B R E A S T F A C E

Pump upthe volume

Addition of fat grafting for volumetric enhancement

to surgical contouring procedures has become

mainstream in cosmetic surgery

Rochelle NataloniSENIOR STAFF CDRRESPOKDENT

NEW YORK — When it comes to breast augmentation/mastopexy and even facial rejuvenation, surgicalshaping alone is not enough, say surgeonswho combine such procedures with volumetricenhancement to attain results that they say are notpossible with either modality alone.

"Fat gave us a tool to shape the face and body inthree dimensions that we simply never had before,"says Sydney Coieman, M.D., a New York surgeon,"And now that there are so many other fillersavailable and in demand, the practice of addingvolume is here to stay."

The combination of volumeenhancement with surgical shapingshould be a standard part of everyaesthetic surgeon's armamentarium,says Nashville, Tenn., surgeon PatrickMaxwell, M.D,

Dr. Coieman

"These should not be viewed as different operationsbut rather required additive techniques within agiven procedure to achieve improved outcomes," hesays. "One plus one is more than two. Volumetricenhancement plus surgical shaping advances thepredictability and desirability of outcomes beyondwhat either of these techniques could do alone."

Fat gave us a tool to shape theface and body in three dimensionsthat we simply never had ^^Sydney Coleman, M,D.New York

VECTOR OF AGING Historically, peopleidentified the vector of aging as being a downwardphenomenon. Dr. Coieman says. "For quite along time, the focus of plastic surgery was to liftanything that sagged. It's taken us the last 15 yearsof readjusting the way we think to realize that theremoval of the signs of aging like wrinkling and jowlsby cutting them out really doesn't restore a youthfullook; it deforms a person's face into something thathas no wrinkles or jowls but does not look the way itlooked when the person was young.

"We've gradually figured out that if you don't addressthe loss of fullness, it doesn't result in rejuvenation,"he adds. "It just results in deformities that removethe signs the aging,"

Says Dr. Maxwell, "Over the years, surgeons havebecome able to add predictable fat transfer to

Volumetrie enhancement plus surgical shaping advances the predictability anddesirability of outcomes beyond what either of these techniques could do alone.

Patrick Maxwell, M.D.Nashville, Tenn.

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surgical tissue tightening or enhancement. Beginning withthe addition of small-volume fat transfer combined withfacelifts, mostly enhancing the malar area, surgeons havebecome accustomed to techniques of fat removal, cellwashing and simple yet refined injection of fat layering intothe tissues.

"Additionally, in breast reconstruction, this has long beena frequently used technique where smaller volumes of fathelp blend implant contours into the chest or fill chestdeformities in combination with implants," Dr. Maxwelladds. "These applications have enabled surgeons to becomepredictable in fat transfer techniques, which has led toadaptation, with more sophistication in other areas."

' ' " •-'-•'^ ^ ' ••- CHALLENGE Fat transfer for volumetricenhancement and acellular dermal matrices (a form ofbiologic scaffolding) have enabled surgeons to increasevolume over and around breast implants effectively. Dr.Maxwell says.

"These combinations of regenerative techniques plusimplants have made even the most challenging breastrevision cases involving multiple capsular contractures,repeated bottoming out, stretched deformities and ptosis tobe predictably revised with consistently improved outcomes,"he says, adding that this has led to the frequent use of fatgrafting in primary aesthetic breast surgery. For example,one could use enhanced fat grafting after placing breastimplants to augment the smaller breast or to simply enhancecleavage, he explains.

"Shaped, form-stable implants enhance predictability inbreast form, and adding fat grafting or biological scaffoldsmay further enhance the volume in addition to surgicalreshaping and contouring," Dr. Maxwell says.

Minimally invasive facial suspension and tighteningprocedures also benefit from volumetric enhancement withfat grafting. Dr. Maxwell says.

"As both of these techniques are minimally invasive and give

desired improvement with long-lasting results, increasingnumbers of patients opt for these facial procedures.

"Likewise, in either primary breast aesthetic procedures ofmastopexy or perhaps augmentation, the enhancement withpredictable fat grafting is significant," he says. "Especiallyin challenging aesthetic breast revisions, the addition of'regenerative' volume is helpful."

Breast techniques that are complemented by the additionof volume include capsulectomy, site change from over themuscle to subpectoral position, creation of neopectoralpockets and mastopexy, according to Dr. Maxwell.

"Acellular dermal matrix scaffolds can support tissue orminimize the possibility of recurrent capsular contracture byadding a regenerative surface layer between the implant andthe tissue, and fat grafting further refines the shape withprecisely desired aesthetic outcomes," he says.

i/ENATiON BENEFITS Sculpting with fatinjections offers a more youthful look just by virtue ofthe additional volume, but fat injections offer an addedrejuvenation bonus. Dr. Coleman explains.

"Fat has the added benefit of rejuvenating the skin. Itactually improves the quality of the skin, the wrinkles,the color, the size of the pores. All of these are improveddramatically by the placement of fat right next to the skin,"he says. "Although volume is an important element, I thinkthe restoration of the quality of the skin that takes place isequally, if not more, important."

While the mechanism of action regarding fat's reparativecapabilities is up for debate. Dr. Coleman says there isconsensus in the aesthetic surgical community that skinquality improves in response to fat injections or grafts.

"It probably has something to do with the fat's stem cells,and it also has something to do with the stem cells releasinggrowth factors," he says. "There are a lot of unknowns. Weare just beginning to scratch the surface." <•