Factors That Can Affect Fat Grafting Success in Brazilian Butt Lift

Fat grafting is the latest trend in body sculpting. A fat grafting procedure transfer autologous fat (from your own body) from areas in which patients have excess fat, such as arms, abs, flanks and back, and injects it into areas that may need volume-enhancement, such as face, hands, breasts or buttocks. In particular, many of my patients who desire a fuller, more curvaceous derriere opt for a buttocks augmentation with fat grafting (BBL). Since the fat grafted is not a foreign material such as an implant, there is no risk of rejection and very little risk of complications associated with implants such as often reported ruptures or leaks.

After the autologous fat is re-injected, 65% to 85% of the transferred fat will usually take and stay in the area for years to come, providing a permanent solution for the patient’s cosmetic needs. The rest of the transplanted fat will be harmlessly and naturally metabolized by the body.Due to this variable amount of fat graft take patients frequently require more than one session of grafting to attain their desired result. The percentage of the fat that survive will vary depending on many factors, some of which doctors can affect (the method of harvesting, processing and placement) and some others which are under patients’ control.

 The method of harvesting is among the factors that enhance survival of the transferred autologous fats, and surgeons can definitely influence it. Clinical studies have shown that fat transfer procedures success is dependent on factors during the removal of the fat, such as the aspiration pressure used, and the cannula’s size used. The area where the fat comes from per se is not a determinant factor in fat grafting attainment. In this respect, I favor VASER liposuction system for viable fat harvesting. Fat cells treated and removed during VASERlipo procedures are typically of high quality and are viable to re-introduce the body (1). The VASER lipo system was designed to maintain the integrity of fat cells, by using ultrasound energy to selectively target and dislodge fat cells from the fatty tissue matrix. Atraumatic VentX cannulas give you the ability to fine tune suction pressure to remove the treated fat. Typically, 2.9mm to 4.0mm precision cannulas are used, depending on the donor site, and the pressure utilized to extract the fat with VASERlipo system is minimal (around 15 inch Hg) as opposed to the standard 25 inch Hg, which can affect the viability of the fat cells harvested. Two recent, independents studies have confirmed the viability of fat removed with VASERlipo: Cytori Therapeutics conducted a multi-site study that confirmed the viability of VASER-treated fat at 85% and regenerative cells at 87%, and the University of Pittsburgh Medical Center found the viability of VASER-treated fat to be over 80%, six weeks post re-injection (2). Research concluded that breaking apart adipose tissue prior to aspiration allows the use of atraumatic cannula and lower vacuum levels, which prevent the fat from tearing or shearing during aspiration.  

Moreover, the method of processing is the second key factor that surgeons can use to maximize fat survival. The preparation process clears the donor fat of blood, pain killers and other unwanted elements that could cause infections or other undesirable complications. Separation from excess fluid (purification of the fat) ensures that the surgeon is injecting a higher proportion of fat. After the fat selection process is completed, only 500cc to 1500cc of the fat will be injected into each butt cheek. Three primary methods (sedimentation by gravity, filtering technique, and centrifugation) have been used clinically to process fat grafts. In this respect, centrifugation is the more effective method of choice for processing facts, based on numerous clinical studies that concluded: “although may be more aggressive on adipocytes, centrifugation clears the fat from most blood remnants and is able to possibly maintain the highest concentration of stem cells within the processed lipoaspirates” (3). For fat processing, centrifugation at a low speed is preferable to high-speed centrifugation, sedimentation by gravity or filtering technique. Research determined that fat grafts processed with centrifugation at 1200 g for 3 minutes have better viability and should be recommend for processing fat grafts.

Third, high success rates of fat survival can be achieved by choosing a proper method of placement. After the harvested fat is purified, the surgeon carefully transfers fat cells into each buttock. To do so successfully, he or she will make small incisions (less than 1cm in diameter) in the butt cheeks and use a hollow tube to insert small quantities of fat cells into each side of the buttocks (micro-fat injections). This process is repeated until the desired correction has been achieved, creating a grid of grafted fat. At the end, the surgeon proceeds to massage the grafted areas to create a satisfactory contour. By all means, fat placement requires slow injection techniques and is time consuming. Clinical studies in patients found that “a slow injection speed of 0.5 to 1.0ml/second resulted in larger fat grafts compared with a fast injection speed of 3.0 to 5.0 ml/second” (4). Increasing injection speeds can result in cellular damage. The studies also reinforce the principle that fat grafts, once placed, should have a maximal amount of contact with the vascularized tissue in the recipient site for better survival.

Lastly, proper BBL post-operative care and healthy lifestyle habits are factors that significantly affect fat survival. Patients can actively contribute a great deal on the success of the procedure and longevity of the results by following their surgeon’s recovery recommendations. In my experience, patients who successfully avoid sitting or putting pressure on their buttocks or stretching for the first eight weeks after their surgery are much more likely to have long-lasting results than patients who fail to follow this advice. The longevity of transplanted fat cells can also be affected by lifestyle factors. In particular, smoking can lead to the degradation of new cells because reduces circulation throughout the body. By eating right and avoiding cigarettes, patients can considerably increase the longevity of their Brazilian Butt Lift.

References:

(1) Schafer, M.E., et al. “Acute Adipocyte Viability After Third-Generation Ultrasound-Assisted Liposuction”. Aesthetic Surgery Journal. 2013 Jul; 33(5):698-704.

(2) Fisher, C., et al. Comparison of Harvest and Processing Techniques for Fat Grafting and Adipose Stem Cell Isolation. Plastic Reconstructive Surgery. 2013 Aug; 132(2):351-61

(3) Lee L.Q. Pu. “Towards more rationalized approach to autologous fat grafting”. Journal of Plastic, Reconstructive & Aesthetic Surgery.pdfs.semanticscholar.org

(4) Strong, Amy L. “The Current State of Fat Grafting: A Review of Harvesting, Processing, and Injection Techniques”. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov

BRAZILIAN BUTT LIFT: ONE OF THE FASTEST GROWING PLASTIC SURGERY PROCEDURES IN AMERICA

Many people who desire a fuller, beautiful, curvy backside will opt for a buttocks augmentation with fat grafting (generally known as “Brazilian Butt Lift”). This is a popular cosmetic procedure which uses fat transfer to provide a more curvaceous buttock without the use of an implant. Liposuction is generally used to both sculpt the surrounding area and collect the autologous fat (from your own body) to be injected.

According to the statistics issued by the American Society of Plastic Surgeons, more than 18,000 buttock augmentations with fat grafting were performed in the United States in 2016(1). This figure surpasses in 26% the statistics corresponding to the previous year. Experts say butt augmentation surgery with fat grafting is by far the most popular butt enhancing procedure they perform and many significant advantages are accountable for patients’ preference of this procedure over buttocks implants and dermal fillers, and its steady increasing demand.

Before and After Brazilian Butt Lift performed by Dr. De La Cruz

Patients’ welfare is among the main reason why Brazilian Butt Lift’s requests are on the rising. This is proven to be a safer procedure in comparison with butt implants. In fact, patients who have implants can experience pain and infection, and have trouble sitting on their butts for a longer period of time. Moreover, implant patients are more likely to develop seromas (lumps caused by an accumulation of serum within the tissue) and experience dehiscence and capsular contracture(2). Also, since BBL utilizes autologous fat, the chance of allergic reactions to foreign substances, such as dermal fillers and silicone prosthesis (implants) are reduced, and the results are longer lasting. Recovery is also better with butt augmentation with fat grafting. BBL’s patients can typically return to work a week after surgery, as opposed to those who receive butt implants and would need at least two weeks to resume their regular activities.     

References:

(1) “Plastic Surgery Statistics Report 2016”. American Society of Plastic Surgeons. www.plasticsurgery.org

(2) Chugay, Paul. “Buttock Augmentation with Implants and Fat Grafting: A Comparative Study”. The American Journal of Cosmetic Surgery. www.journals.sagepub.com

VASER Liposuction: A Good Source for Mesenchymal Stromal Cells

Mesenchymal stromal cells (MSCs) are the spindle shaped plastic-adherent cells isolated from bone marrow, adipose, and other tissue sources, with multipotent differentiation capacity in vitro.  These mesenchymal stromal cells could differentiate to bone in vitro and a subset of the cells that has a high proliferative potential . The notion of a mesenchymal stem cell was popularized by Arnold Caplan proposing that MSCs gave rise to bone, cartilage, tendon, ligament, marrow stroma, adipocytes, dermis, muscle and connective tissue. Adipose-derived mesenchymal stromal cells (ASCs) are concentrated in fat tissue, and the ease of harvest via liposuction makes them a particularly interesting cell source.   Thus, fat has been transferred to the face for facial rejuvenation, as well as to the buttock for buttock augmentation.  It has shown that radiation-induced damage skin are dramatically improved by fat transfer.  

Recently, ultrasound-assisted liposuction using VASER liposuction and Lysosonix were found to harvest viable mesenchymal stromal cells.  "UAL samples demonstrated equivalent ASC yield and viability. VASER Liposuction adipose-derived mesenchymal stem cells showed higher osteogenic and adipogenic marker expression, but a comparable differentiation capacity was observed. Soft tissue healing and neovascularization were significantly enhanced via both UAL-derived ASCs in vivo, and there was no significant difference between the cell therapy groups."

VASER Liposuction allows safe and efficient harvesting of the mesenchymal stromal cellular fraction of adipose tissue and that cells harvested via this approach are suitable for cell therapy and tissue engineering applications.

Recent studies have shown that adipose tissue derived using the VASER liposuction system were viable at harvest and suitable for autologous fat grafts, such as in Brazilian Butt Lifts.   The study had shown that "the lipolysis assay revealed metabolically active adipocytes with a mean (SD) correlative viability of 85.1%. Direct measures of acute viability via propidium iodide staining resulted in a mean (SD) viability measure of 88.7%.

Reference:

Duscher, et al. Ultrasound-assisted liposuction provides a source for functional adipose-derived stromal cells. Cytotherapy. 2017 Sep 13. pii: S1465-3249(17)30658-8. doi: 10.1016/j.jcyt.2017.07.013. [Epub ahead of print]

Schafer et al.  Acute adipocyte viability after third-generation ultrasound-assisted liposuction.  Aesthetic Surgery Journal. 2013 Jul;33(5):698-704. doi: 10.1177/1090820X13485239. Epub 2013 May 29.

Emmanuel De La Cruz MD, PLLC

Houston Plastic Surgeon

Keys to a Long-term Success in Liposuction

After liposuction, patient needs to have a realistic expectation to have a long-term succesful outcome.  There are 4 key elements to have a succesful outcome after liposuction:

1)Exercise - Exercising after liposuction is very important, especially after the initial surgery.  We encourage our patient to start exercising 2 to 4 weeks after their surgery.

2)Proper Diet - It is very important to eat a healthy diet consisting of fruits, vegetables and fish.  We recommend avoiding fatty food, drinking sodas, and eating excessively.  We recommend consulting with a nutritionist if one is having difficulty having a proper healthy diet.

3)Positive Lifestyle Changes

4)Succesful Body Contouring - It is important to choose the right surgeon who would perform your procedure.  Unfortunately, cosmetic surgery is unregulated here in the United States, and we recommend choosing a plastic surgeon who is trained in liposculpture surgery to perform your procedure.

Before & After Photos of VASER Liposuction (6 weeks after surgery) performed by Emmanuel De La Cruz MD, PLLC.

A clinical study conducted by Dr. Rohrich revealed that:

• "Among the 57 percent of patients who did not gain weight, 35 percent report exercising more postoperatively (compared with only 10 percent in the weight gain group, p = 0.002) and 50 percent report eating a healthier diet (22 percent in the weight gain group report eating a healthier diet, p = 0.002). "
• In the weight gain group, 67 percent report no change in their diet regimen and only 17 percent thought their productivity increased (compared with 25 percent among the no weight gain group, p = 0.002). Successful body contouring surgery requires a patient to embrace positive lifestyle habits. "

Thus, the long-term success of a liposuction procedure is dependent on having a healthy proper diet and exercise.  One can still gain weight after your liposuction procedure if one does not exercise and eat a healthy diet.

Reference: Rohrich, et al. The key to long-term success in liposuction: a guide for plastic surgeons and patients. Plast Reconstr Surg. 2004 Dec;114(7):1945-52; discussion 1953.

Emmanuel De La Cruz MD, PLLC

Plastic & Reconstructive Surgeon

Houston, Texas

SmartLipo versus Traditional Tumescent Liposuction - Houston, Texas

A previous randomized clinical trial comparing traditional tumescent liposuction and SmartLipo was performed, and this showed the following findings:

• Less post-operative pain with SmartLipo.
• Cytologic studies showed more damage of the adipocytes (fat cells) in SmartLipo.  Thus, fat harvested from SmartLipo is not suitable for fat grafting, such as in Brazilian Butt Lift.
• No major clinical differences found between SmartLipo versus Traditional Tumescent liposuction.
• Surgical time was longer with the SmartLipo group.
• Higher concentration of free fatty acids were found in the SmartLipo group.
• Lipocrit is lower in the SmartLipo group.

Lower Lipocrit Volume was obtained with the SmartLipo group as compared to the Traditional Tumescent Liposuction group.

In conclusion:  "No major clinical differences for suction-assisted lipoplasty versus laser-assisted lipoplasty were found. Higher concentrations of free-fatty acids after laser-assisted lipoplasty must alert us to possible hepatic and renal toxicity."

Reference:  Prado, et al. A prospective, randomized, double-blind, controlled clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. Plast Reconstr Surg. 2006 Sep 15;118(4):1032-45.

Emmanuel De La Cruz MD, PLLC

Plastic & Reconstructive Surgeon

Houston, Texas

Reducing Risk of Contour/Skin Irregularities after Liposuction

Patients with poor skin elasticity should be forewarned about the risk for contour irregularities and suboptimal skin contraction. Similarly, pre-existing cellulite, indentations and scars may be present and will not be corrected with liposuction.  

How to Prevent Skin Contour Irregularities after Liposuction

• Intraoperatively, use of micro-cannulae and careful use of the criss-cross technique of liposuction are recommended to prevent waviness
• Using the VASER Liposuction machine may reduce the risk for contour irregularities

Using a smaller cannulae produces less skin contour irregularity as compared to a larger liposuction cannulae.

Before & After Correction of Skin Contour Irregularities.  Patient previously had traditional liposuction from another plastic surgeon and she developed skin contour irregularity.  Dr. De La Cruz performed the VASER liposuction of the thighs with fat transfer to correct the contour irregularity.

Before & After Correction of Skin Contour Irregularities (Frontal View).  Patient previously had traditional liposuction from another plastic surgeon and she developed skin contour irregularity.  Dr. De La Cruz performed the VASER liposuction of the thighs with fat transfer to correct the contour irregularity.

Emmanuel De La Cruz MD, PLLC

Plastic & Reconstructive Surgeon

Tumescent Liposuction - Houston, Texas

What is Tumescent Liposuction?

• The word tumescent refers to anything that is swollen and firm. With tumescent liposuction, a large volume of very dilute solution of local anesthesia (lidocaine, bicarbonate and epinephrine) is injected into the fat beneath the skin, causing the targeted area to become swollen and firm. The local anesthetic lidocaine in the solution used for tumescent liposuction reduces the pain that one would experience after liposuction. The drug epinephrine (adrenalin) provides profound localized vasoconstriction that it reduces surgical bleeding during tumescent liposuction.

• Tumescent liposuction can be combined with other forms of liposuction such as in VASER liposuction.  In fact, the tumescent technique liposuction is essential for VASER liposuction to work since ultrasonic energy used in the VASER liposuction needs "water" to emulsify or liquefy the fat.  The fluid in the tumescent solution also prevents "skin burn injuries" from VASER liposuction.

Before & After Photos:  4D VASER Liposuction 6 weeks after surgery.  Procedure performed by Dr. De La Cruz

Benefits of Tumescent Liposuction

• Less blood is lost.

• Intravenous fluid replacement is not necessary.

• Bacteriostatic lidocaine may decrease the risk of infections.

• Tumescence magnifies defects; therefore, the likelihood of needing a secondary procedure may be less.

• Lipid-soluble lidocaine is somewhat suctioned out with the aspirated fat.

• Vasoconstriction minimizes absorption.

• The epinephrine may increase the cardiac output, which, in turn, hastens the hepatic metabolism of the lidocaine.

• The duration of anesthetic effect may last as long as 24 hours.

• The lidocaine may be given safely up to 45 mg/kg and even higher in certain conditions.

Does VASER Liposuction Employs Tumescent Liposuction Technique?

• It is standard of care to employ the tumescent liposuction technique in most liposuction methods, including the VASER liposelection/liposculpture.
• Infilitrating the area of fat with tumescent solution reduces the risk of burn injuries that may occur in VASER liposuction or Laser-assisted liposuction.

Emmanuel De La Cruz MD, PLLC

Plastic & Reconstructive Surgeon

Lymphatic Massage after Liposuction

One may notice a hardness or lumpiness to the areas treated with liposuction and/or with other body contouring procedures (such as fat injections for what is popularly known as the Brazilian Butt Lift).   This post-surgical lymphedema is caused by inflammation and trauma from the cannula (instrument that sucks out the fat) moving under the skin.  Channels are formed by the cannula that can fill up with fluid and the tissue also becomes swollen.  Manual Lymphatic Massage helps to move the fluid by gently pumping it back into the lymph vessels.  Reducing the swelling can reduce discomfort and may reduce contour irregularities after a   liposuction procedure.  Without Lymph Massage (LDT or MLD) the inflammation can evolve into fibrosis (a permanent hardening of the tissue) or a seroma ( pocket of serum) can form.  It is imperative that one should follow the post-operative protocol of your plastic surgeon to achieve the best possible results and avoid developing fibrosis and even possibly contour irreguarities.

Clinical studies have shown that lymphatic massage also improved the clinical outcome after a cryolipolysis procedure.   The study had shown that post-treatment manual massage resulted in a mean fat layer reduction was 68% greater in the massage side than in the non-massage side as measured by ultrasound at 2 months post-treatment.  At 4 months, mean fat layer reduction was 44% greater in the massage side.   Histological results showed no evidence of necrosis or fibrosis resulting from the massage.

I do NOT recommend receiving a general therapeutic, deep tissue or Swedish Massage in lieu of a lymphatic massage therapy after a liposuction procedure.

Emmanuel De La Cruz MD, PLLC

Plastic & Reconstructive Surgeon, Houston Texas

References:

Boey, et al.  Enhanced clinical outcome with manual massage following cryolipolysis treatment: a 4-month study of safety and efficacy.  Lasers Surg Med. 2014 Jan;46(1):20-6.