple small droplet-like globules so there is a higher chance of survival. This is because of the high volume–surface-area ratio of the deposits that aids the local blood vessels to keep the fat alive. Injection of fat in one big load or simply putting in a lump of fat by an open surgical method would be much more unpredictable and will usually not work. Fat also has some amazing intrinsic properties. It contains a significant percentage of “stem cells”. This means that injected fat can turn in to other types of cells such as blood vessels, so that it can improve the blood supply in areas where it has been inserted.

The implications for plastic reconstructive and cosmetic surgery have been immense. The applications have ranged from the treatment of volumetric asymmetry in Romberg’s disease to facial rejuvenation, correction of breast asymmetry, breast augmentation as well as soft tissue defects caused by the loss of fat from trauma. It has also has a role in revision of painful scars or certain types of damaged skin. I mentioned the shock absorbing or cushioning role of fat. Lipofilling can sometimes improve the appearance of scars. The stem cells that fat contains, increases the blood supply of the overlying skin. This can lead to better scar quality. Lipofilling has also been used to treat skin, which has been damaged by radiotherapy.

In cosmetic facial surgery fat has become the ultimate filler. For example, as we age, the fat in our face migrates as the fine ligamentous tissues that hold the fat in its place stretch due to the affects of time and gravity. A significant component of youthful beauty could be defined as the fat of the right volume in the correct place! By restoring volume to the cheeks and with careful lipofilling of creases and frown lines, re-freshening or facial rejeuvenation can be achieved without the need for extensive surgery. However these procedures are often also carried as an adjunct to facelift surgery. The purpose of the face lift is not only to pull the face in the correct vector (direction) but also to restore the cheek fat pads into the correct position. Sometimes if the fat pads have aged and shrunk, lipofilling at the time of surgery is very useful.

The use of lipofilling for breast asymmetry and augmentation has been another rapid area development. BreastsAt present I think that it is less predicable than silicone implants because a variable amount of fat will disappear. This phenomenon of fat regression unfortunately occurs for all lipofilling. This can range from 40-60% of the fat injected. Sometimes there is no regression and unfortunately, although uncommon, total regression can also occur. It is for this reason that I believe that lipofilling is an art. It does require touch and judgment as well as technique. The patient has to understand that it will take about three months before we know how much of the fat has regressed. They need to be prepared for possible further lipofilling if needed. At present, in my practice lipofilling for breast augmentation is carried out when the aim is for relatively modest or moderate increases in volume, especially in women who do not want implants or who have had a history of capsular contracture or implant failure. Several lipofilling episodes maybe needed before a large stable volume is achieved. However the beauty of lipofilling is that it is safe, usually affective but also repeatable. The recovery from lipofilling is rapid as it can almost always be carried out under local anaesthetic with or without sedation as a day case. The technique uses your own cells and so there is no chance of allergic or foreign body reactions. I believe that for many conditions, which were previously difficult to treat, lipofilling has become a first line treatment. Lipofilling techniques are also improving and for all these reasons I believe that the future is fat.