Hand Rejuvenation using Fat Grafting

Apart from the most obvious region (face & neck) where aging can be seen and where most aesthetic surgery for rejuvenation are performed,  the dorsum of the hand is the next obvious area where aging can be seen and is continuously visible in daily life.  What they used to say,"If you want to know a woman's age, look at her hands" still holds true.

The region of the hand exhibits laxity of the skin with subcutaneous atrophy and age-related pigmentations in a comparable manner to the face. Fat transfer to the dorsum of the hand enables subcutaneous regeneration by refilling the subcutaneous space and hence reducing some of the age-related degenerative process.

Areas of Concern of the Aging Hand

• Bony-looking hands due to loss of some of the fat beneath the skin that occurs with age
• Prominent veins
• Brown aging spots (liver spots)

Rejuvenation Treatment for the Aging Hand

•    Chemical peels to improve the overall appearance of the skin on the back of the hand 
• Fillers or Fat transfer onto the dorsum or back of the hand to make them appear less bony.  Fat transfer is ideal since this may improve the texture of the skin.

Please consult your plastic surgeon regarding hand rejuvenation.

Emmanuel De La Cruz MD, PLLC

Plastic & Reconstructive Surgeon, and Hand Surgeon

References:   

• Coleman SR.  Hand rejuvenation with structural fat grafting. Plast Reconstr Surg. 2002 Dec;110(7):1731-44; discussion 1745-7. 
• Villanueva, et al.  Technical Refinements in Autologous Hand Rejuvenation.  Plast Reconstr Surg. 2015 Dec;136(6):1175-9.

Brazilian Butt Lift

Harvesting for Fat Transfer in Brazilian Butt Lift

The success of an autologous fat graft depends in part on its total stromal vascular fraction (SVF) and adipose-derived stem cells (ASCs). This is important when it comes to harvesting of fat for fat transfer such as in Brazilian Butt Lift. 

• Subcutaneous fat tissues from the abdomen, flank, or axilla were harvested in the study conducted by Iyyanki from patients of various ages by mechanical liposuction, direct surgical excision, or Coleman's technique with or without centrifugation.
• Compared with Coleman's technique without centrifugation, direct excision yielded significantly more ASCs (P < .001) and total SVF cells (P = .007); liposuction yielded significantly fewer ASCs (P < .001) and total SVF cells (P < .05);
• Coleman's technique with centrifugation yielded significantly more total SVF cells (P < .005), but not ASCs.
• The total number of SVF cells in fat harvested from the abdomen was significantly larger than the number in fat harvested from the flank or axilla (P < .05).
• Adipose tissue harvested from the abdomen through direct excision or Coleman's technique with centrifugation was found to yield the most SVF cells and ASCs.

Reference: 

Iyyanki, et al.  Harvesting technique affects adipose-derived stem cell yield. Aesthetic Surgery J. 2015 May;35(4):467-76. doi: 10.1093/asj/sju055. Epub 2015 Mar 18.

Emmanuel De La Cruz MD, PLLC

Plastic Surgeon, Houston Texas

Fat Graft Harvested via VASER liposuction is Suitable for Brazilian Butt Lift

Fat Graft Harvested via VASER Liposuction is Viable and Suitable for Fat Transfer in Brazilian Butt Lift Patients

Although there's clinical evidence of successful autologous fat transfer (AFT), such as in Brazilian Butt Lift, using VASER liposuction is readily available, no study has quantified adipocyte viability using standardized methods until recently.

• The UAL system (VASER; Sound Surgical Technologies, Inc, Louisville, Colorado) was set at 60% amplitude in pulsed mode with vacuum aspiration of 15 in Hg or less.
• Laboratory analysis included free lipid volume, viability via lipolysis and propidium iodide staining, and cytological analysis, including cell surface protein examination and hematoxylin and eosin staining.
• 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%
• Adipose tissue acquired via VASER liposuction is viable at harvest and isa suitable source for autologous fat grafts, especially for Brazilian Butt Lift.
• Adiposed-derived stem cells (fat for fat transfer) obtained via VASER liposuction were of equal quality when directly compared with the current gold standard harvest method according to a study conducted by Duscher.   "UAL- and SAL-derived samples demonstrated equivalent ASC yield and viability, and UAL ASCs were not impaired in their osteogenic, adipogenic, or chondrogenic differentiation capacity."

4D VASER Liposuction performed by Dr. Emmanuel De La Cruz of Houston, Texas

Reference:

Duscher, et al. Ultrasound-Assisted Liposuction Does Not Compromise the Regenerative Potential of Adipose-Derived Stem Cells.  Stem Cells Transl Med. 2016 Feb;5(2):248-57. doi: 10.5966/sctm.2015-0064. Epub 2015 Dec 23.

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

Improvement of Diabetes after VASER Liposuction

Improvement of Diabetes after a VASER Liposuction

Recently, there has been a study conducted to examine the liposuction-induced metabolic changes with regard to release of major adipokines and insulin sensitivity in overweight male patients.

Figure 1:  Before and After Photos (6 weeks after surgery) of 4 D VASER Liposuction performed by Dr. Emmanuel De La Cruz in Houston, Texas.

• "To eliminate the confounding effects of postsurgical inflammation and to evaluate delayed metabolic effects, fasting blood was collected on the day of liposuction, within 1 to 2 months and more than 6 months after surgery."
• "Both treatment groups (diabetic and nondiabetic patients) experienced similar postsurgical weight reduction with concomitant lowering of body mass index value at 1 to 2 months follow-up, which was sustained after 6 months from surgery."
• "Improvement in insulin sensitivity at 1 to 2 months follow-up was observed ( p = .017 and p = .002, for diabetics and nondiabetics, respectively) and this change persisted over the next 4 months."

This study shows that there may be beneficial effects of VASER Liposuction in overweight diabetic and non-diabetic males by improving their insulin sensitivity.

Reference:

Gibas-Dorna, et al.. The Effect of VASER Abdominal Liposuction on Metabolic Profile in Overweight Males.  Am J Mens Health. 2017 Mar;11(2):284-293. doi: 10.1177/1557988316674841. Epub 2016 Oct 22.

Emmanuel De La Cruz MD

Plastic & Reconstructive Surgeon

Skin Retraction After VASER Liposuction

April 06, 2017  /  emmanuel de la cruz

A recent randomized clinical trial had shown that the VASER liposuction produced clinical significant skin retraction. 

• "Regarding skin retraction, the VASER-assisted lipoplasty-treated side resulted in a statistically significant improvement in skin retraction of 53 percent relative to suction-assisted lipoplasty (17 percent per liter versus 11 percent per liter, p = 0.003) with 33 paired sites using a two-tailed t test. "

Figure 1:  Before and After Photos (3 months after surgery) after VASER Hi-Definition Liposuction performed by Dr. De La Cruz.  Note that there was significant skin retraction after surgery.

Reference:

Nagy, et al.. A multicenter, prospective, randomized, single-blind, controlled clinical trial comparing VASER-assisted Lipoplasty and suction-assisted Lipoplasty. Plast Reconstr Surg. 2012 Apr;129(4):681e-9e. doi: 10.1097/PRS.0b013e3182442274.

Emmanuel De La Cruz MD, PLLC

Plastic & Reconstructive Surgeon

Treatment of Contour Irregularities from Liposuction

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

Smart Lipo versus Tumescent Liposuction

SmartLipo versus Traditional Tumescent Liposuction - Houston, Texas

A previous randomized clinical trial comparing traditional tumescent liposuction and Smart Lipo 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

Long-term Success in Liposuction

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

Biopolymer Buttock Injection Removal

Treatment of Biopolymer/Hydrogel Buttock Injections

Recently, there had been numerous cases of the use of industrial grade products injected into the body, such as the buttocks and thighs, performed by unlicensed or unskilled practitioners.  Some of these products range from injectable silicone or high-volume hyaluronic acid or hydrogel. Even though some of these products, such as silicone, may be biologically inert, these materials have been implicated in a variety of adverse reactions including granulomas, disfiguring nodules, and lymphedema, sometimes with latent periods of decades.  Often, they may cause disfiguring chronic infections that may require intravenous antibiotics or extensive surgical debridement.  

There had been a few cases that the chronic infections  resulting from illegally injected industrial grade products into the lower extremities, such as the legs, resulted in amputations as a life-saving procedure.  

Figure 1:  Chronic infection from an Biopolymer injections into the buttocks and thighs performed by an unlicensed and unskilled practitioner. 

Clinical Manifestations & Symptoms

• Chronic infection, such as cellulitis, that are recurrent despite antibiotics
• Firmess or hardening of the area of injections
• Chronic pain, such as buttock pain
• Numbness sensation of the area of injection
• Discoloration of the skin of the area of injection

Clinical Management

• We recommend obtaining an MRI of the area of injection to determine the extent of injection as well as the area where the material has potentially migrated.  The MRI would act as a map to determine where your surgeon would remove the biopolymer.

Treatment

• The treatment varies from patient to patient.  This may range from surgical excision, to hyaluronidase injection followed by VASER liposuction and fat transfer into the area to correct the resultant deformity.  Unfortunately, it is not possible to completely remove the biopolymer and not result in a significant deformity of the area involved.  Complete removal, such as surgical excision, may result in a life-changing deformity.  

Figure 2:  Hydrogel/Biopolymer removal from the buttocks using the VASER Liposuction with fat transfer to the buttocks to correct the resulting deformity from removal of the biopolymer.  Patient had resolution of a chronic buttock pain after surgery.

I recommend seeing a plastic surgeon for evaluation and possible removal of the biopolymer injected into one's body.  An MRI may be necessary to evaluate the location of the injected material.  Every person is different, and each treatment may be different.

Emmanuel De La Cruz MD, PLLC

Plastic & Reconstructive Surgeon Houston, Texas

History of Liposuction

Liposuction has been around since the 1920s when Dr. Dujarrier used a uterine curette to remove fat from the knee of a well-known ballerina.  Unfortunately during that time, the gynecologic surgeon damaged the femoral artery which resulted to amputation of the leg.

Liposuction really began evolving in the late 1960s and became what we know it as in 1974.   Dr. Yves-Gerard Illouz of Paris France created modern liposuction in 1982.  The procedure he created was the "Illouz Method", which was actually Suction Assisted Liposuction (SAL). 

History of Liposuction:  Timeline

1921 -  Dujarrier used a uterine curette to remove fat from the knee of a ballerina

1960 -  Schrudde rekindled the interest in liposuction with sharp removal of fat

1978 - Kesselring and Meyer added suction to sharp curretage

1970 - Illouz (Paris, France) used a blunt cannula attached to suction device

1982 - "Illouz Method" of liposuction or Suction Assisted Liposuction

1983 - Hetter used epinephrine and 0.25% lidocaine as a solution to reduce post-operative bleeding

1984 - Hetter described the use of adequate pressure to induce lipolysis

1980 - Klein proposed the tumescent liposuction technique

Figure 1: Before & After Photos of 4D VASER Liposuction with Brazilian Buttlift performed by Dr. Emmanuel De La Cruz (8 weeks after surgery)

In 1985, "Tumescent Liposuction" was invented by Dr. Klein and Dr. Lillis. Liposuction could all of a sudden be performed in an office-setting with only local anesthesia via IV sedation rather than general anesthesia. The "Super Wet" technique was invented right after tumescent, because of the high volume of fluid and potential toxicity of the fluid used (lidocaine). So this lower volume 'wet' technique, Super Wet, was invented.

With modern technology, plastic surgeons discovered Ultrasound Assisted Liposuction (UAL) in the late 1990s.  It was used to emulsify fat or liquefy fat using ultrasonic energy.   Fat is subsequently removed with lower pressure liposuction.   VASER liposuction, a third-generation ultrasonic-assisted liposuction,  was subsequently invented. It's an improved liposuction machine with lower complication rates and improved skin retraction post-liposuction.

Emmanuel De La Cruz MD, PLLC
Plastic & Reconstructive Surgery

Houston, Texas

  

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Removal of Silicone from the Buttocks

Removal of Silicone Granuloma from the Buttocks using VASER Liposuction

September 14, 2017  /  emmanuel de la cruz

Patients who present with a history of silicone injection to the buttocks or gluteal region may present with debilitating complications, such as chronic pain, chronic infections such as cellulitis and abscesses; skin necrosis and silicone granulomas that may cause deformity of the buttocks.  Unfortunately, silicone toxicosis of the gluteal region (buttock) can be difficult to manage.

Management of Silicone Toxicosis of the Buttock

• An MRI of the gluteal region will need to be obtained to evaluate the location and extent of the silicone granulomas
• Treatment may range from surgical excision versus suction-assisted lipectomy with VASER liposuction with concomitant fat transfer to the buttock to correct the resulting deformity from liposuction

Clinical Study using VASER Liposuction for Removal of Silicone Granulomas of the Buttocks

• "Average patient age was 36 years (range, 25-43 years). All patients initially presented with intense pain as assessed by a visual analog scale; by the 12th week postoperatively, the entire cohort experienced remission in pain. At 1 year postoperatively, no patients had infections (vs 75% preoperatively; P = .028), visited the ER (vs 50% preoperatively; P = .058), or were hospitalized (vs an average of 1.5 hospitalizations per patient preoperatively; P = .066)."
• "Liposuction with immediate intramuscular fat transfer for buttock augmentation appears to be a safe surgical option that preserves aesthetic appearance for patients with gluteal silicone toxicosis."

References:

Salgado, et al.  Liposuction and lipofilling for treatment of symptomatic silicone toxicosis of the gluteal region. Aesthet Surg J. 2014 May 1;34(4):571-7. doi: 10.1177/1090820X14527107. Epub 2014 Mar 27.

Emmanuel De La Cruz MD, PLLC

Plastic & Reconstructive Surgeon

Houston, Texas

VASER Liposuction used for Fat Transfer

VASER Liposuction: A Good Source for Mesenchymal Stromal Cells

September 24, 2017  /  emmanuel de la cruz

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