Joshua Lampert, M.D., Board Certified Plastic and Reconstructive Surgeon of LampertMD.com, talks about fat grafting for post-cancer breast reconstruction surgery.
What is this fat grafting?
Dr. Lampert: Fat grafting is when you harvest fat from somewhere on the body where you do not want it and place it where you do want it. The technique has really evolved a lot over the last ten years. It is not a new technique as it has been around for a long time. But with the evolution and technology available now, we can keep more fat around and have a higher rate of fat survival when we are transferring it from one place to another.
Who is a good candidate for fat grafting and what do you use it for?
Dr. Lampert: To do fat grafting, the patient must have an area of fat that we can harvest with liposuction. We use a special low-pressure liposuction system because it avoids fat cell rupture. So, the patient needs to have fat somewhere, even athletes usually have a little area on the love handle or thigh that we can harvest fat from. Then we take it, process it and inject that fat to any number of areas from a post-surgical cancer tumor, resection, breast augmentation, the face to buttock augmentation and a variety of other areas of soft tissue filler.
So, this can be used for breast cancer reconstruction?
Dr. Lampert: Fat grafting has become a popular reconstructive procedure in patients who have had breast cancer. Commonly fat grafting is used in patients who have had breast cancer and a mastectomy. We will use it to thicken the skin envelope more because all the breast tissue has been removed. The only thing you can cover the implant with is muscle and skin and it can be thin. So, it is nice to harvest fat from the abdomen or flanks and then do liposuction under low pressure, graft the fat over the implant to hide it and make it look a little more natural. So, the fat camouflages the implant and gives it a more natural appearance and some of the patients want the liposuction too.
So, what is the process of harvesting the fat?
Dr. Lampert: The process has evolved over time. Initially it was just harvesting with liposuction. When I started doing fat grafting, we used a sieve from Williams and Sonoma. We autoclaved it and it was sterile. We harvested the liposuction and then pour the fat into the sieve and filtered it out. We would filter it with an antibiotic solution through something like a cheesecloth. We would then place it in syringes and inject it. Today we do it a lot different. We use what they call a closed system. We do something like conventional liposuction, but we use a special system that keeps it exceptionally low pressure because high pressure makes the fat cells pop which kills them and that makes it non-viable. So, by performing the suction under low pressure, we can keep more fat cells alive. Then it gets sucked into a closed system, so it never gets exposed to the air. Exposure to the air can cause certain problems with infection and things like that. So, it gets mixed into a separate closed container with antibiotic solution and that separates the fat. Then we can suction it out into a syringe, so it is never in contact with the air. The fat is then grafted in a series of passes with a fine cannula which is a long blunt needle and we are able to go back and forth within the tissue and put little droplets of fat within the vascular tissue in the hope that each one of those little droplets will be surrounded by a good environment of nutrients and survive.
So, it basically plumps up the area of the body, so it creates an aesthetically pleasing look.
Dr. Lampert: Fat grafting allows an area of soft tissue volume. So areas where there is soft tissue volume deficits, whether it’s from a tumor resection, aging, loss of fat or weight loss, anything we want to add fat or volume to whether it’s a defect from another surgery, underneath a scar where it’s retracted, adding quality to the skin or volumize the lips in patients who’ve got a little older and lost some facial fat atrophy. It is a great source of volume for those patients.
So, it is safe to take fat from somewhere else on the body and then inject it into someone’s face or lips?
Dr. Lampert: In the hands of a board-certified plastic surgeon, fat grafting is safe. What we must be careful with is fat grafting of the buttock region. You have seen on TV the fear of Brazilian butt lifts and fat grafting. It is the most dangerous procedure that we plastic surgeons perform. The reason is deep in the muscle of the buttock are the gluteus muscles, and there is a large system of veins that feed into the hip vessels, called the iliac vessels. Those veins are about the size of my pinky. So, if you use a smaller needle and inject some of the fat into those large veins, that fat could go up to the lung or heart and cause a fat embolus which could kill a patient. That is why board-certified plastic surgeons who are concerned about safety do not inject deep into the muscle. They inject more superficially into the subcutaneous tissue. So, you must be super careful in certain areas with fat grafting as far as where you are injecting it. Some areas are a lot safer. If we are injecting fat into the breast or other areas of the body, most of the veins are super small so in those areas we do not worry as much. Although most board-certified plastic surgeons worry about everything, we worry more about injecting anywhere near the buttock or extremely large veins that go to our two largest and longest appendages, our legs.
Going back to the procedure with Kali, what did her leg look like at the time?
Dr. Lampert: When I first saw Kali, she had a giant hematoma. She had surgery with another doctor and a benign tumor was removed. It was not done in an operating room and she had a post-operative bleed which got infected. So, she had a hematoma after surgery, and it got infected. This created a problem because an infected blood clot must be removed. So, I had to open the old stitches which were starting to separate and wash out the infected blood and puss and get everything out. It was too infected to close the wound, so we had to leave it open. When the wound healed, it created a big crater in her leg which is a big and deep defect, and the skin healed all the way down to her lateral quadriceps muscle. That created an excessively big crater indentation which was not only painful but was hard for her to stomach when she saw it in the mirror. It created a lot of issues for her going to the beach, pool or anything we do in shorts here in Florida.
Was it a dangerous situation for her and could there have been a blood-borne infection?
Dr. Lampert: Initially she had a bad infection and it had to be treated. It was so painful, and it was hurting her. It was a bad infection. If we left it, she could have gotten bacteremia or sepsis. It could have led to a potentially life-threatening situation. A lot of times the body will create a pressure system where the wound opens, and the blood or hematoma pours out on their own. That could have happened as well. But either way when you see an infection like that you must drain it.
How did you use the fat grafting on her and how many procedures did you have to do?
Dr. Lampert: The first thing you do with any patient who has a bad infection is treat the infection and let it heal. You make sure everything has completely healed, the blood supply has grown through the scar tissue and that all the necessary antibiotics are taken. Once things have healed, we usually wait three to six months to give the body time to recover. Then you can start talk about fat grafting. So, when the wound healed on her thigh, she ended up with this excessively big indentation. It was painful and looked terrible and we waited six months before doing the surgery. Once we did, we could better evaluate as the scar had softened, but the problem was it really did not improve. So, I knew we had to put something in there to fill up that space. I think 10 or 15 years ago if we tried to fat graft, we would have lost a large percentage of the fat cells and would have not had as nearly as good a result. The fat grafting procedure is performed under general anesthesia and patients get their preoperative labs and clearance before surgery. Basically, we pick an area that the patient wants liposuction, we look at where they want to improve some contour. Then we use a local anesthetic that will be injected under general anesthesia. So, the patient’s asleep and they do not feel any pain. Then we harvest the fat with a low-pressure system and fine cannulas from the areas that we want. It gets processed in our low-pressure system. The machine that I use is called a power assist liposuction device. So, we used these thermal devices, also known as liposuction cannulas and when they do the suction, they create a thermal injury. There were a bunch of them on the market in the past and they caused more skin retraction. They were really popular in the early 2000s, late ’90s. Even in the early ’90s, some of the devices using ultrasound would cause heat injuries, which would cause the skin to retract. But what most of us have found is these devices cook the fat cells. So, if the fat cells are cooked, they also will not survive. What we found now is a power assist liposuction device, which is a cold steel cannula that performs liposuction and connects to a small motor. That motor has gotten better over time where it oscillates back and forth and that allows us to harvest a larger percentage of fat and avoid some rotator cuff injury when the plastic surgeon is performing the fat harvest. Once it is harvested and separated, we can inject it deep into the scar and raise the scar by injecting the fat which pushing it up a bit. The procedure itself is not that challenging, to be honest but the technology today has allowed us to artistically shape by injecting the fat and trying to release the scar.
In Kali’s case, how many procedures did you need for the scar to be filled?
Dr. Lampert: With Kali, there was the procedure to remove that initial infection. After we removed the initial infection, in the first surgery we did a larger volume of fat grafting. Typically, 10 or 15 years ago you would lose 75 to 80 percent of the fat. But with Kali, we kept about 75 or 80 percent of the fat. So, we kept a high percentage of the fat and she noticed an immediate improvement with her scar very thick and tethered down. So, with the initial grafting, we were able to fill 75 percent of the cavity. We planned to do multiple surgeries and we ended up doing three sessions of liposuction and fat grafting before we got to the point where we were happy. With the last one, the fat stretched the skin out a little more. So, I was able to excise and cut out a portion of the scar and close it in the plastic surgery to improve the appearance.
Is it exceptionally smooth today?
Dr. Lampert: Yeah, I think we could do another little tweak to even make it look better. But a lot of times I want to do it and the patient does not want to.
So, the process can take a while. Is it painful and what is the recovery like?
Dr. Lampert: Yeah. The fat grafting itself usually is not that painful. Most patients do not complain about us injecting the fat into the area to be volumize. They complain more about where we harvested the fat. It is like liposuction. We usually have patients wearing garments or some type of compression. In Miami we call it a faja which gives a little bit of compression and squeezes out some of the fluid that was injected. The fluid has the numbing solution in it and helps to contour the liposuction to maintain the shape that we want. Usually that is when people complain of pain. After about a week, most patients are not taking pain medication and it tends to be an easier recovery than a lot of the procedures we do.
Is there anyone that is not a good candidate?
Dr. Lampert: The patients that are not good candidates for fat grafting are those who are incredibly thin and have had prior liposuction. If patients have had prior liposuction, what happens is the scar tissue from the past liposuction makes it a lot more difficult to harvest the fat. If patients are incredibly thin it is hard to get adequate fat. A lot of times patients are really fit and athletic and we can still find some target areas from the love handles, the lateral thigh or the lower abdomen to at least do one fat graft session. So, we can still find a little bit of fat, especially if we can harvest from a few different areas. But everybody is different.
What is the procedure you would use for grafting for A, B, C and D?
Dr. Lampert: We commonly use fat grafting for procedures like breast reconstruction and breast augmentation to refill any soft tissue defect left after a tumor removal. I use them routinely with facelifts and blepharoplasty eyelid procedures to restore volume to the face. We use fat grafting on the back of the hands for patients who are older and want then to look more youthful. We use fat grafting pretty much anywhere we want soft tissue volume, and it allows us to be creative in how we utilize it.
Can you give us an idea of what this would cost?
Dr. Lampert: Routinely we will get fat grafting covered by insurance for things like breast cancer reconstruction and tumor extirpation reconstruction. It is one of the very few times I have seen insurance companies cover any form of liposuction because we are using liposuction to harvest the fat. So, if it is a reconstructive procedure that is medically necessary like breast cancer reconstruction, tumor reconstruction or fat grafting for a scar revision, medical insurance should cover that. But sometimes it is a fight because any time the insurance company sees a plastic surgeon working on it, they automatically assume it is for cosmetic reasons. We routinely do fat grafting with face and neck lifts, and those types of procedures usually start around $20,000 to start. Breast augmentation with fat grafting is more expensive than breast implants because the procedure takes longer because you must harvest the fat. You have got to process the fat and then you inject it. So those procedures are typically more expensive than your run of the mill breast augmentation.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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