Once upon a time in an operating room near you, plastic surgeons hated fat.
No matter what the body part, it seemed that all we wanted to do was to cut it out, suck it out, burn it off and just plain obliterate it. We had declared war on fat. My, how times have changed.
These days, fat is the darling of plastic surgery, both in reconstructive and aesthetic surgery.
I can’t seem to open an aesthetic surgery journal, a textbook on reconstruction, or attend a plastic surgery conference without hearing about what’s new with fat. There is cutting-edge research looking at how we can better use fat to enhance aesthetics, rather than only working to eliminate unwanted fat. The main thrust of the current thinking about fat in plastic surgery involves taking fat from one body part and using it in another body part, a process known as fat grafting.
I began my love affair with fat years ago during my reconstructive career.
I saw patients who had lumpectomies for breast cancer, with residual volume and contour defects in their breasts. What used to be a fantasy, sucking unwanted fat from the abdomen or thighs, and transferring it to the breasts, became a reality. Contour deformities that used to require a patient to either “just live with it”, or to have a major reconstructive procedure, became a simple matter to correct using the early principles of fat grafting.
Fat grafting has great benefits in mastectomy as well.
In the past, mastectomy patients often had one of two different types of reconstruction procedures. Sometimes they had a flap reconstruction using a piece of tissue from the abdomen, and sometimes they had implant reconstruction. But no matter which of these techniques they had, almost all of them were left with thin tissues, upper pole volume deficits, inadequate projection or some other shaping or volume problem. Once again, fat grafting came to the rescue! Almost every problem we see after reconstructive breast surgery can be fairly easily remedied with this very simple procedure.
When it comes to aesthetic surgery, the revolution in fat has been no less impactful.
These days, given the right circumstances, it’s not impossible to do a breast augmentation with nothing but fat removed from a part of the body where it’s not wanted, and placed in the breasts where it is wanted. While the indications for this procedure remain somewhat limited, in the right person, with the right expectations and the right anatomy, it is fantastic!
Perhaps my favourite way to use fat in breast surgery is in the procedure we call a “composite breast augmentation”. That operation involves placing a breast implant in the space beneath the breast tissue (subglandular placement) while leaving the underlying muscle alone. The fat graft is then used to enhance the upper pole of the breast and the cleavage area and to add a bit more volume. A major benefit is to make a sub glandular implant look as natural as a submuscular one. The reason this is so great, is that the same natural looking aesthetic result could only be achieved in the past by cutting the pectoralis major muscle, elevating it off the chest wall, and placing the breast implant beneath it. While sub-muscular procedures remain very common and do have their place, they certainly bring with them some complications. Using modern principles of fat grafting, our composite breast augmentation procedure gives the same beautiful, natural aesthetic results of submuscular breast augmentation, and the muscle can be left alone in the anatomic position where mother nature put it in the first place.
Another fascinating use for fat grafting is in facial rejuvenation.
Putting small amounts of fat graft in the cheeks, the nasolabial folds, the marionette lines, the lips, and the tear troughs has made facelift surgery better, and in some cases, eliminated the need for surgery altogether! For most modern aesthetic surgeons, the notion of doing a facelift without using a fat graft is unthinkable. Fat grafting has become an integral part of almost every surgical procedure for facial rejuvenation.
Perhaps the most interesting change in the philosophy of fat is in the lower eyelids. Back in the day, lower eyelid surgery consisted of two major steps: tighten the skin and remove as much fat as possible to eliminate the under eye “bags”. The problem with that approach was that while the initial results looked good, the eyes ended up looking hollow and sunken as the months and years went by. Today, we remove almost no fat at all. We just reposition it to make the lower lid “bags” disappear and look youthful. The fat remains pedicled (attached to its blood supply) and just gets re-draped on to the upper part of the cheekbone to harmoniously unify the mythical “lid-cheek junction”. What would have been unthinkable 20 years ago is standard today.
In these modern times, fat is no longer always the enemy. We are finding better and smarter ways to limit its removal, use it for its structural and rejuvenating properties, and make people of all ages and stages look and feel better.
The war on fat is over, and the love affair has begun.
– Dr. Robert Shenker
