Monique Ramsey (00:02):
Welcome everyone to The La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey. Today we have Dr. Luke Swistun in the studio to talk about fat grafting and complications from fat grafting, and it's going to be a very interesting topic today. So welcome Dr. Swistun.

Dr. Swistun (00:22):
Thank you for having me on.

Monique Ramsey (00:24):
Thank you for coming. So a lot of people want to take fat from one place, move it to another. That's very common. It's been done for a long time. So let's just start with the beginnings of the fat graft and what is really happening.

Dr. Swistun (00:39):
Sure. Well, fat grafting is a known technique. It's been around for a very long time. It's used in reconstructive surgery also such as reconstructive breast cancer surgery, patients who had breasts removed or portions of breasts removed and used fat grafting in order to reshape the breast, add more volume to it. But the bottom line is, the simple way to think about this is that you're born with all the fat cells that you're ever going to have in your life, and then that's a simplification, but let's just use it for the sake of this argument. And when a patient gains weight or loses weight in their lifetime, each one of the fat cells just gets a little bit bigger when they gain weight and each fat cell in their body from head to toe gets a little bit smaller when they lose weight. Okay? And what we're doing is we're basically redistributing the ratio of where those fat cells live in their body.

(01:24):
So to give you an example, like a lot of patients gain weight and it's always a stubborn area in the flanks or in the abdomen, and they know that whenever they gain weight, that's where it goes. You could theoretically liposuction those specific areas and take 80, 90% of the fat cells out of that area and then use those fat cells and put 'em somewhere else, let's say in their breasts or in their buttocks or in their face. And then when the patient gains or loses weight in the future, they will gain proportionately less in the area where we liposuctioned from and they will gain proportionately more in the area that we grafted to. So it's a nice combination of results and it's a nice long-term investment for much more graceful aging in the future once you rearrange the fat cells and where they live in your body and the ratios of where they are to the more favorable.

Monique Ramsey (02:13):
Well as a woman in her mid fifties, I can agree that things do sort of accumulate in a way that you weren't expecting when you were in your twenties and thirties, so there might be some point to that. So then let's talk about when you're moving it into its new home, what needs to happen and what is the technique involved and to make sure that the fat survives and thrives in its new home and what's physiologically going on?

Dr. Swistun (02:44):
So obviously what we are doing was we are performing liposuction in order to remove fat from one place in the body, which is called the donor site essentially, and then we're putting it into another place, which is the target area. Classically, sort of in the reconstructive realm, the donor site wasn't really a big deal. Patients basically would identify an area, oh, I'll just take it from the abdomen, from the flanks or something. And sometimes some reconstructive surgeons that I've observed even not really pay attention too much to the donor site, which to me is sort of a wasted opportunity because if you are going to perform liposuction on someone, you should, I think take the time to give 'em a really nice result in the liposuction area and then obviously you take that fat and then you inject it back into the body and the area where you do want it.

(03:31):
I guess the caveat to this surgery specifically is that this is probably the single most patient dependent, surgeon dependent, technique dependent surgery that there is that we perform. First of all, patients come in all shapes and sizes, which is to say they may have a lot of fat in the places where they want to get rid of it or they may not may have very little fat. So one of your limiting factors will be the amount of fat that you can actually get to graft. The other thing is that the area that you're grafting into may also be well developed and larger, which is good because there's more blood supply there to accept the new graft or they may have very, very little tissue. So the classic example is a patient who had double mastectomies for breast cancer. That is a very huge challenge surgically because that patient just has skin on their chest wall by definition because their breast tissue was removed.

(04:19):
So there's very little tissue and therefore very little blood supply left to graft into. So therefore those patients typically benefit from serial fat grafting, which is to say doing it several times six months apart so that you kind of build up the blood supply back into that area so that you can graft more and more as time goes on and each session goes on. Typically patients who undergo serial fat grafting are usually honestly reconstructive patients because their insurance covers these procedures and so they can sort of afford to have a surgery every six months for 2, 3, 4, 5 times even. Whereas in the cosmetic realm, that becomes a lot more challenging because of the recovery involved, because of the cost involved. But nevertheless, that's sort of the best way to do it, the safest way to do it to avoid complications, which we'll talk about in a second.

(05:06):
And then also surgeon dependent. The surgeon has to have sort of the mental capacity to limit themselves. Obviously as surgeons as plastic surgeons, we want to give the patients the best result we possibly can. So usually that becomes an issue when we graft and the patient doesn't have a lot of volume and we want to give them a noticeable difference. It is a mistake to over graft. If you put too much fat into an area that can't accept that much fat, that fat will die and it will basically turn into those complications that we dread like fat necrosis or oil cysts and things like that. Basically what fat necrosis or oil cysts are is basically fat that was inserted under the skin that did not have adequate blood supply to reestablish its own blood supply and therefore stay alive and it basically just died. And if you have a lot of that in a single area, then that will turn into a big oil cyst or worse yet, it'll scar down and become fat necrosis like a hard lump.

(06:06):
So typically those are consequences of over grafting and it's up to the surgeon to really inform their patient about the realistic result that we can get with their tissue and also be diligent about net over grafting on the table. We're all tempted to do it. Basically it's like, I want to give this patient the best result I can. Let's put in just a little bit more. But again, that's a mistake. A lot of times what I'll do is I'll assess the tissue beforehand before we go to surgery and I will have a mental number in my head. I'm only going to put in 100 ccs in this patient or 200 ccs in that patient and no more, and maybe give or take 50, but that's it. And that's sort of the approach that you really must take in order to try to limit your complications because once you get those complications, they're very hard to fix. They're very troublesome and they're very frustrating to deal with.

Monique Ramsey (06:52):
Yeah. What do the patients, I am sure you've seen patients come in who might've had surgery elsewhere, they've had some complications, and when they come to you, what are the things that they're complaining of? Truly, if there's an oil cyst, does that mean it's like coming through their skin onto their clothing or how do we picture that?

Dr. Swistun (07:11):
No usually these are entities that are buried inside of the tissue, but they are symptomatic. So I had a patient recently that had a fat grafting done by another surgeon who was actually prominent in this field who kind of very well known for this, and then this patient, unfortunately, she had the unfortunate complication of a lot of that fat did not survive and it turned into lumps that she could feel under the skin. This is a thin patient, so she didn't have a lot of padding around as far as her own tissue as far as her own fat and breast tissue. She didn't have a lot of padding around those complicated areas, which were basically just hard lumps, almost like large marbles under her skin in the breasts, which she could feel pretty much every day all the time. When she touched that area, she felt it when she felt laid down to bed and slept on her stomach, she could feel that pushing into her chest and they were literally daily symptomatic for her, and this is why she came to me and asked what else can be done? And unfortunately the options are just resecting that and causing another deficit, another contour problem sometimes because you're just taking a large portion of whatever tissue's in there away and maybe causing a dent in the breast

Monique Ramsey (08:17):
And resecting means cutting it out, right?

Dr. Swistun (08:20):
Just cutting it out. Yes, correct.

Monique Ramsey (08:21):
Wow.

Dr. Swistun (08:21):
That's really all you can do is just a big scar lump that if you want to get rid of it and go back to baseline, go back to nice soft tissue all around, you really just have to cut it out. And then that depending on the size, that can create a contour deformity, basically a dent in the breast. And then how do you deal with that? Well, you can fat graft again, but you have to be a lot less aggressive, and obviously you have to first let this tissue heal and then come back six months later and graft a little bit and hopefully make an improvement. And if it's good enough, we're done. If not, maybe graft a little bit more six months after that. It becomes a lot more frustrating, a lot more time consuming and expensive I suppose, once that complication happens.

Monique Ramsey (09:00):
So how would a patient interview a surgeon to sort of make sure that doesn't happen? And I know there's no way to say I'm kicking this doctor or not. I won't have a complication, but what are maybe some of the things they should ask or what they should look for?

Dr. Swistun (09:19):
Yeah, it is very difficult to answer because honestly, the patient trusts the doctor to make the decision. The patient has a specific request and it's really the doctor's job to guide them through what their options actually are based on their body habit is based on how much tissue they have, based on how much fat they can donate from their own body and based on how much tissue they have in the area that we're going to graft into. Ultimately, I think a lot of surgeons will present themselves as confident and know what they're doing and they'll show you the best results best before and afters may not disclose necessarily the patients that had the complications and honestly, all of us have complications. This is just the art of surgery and the art of medicine, but I guess look at their before and afters, but also look at their ratings, talk to other patients who have had surgery with them. And yeah, I suppose that's really the only research you can do.

Monique Ramsey (10:10):
Is fat, fat no matter where it comes from. If it comes from a patient's arms or their flanks or their belly and you're moving it around, is it all kind of the same or is fat different?

Dr. Swistun (10:22):
There are some studies that kind of look at that specifically and look at retention rates after fat grafting from specific areas. And I think the abdomen, the flanks and the inner thigh were sort of identified as the ideal fat donor sites, which is good because those are usually the areas that patients want to dress anyway. There are some patients that don't have a lot of fat, so then we look for other options like other areas. We try to take it from a little bit of the arm, sometimes the upper back. Those areas tend to be a little bit more fibrous, which is to say a little bit less fat, a little bit more connective tissue, and that fat is of a little bit less quality just in general, and that may not have such high retention rates. Again, and it's doctor dependent as well. I mean, one of the things that I've really noticed in my practice that I try to structure my entire surgery around is putting the fat back in as soon as possible.

(11:10):
The way I think about it is if you liposuction, then as soon as that fat is removed from the body, it's disconnected from its blood supply and it's just suffocating, and the sooner you get it back into the body so it can start on reestablishing its blood supply, the better. Basically the physiology is restored, it's back in its own happy environment, and it just kind of has a higher retention rate. So I basically organize my entire surgeries based on that. It's like this is where we're going to take the fat from. How quickly can I get it back into that tissue? Okay, this is the position we're going to start, and then as soon as that's done, the fat can be processed while we're turning the patient. So as soon as they're turned, I can get it back in. I found that that's one of very important variables, but again, that's surgeon dependent. Not every surgeon does that. Sometimes it's more convenient to perform an entire liposuction of a specific area and then flip the patient and then graft when you're ready for it, which may be an hour later or two hours later, and that may result in a slightly lower fat retention rate.

Monique Ramsey (12:09):
And does age matter if somebody's in their twenties, is their fat better than when somebody's in their fifties?

Dr. Swistun (12:16):
I believe it does just because of the vasculature. Again, I think it's all about blood supply and patients who may be older, patients who may have acquired some diseases over time, patients with diabetes, patients who have history of smoking, all those things affect capillary restructure in their body, basically their blood flow on the microscopic level, and I think that makes a difference.

Monique Ramsey (12:39):
And you mentioned processing, so we're taking it out, it's processing, somebody's processing it, and then it's put back in. What does that look like?

Dr. Swistun (12:48):
There's lots of different competing articles on that. What's the best way to process? There's some articles that used to advocate just taking the fat and washing it out with saline, so it's the cleanest and the purest and sort of the most yellow, so to speak, and then injecting that. And then there's other articles that basically show that actually leaving a little bit of blood in there is not a bad idea because that has PRP, platelet rich plasma, which has some growth factors in it. So injecting growth factors with the fat will actually promote better uptake and things like that. Obviously, the other thing is exposure. If you take the fat and liposuction, I put it in a canister. If you take it from a canister to one container and then from that to another container and then to a third container and then transfer it over, all these processes tend to sort of hurt the fat, so to speak, I think. So I think the less you do with it the better. There are some purists that basically just advocate doing the least possible with it. They basically put it in a canister and then fat graft it right back from that same canister right back to the body as soon as possible with all the growth factors in it. And that tends to have pretty good success rates as well. I'm sort of more on that side. I mean, again, my intent is to get the fat back in there as soon as I can. So I think the less that you do with it and the faster you get it back in, the better.

Monique Ramsey (14:04):
It makes total sense. But I'm sure everybody thinks their technique makes sense to them.

Dr. Swistun (14:09):
But we want to do evidence-based medicine also. So there are studies, there are patients, I mean there are doctors that focus in on this and do studies and they think they come to similar conclusions in a lot of the studies.

Monique Ramsey (14:19):
So we are talking, you can put the fat in your rear end, you can put the fat in the hip dips, you can put the fat in the breasts. Let's talk about fat in the face and what does that look like in terms of where in the face do you find that people have lost volume and is a good place to put fat?

Dr. Swistun (14:38):
Yeah, so I mean the generalize on your question, you can put fat anywhere you want. So that's why it's used in reconstructive plastics. You can have a soft tissue deficit on your leg from a traumatic accident and you can fat graft that to give it a better contour. The face specifically, there's lots of facial plastic surgeons that do fat grafting. The common areas aging is fat loss from the face, which is sort of what happens if you look at a baby, they're basically just all fat. Basically, it's a big round face with just eyes and nose and mouth, just nice features. And then if you go to the other extreme and look at somebody who's much older, then they just have all these shadows that sort of creep in over time because of volume loss. There's fat compartments all over the face that are responsible for keeping that volume youthful.

(15:20):
And when that volume goes away, that's when we get hollow points. That's when we get depression of the skin. Skin aging is not so much face skin drooping down is basically the volume going away. The face and the facial skin sort of draping on itself in a way that there's more shadows and more valleys and divots in there now. And to some extent adding volume back into those areas that atrophied restores youth to a large extent. And obviously that works to a point. At some point you do have to do a facelift, which involves skin removal as well. So the cheeks are usually by far the most common intervention that's really effective. A lot of fat compartments in the cheeks. And once those start atrophying, those are the first signs of aging. People get a line right here. People get exposure or the tear trough deformities, which is basically fat going away from these and sort of exposing these anatomical landmarks that we all have that are normally hidden under the fat.

(16:13):
But once the fat is gone, then these become forefront on display. So restoring fat in this area is really treats the midface and also gives a little bit more volume to the cheeks, which in turn lifts the cheeks, which in turn makes the nasal labial folds kind of go away and mask a little bit as well. So that's a very powerful modality. The other area that I really like to focus on is restoring the jawline. One of the youthful signs, signs of youth, I should say, is a straight jawline from the angle to the mandible all the way to the tip of the chin. If you have a straight line there, that is a sign of youth. And as soon as these irregularities start creeping in, if I use myself as an example, there's a little bit of a divot here, which isolates separates the chin away from the rest of the mandible.

(16:56):
That's a sign of aging because then after that the jowl creeps in and then you have a little bit of a dip here that's the platysmal band just kind of like pulling down, and then that pulls on this area. So you have a dip here and then a tight spot here and then a chin that is a little bit more of an aged look. So what you can do is restore that straight line by grafting this sulcus right here, which is basically that little divot on the pre jowl sulcus is what we call it. And a lot of times adding fat just to the chin itself will give you a little bit more of a prominent chin. We'll pull that skin a little bit further out and restoring this, we'll restore that jawline to some extent. We can do that with fillers, but we can do that with fat as well.

Monique Ramsey (17:35):
I kind of love the fat that with fat, it's your own. And I'm assuming maybe not a hundred percent of it stays because maybe some percent does not get happy in its new home. But once it's there, it's there forever. Right?

Dr. Swistun (17:54):
The fat that survives is there forever. And this is the question that I always get. How long does the fat grafting last? Well, it's not like a filler. Filler does have a longevity associated with it. You put in specific filler, it's gone nine months later or two years later or whatever, depending on the filler you used. For fat, the mentality is that as soon as you graft it, not all of the fat cells will survive, but the ones that do are there forever. Okay. So in general, I quote patients, I tell them that I think I expect about 50% of the fats to survive.

Monique Ramsey (18:23):
Are the lips a place you can put fat or are the lips too, is the skin too thin?

Dr. Swistun (18:31):
No, they are, in my experience particularly, I think they're the most difficult to predict a nice result with the lips. I mean of patients that I fat grafted the lips where they had a really nice, very visible, sustained result in the long term. There are some other patients who basically just kind of reabsorbed it. There was one in particular that I graphed after a reconstructive surgery. She had a dog bite. It's actually one of my favorite cases that I've documented on my Instagram page. But she had a dog bite with a big deficit over here. That dog just literally swallowed this tissue. So she was missing about a third of her lips. So there is a way to sort of make incisions and use the remaining lip to reconnect and close bridge that area over. And she had a great result with that. But because of that, the lower lip was thinned out. So we ended up fat grafting her six months later after her reconstruction. But I was less than impressed with how much fat stayed, probably because of the vascular supply already being stressed by the reconstruction and also because she had additional scars there. And scar tissue doesn't expand as well as new tissue. So all these variables come into play. I think the lips are also a very mobile area, so a lot of that may reabsorb the fat.

Monique Ramsey (19:42):
Now you also talked about this being a very patient dependent procedure, and I would think because all surgeries have a whole list of things that the patient's supposed to do and not do after surgery. So let's talk about what are the instructions and how does the patient's compliance with those instructions, how does that factor in after surgery for a good result?

Dr. Swistun (20:09):
Yeah, so you just want to basically preserve that fat and preserve blood supply in these areas so that the fat can survive. It takes a couple of weeks, couple of months for this fat to really reestablish itself in its new place. So you want to avoid pressure in those areas because pressure will increase with the blood flow in that area, especially for a long time. If you just, let's say you had fat grafting into the buttocks and you sit down for two minutes and then you give up again, it doesn't really matter that much just because that blood supply will come right back. But if you fall asleep on your butt for an hour or two or six, then that pressure will basically change the blood flow to that area for a very long time, and that may interfere with how much fat actually will survive.

(20:48):
The other thing is to keep hydrated, obviously, the more hydration you have, the better vasculature, the less vasoconstriction and the blood flow will be better to all these surgical areas. For patients who have low blood counts, for whatever reason, who are anemic, they need to be on iron supplements. Or in one case I had a patient who was actually on transfusions for a different reason, but we just wanted to make sure that the timing of our surgery is sort of in between her treatments so that we can optimize her healing because obviously red blood cells deliver oxygen to all tissues, including obviously the new fat grafted tissue.

Monique Ramsey (21:21):
So is there anybody who you would say is not a good candidate for fat grafting?

Dr. Swistun (21:27):
Somebody who's remarkably thin and with the caveat of even in that instance, I am usually able to find fats somewhere. And these are usually patients that don't expect a huge result. They're very realistic about it. I do have some patients who are very thin who have very little breast tissue, basically no breast tissue, they just have a flat chest with kind of a nipple there. And they said, I just want something, just want a little bit of a shadow of a breast just so there's a proportion there and things like that. And I've been able to do that. This is a patient that had serial fat grafting. We did fat grafting on two different occasions and we prioritized her fat. In the first instance we liposuction from her flanks. She didn't have a lot, but she had something and we were able to obtain some fat and then graft both sides.

(22:14):
And she had a little bit of a modest result and she was very happy with the fact that now there is something there. And she said, can we do a little bit more? So six months later she came back and we went after her medial thighs, inner thighs and got a little bit more fat out and drafted that again. And then she had an even better result and she was very happy with that. So I would say that that's probably the more challenging patient is where your options are really limited with regards to how much fat she has to donate and also how much tissue she has to graft into.

Monique Ramsey (22:45):
And we have some other episodes where we talk about BBL, skinny BBL, we go into more depth. So if anybody in the audience is interested, we can put those in the show notes. So where we take more of a deep dive, but I love that we're kind of concentrating on what are the complications that could happen. So to recap, we've got oil cysts, lumps, fat necrosis meaning fat dying and maybe turning into that lump. Anything else that you've seen?

Dr. Swistun (23:17):
Not really. I mean, this is all essentially the same thing is basically if you take up big lump of fat and inject it into one area inside the breast, let's say only the outside cells of that entire lump are in contact with new blood supply and those will survive. But everything on the inside, which is the vast majority of it, will just not survive. And that can turn into a big oil cyst or worse yet scar down and become fat necrosis and a hard lump. An oil cyst can be drained with a needle, hard lump skin has to be removed surgically. I suppose other complications that you can do, that you can get with this whole procedure is contour deformities to the donor site.

Monique Ramsey (23:57):
I was just thinking the same thing. I was like, what happens where we took it from?

Dr. Swistun (24:02):
Exactly. So again, I've seen this sometimes in the reconstructive realm where the focus was really the breast. Let's say they're reconstructing the breast, so they don't care about the donor side, they just care about the breast because their job is to, it's a little bit more narrow-minded where they just focus on the breast itself. So it's like, oh, we'll get the fat from somewhere. And I've had patients come back with a dent on one side of the abdomen or one thigh was liposuction, but the other one wasn't, and that was the asymmetry that they got. Or sometimes it's very aggressive liposuction maybe from both thighs, but they were so aggressive because they wanted to get a lot of fat, then they left contour deformities. They basically liposuction the deep fat and then maybe also the fat immediately under the skin. And that can cause a lot of dimpling, a lot of contour deformities, skin deformities on the surface. And that's another thing that you have to be careful. So I think somebody who has experience with liposuction as well as with fat grafting is sort of the best choice for your surgeon because I think they will pay attention to the aesthetics of your donor site just as much as they'll pay attention to the outcome of your fat graft.

Monique Ramsey (25:07):
I love that. Well, this was so interesting. Thank you for coming in and going over this because I think fat grafting has become so much more popular lately, and we're realizing it's like liquid gold, don't throw it away. Where can we put it? Right?

Dr. Swistun (25:25):
It is. In fact, that's something I mentioned for every patient that comes in for liposuction, I basically tell them that it's like, I don't want to upsell you on another surgery, but if we are doing liposuction to your entire body, I am obligated to tell you that there's two choices you have with the fat that we're going to get. Number one, we can throw it away and you'll never see it again. Or we can use it somewhere. So if you ever were thinking about putting your fat somewhere else, now is the time because now is when we're going to have it available to us. And the other caveat question I get and something I was going to leave the audience with, which is a common question is like, well, can I donate fat to my sister? Or whatever? Or the husband's like, oh, I got a lot of fat. We can don, I can give her a lot of fat. It's like, so, the short answer is no, except if you have a genetically identical twin. So for having of anybody out there who does have the fortune of having a genetically identical twin, that is the only person in the world that can donate that to you.

Monique Ramsey (26:24):
That's interesting.I love it. I love it.

Dr. Swistun (26:26):
It's not going to get rejected.

Monique Ramsey (26:29):
Well, thank you, Dr. Swistun and everybody, check the show notes, and if you liked this, give us a review, right? Because we've been doing this for three years, and we're so happy to have you as a listener and tell us what you want to hear next. And thank you again Dr. Swistun for joining us.

Dr. Swistun (26:46):
Thank you for having me.

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