Time to rethink fat

Plastic surgeon Stephen Gilbert tells us about fat and why, after years of battling it, it may be our best friend in the fight against ageing.

Sagging jowls, temples, tear troughs and cheeks, thinner lips and fine lines are typical concerns of men and women over the age of 40. A face begins to look old due to the loss of fat. When we’re younger we tend not to like our fuller face. And when we’re older, we lament the loss of this youthful fat.

Plastic surgeons have been transferring stem cells as part of a multivector SMAS facelift for years. However, more and more people are wanting a rested, youthful look without undergoing a facelift, especially those who are dissatisfied with the short-term benefits of dermal fillers or who want to delay having a facelift for several years.

We are fortunate that scientists have discovered that fat carries a large number of stem cells which have the ability to refresh the underlying collagen and improve the quality of the skin. The ultimate way of injecting fat to rejuvenate the face is to use freeze dried fat containing stem cells taken when you are a teenager and then injecting them when you are older. The problem with this technique is the cost of storage and risk of contamination.

Earlier this year at the Vienna Conference of world experts in Plastic Surgery, we determined that currently the best practical way of restoring youth to the ageing face is to aspirate some of your own fat from an unwanted area, centrifuge it for three minutes to separate out the stem cell rich fat cells from the unwanted blood and oil and then inject it with a fine cannula in multiple tunnels to build up contour and refresh the skin.

This procedure can be achieved almost painlessly by local anaesthetic combined with oral sedation, which relaxes you but does not usually put you to sleep. Fat can be applied to the temples, brow, under the eye, the cheek mounds, the cheek folds, the lips and along the jaw line to give you a fuller, smoother, more youthful face. But in looser faces this has to be combined with a mid face lift to give the best result. In older faces with a loose neck fat, injecting is combined with a face and neck lift to get the best result.

The SNIF (Sharp Needle Intradermal Fat grafting) technique was introduced at the Asian-Australasian Fat Grafting Summit earlier this year. This involves injecting only the stem cell rich component of fat more superficially into the deep layer of the skin to smooth out thin wrinkles. This shows promise but time will tell how effective it will be, especially for fine lines on the upper lip.

CoolSculpting is the new non-invasive method of fatty bulge reduction that we have had great success with over the last two years.

This technique involves applying a pad to the bulging areas and cooling the fat to a controlled temperature, which disrupts fat cells resulting in a 20-30 per cent reduction in the unwanted bulge over a period of six months.

Virtually pain-free, CoolSculpting was devised by Harvard University scientists in conjunction with the Massachusettes General Hospital and is FDA approved. It is particularly useful in reducing those diet-resistant, hard-to-get-rid-of bulges in the abdomen, love handles, inner and outer thighs and inner arms. In younger people the skin’s natural elasticity will cause it to adapt to the new contour and older people may see their skin become tighter too.

Traditional liposuction has also become less invasive and smaller areas can be done under local anaesthetic with oral sedation. This applies to areas that are not suitable for CoolSculpting, such as the wobbly bit under the chin or where a more complete fat removal is needed. For more extensive body contouring a general anaesthetic is much better, combined with the skills of an experienced plastic surgeon. In many cases the best result can only be obtained by removal of excess skin such as in an abdominoplasty, thigh or body lift.

The ultimate use of fat is to remove unwanted fat from the body and place it in areas of deficit in the face within the one procedure. This doubly empowers the patient as their body is sculptured into a healthier, more youthful shape and at the same time their face is rejuvenated.

Stephen Talks to Australian Woman’s Weekly – September 2014

Nowadays  the endoscopic brow lift  concentrates on rejuvenating the outer brow by  raising it to a level just above  the  upper margin of the orbit while leaving the inner aspect of the brow slightly lower. Botox takes care of the frown lines  between the eye brows that the brow lift  once addressed inadequately.

Fashionable brows today are low towards the nose arching slightly up wards to their  outer limit , peaking  above the outer third of the eye.  Some cultures  (eg Middle Eastern ) still  look good to the modern eye  with more arching eye brows that were the common ideal of Caucasian beauty in the recent past.

The world-wide beauty trend  is now towards the Pan Asian look. By this I mean slightly upward slanting eyes, fullness below the outer eyebrow, moderately full  over the cheek bones but   mildly sculptured below, a petite chin but full lips, emphasising the  inverted feminine facial triangle rather than squarer jaw often once  seen in Caucasian beauties. For this reason the latter commonly have botox in their masseter muscles  to slim down their jaw line.

An important addition to the lateral (outer) brow lift is the subtle filling of the upper eyelid between the outer eye  brow and the  crease above the eyelashes. This fuller  attractively shaped eye brow is the hall mark of youth and beauty  around the eye and cannot be achieved with a brow lift or upper eye lid skin removal  (Upper Blepharoplasty)  alone.

This filling is best done with the patient’s own fat which if applied in multiple tiny amounts will pick up a blood supply and remain permanently whereas hyaluronic acid fillers will always eventually reabsorb.

The brow lift was popularised in California in the 1970s by plastic surgeon Bruce Connell but the New York plastic surgeons were slow to  recognise its merits . Eventually they took it up and it became popular as an initial ” refreshing ” procedure.

Stephen convenes the scientific programme in Vienna – Facial Ageing

The International Consortium of  Aesthetic Plastic Surgery (ICAPS) held its 16th Annual Scientific meeting in Vienna in May this year.

Fat filling  combined with face lifting was examined in detail and determined to be the best way of restoring youth to an ageing face. Leading world experts Tim Marten and Bryan Mendelson discussed their techniques in detail with contributions from Stephen Gilbert the only NZ member of ICAPS.  Transferring the patient’s own fat  to where it has been lost  from the face  refreshes the skin by the  the transfer of stem cells contained in the fat while also helping  restore the youthful female oval shape. This combined with the multivector SMAS lift which Stephen specialises in  is the  present state of the art technique for  facial rejuvenation. The result can be further improved by the patient using suitable medical products, peels and lasers which Prescription  Skin Care provides.

Stephen Gilbert was in charge of the scientific programme which can be studied in detail  on the ICAPS website aestheticicaps.com

The programme ran for three consecutive mornings with the afternoons  and evenings being devoted to experiencing the cultural delights of Vienna, the baroque art and classical music capital of the world. Highlights were the Lipizzaner horses, an opera by Mozart and  an exhibition of Gustave Klimt paintings.

ICAPS Meeting May 2013 – Singapore

Mr. Stephen Gilbert was the scientific convenor for this annual meeting of the International Confederation of Aesthetic Plastic Surgeons. A full account can be found on the Icaps web site.

Mr Gilbert presented a paper showing his technique for facial restoration which enhances beauty as well as youth by volume replacement with the patient’s own fat at the same operation as a high extended smas multidirectional face and neck lift.

Woffles Wu presented a paper outlining how Asians are usually looking for a narrower more oval face. The modern concept of Asian and western beauty is merging both seeking high but not too wide cheek mounds set off by a mild cheek concavity I and trim jawline.

FROM THE ICAPS WEBSITE

“Stephen showed his surgical approach with fat first being placed radially from a a point on the malar prominence to emphasise the soft female facial curves and then securing the foundation with a high extended multi directional biplanar smas lift but both emphasised the need to raise the maximum projection of the cheek in three quarter view (the ogee curve) to meet present ideas of beauty in Eastern and Western cultures.”

A highlight of the social program was a visit to Dr Wu’s personal night museum where amongst other lively art works he has a number lampooning Mao Zedong. Ironically, once the antithesis of capitalism, Mao has become a marketable commodity.

Stephen Gilbert is a member of the International Consortium of Aesthetic Plastic Surgeons.To access their website, please click here.

ASAPS. Port Douglas Queensland August 2013

Stephen Gilbert attended the master class in volumetric face lifting presented by Tim Marten from San Fransisco at the meeting of the Australasian Society of Aesthetic Plastic Surgeons.
Stephen and Dr Marten both follow the same principles laid down by that Doyen of Facelifting Bruce Connell and have both enhanced their results by adding the patient’s own fat to give a more youthful fuller look without any signs of skin tension
Placed with precision fat can last permanently where it matters.

Mr Gilbert then presented his concept of ‘Arcs of Beauty’ during the meeting proper, using anatomical guidelines from recognised beauties to assist in placing the fat to enhance the patient’s own natural beauty as well as give a look of youthful vigour
Having restored volume and excised excess skin Mr Gilbert insists that the patient have the appropriate skin care to compliment the surgery.
He says it is no good having a youthful shape if the skin looks tired and lifeless.

An interview with Trudi Brewer for Next Magazine

Recently Mr Gilbert was asked to comment on tired eyes. An interview with Trudi Brewer for Next Magazine.  The issue comes out in May.  Below is what he said:

Q: Why do eyes look tired?

A heavy brow allowing the  eye brow itself to  drop and the skin below it to droop over the eyelashes  does tend to make you look half asleep; something male  board members fear. Excess skin and fat in the UPPER EYELID  has the same effect.

Marilyn Monroe was said to have’ bedroom eyes’ because her upper lids were often relaxed giving her a seductive look.

Aspiring female board members should be aware this is not the most appropriate look for them .

So ‘bedroom’ or ‘boardroom’ eyes can be corrected by a Brow Lift if  the  eye  brows are low,  with or without an UPPER BLEPHAROPLASTY to remove excess skin and fat. The brow can also be stabilised at the orbital margin by a deep brow pexy stitch  anchoring it there.

Fashions in eyebrow height change. Today beautiful young women have low slightly curved eyebrows with a subtle fullness just under the eye brows themselves giving them a more seductive look than the enquiring look of the high arched brow of yesteryear. This look goes very well with the modern emphasis on  a toned  curvaceous body.

But tired looking eyes are usually attributed to bags and wrinkles in the LOWER EYELIDS with dark rings below. The bags may be due to fat or fluid collection.

Fluid excess may be due to a medical condition such as kidney or heart failure, diabetes or even pregnancy.  It accumulates here when you  are lying down so bags in the morning may be less obvious later in the day. The tissue here is very thin and fluid collection is obvious

Like all facial tissues eyelids age and become looser with time, supporting the orbital fat around the eye ball less effectively so this bulges out like a hernia  as it  does anywhere else in the body where supporting tissue has weakened, allowing orbital fat to prolapse into the weakened lower eyelid causing bags

The SOLUTION  to this is to smooth out these bulges by redistributing the fat or removing it.

In the past we removed too much fat giving the eye a  hollow look as the eyelid aged.

So we began pushing the fat back into the orbit trying to strengthen the lower eyelid at the same time to prevent it prolapsing again. This was not always successful so the current trend is to remove some fat  and push some back.

RESTORING facial structure and thus rejuvenating the face is all about adding volume now so it seemed a pity to throw away this unwanted fat.

Instead we began redistributing it over the orbital margin to fill in the circles under the eyes. This sometimes worked well especially in conjunction with a smas lift  (superficial musculo-aponeurotic system)  which lifts prolapsed tissues up to meet the redistributed orbital fat, but too often all it did was to reposition the bulge further down the cheek.

Therefore my PREFERRED TECHNIQUE  today is to remove a modest amount  of fat and then fill in the deep circles with fat transfer from somewhere else in the body. It  has to be done with a very precise technique placing aliquots of washed fat across the hollows with avery  fine cannula.  The present concept is that this fat contains stem cells which are primordial cells capable of turning into different tissue such as collagen. Undoubtedly putting this fat in very thin layers under the skin during a face lift does refresh the skin itself. so there is some prospect that this will reduce the dark circles.

The DARK CIRCLES  are due to a number of features. Firstly the skin here is very thin and lies on muscle with very little tissue between. Thus the darker muscle shows through. Here the nose tends to cast a shadow in unfavourable lights  emphasising any darkness. Also any blood pigments accumulating  here will show through  as does any increase in melanin, the dark pigment  in skin cells in the dark circles.

Hydroquinone creams and lasers have little effect.

This is not a good place to put hyaluronic acid fillers because they easily give the thin skin a translucent  bluish look called the Tyndall effect, a sure give away that you have had something injected here.

Fat is much better but not all that is put in may survive  and it may need to be topped up once or twice to get a more lasting look.

The excess fat in the lower eyelid causing the BAGS can be removed  and even redistributed through the conjunctiva lining the back of the eyelid without disturbing the orbicular muscle which supports and helps close the lids thus avoiding a common complication of approaching the fat through the front of the eyelid. This complication is RETRACTION in which the eyelid pulls down slightly exposing too much sclera (white of the eye).

This tendency can be avoided usually by not removing too much skin and then pushing the eyelid up with a finger for ten seconds ten times a day for ten days (ten,ten,ten)  At the same time it is helpful to hitch the muscle up with a stitch to the edge of the orbit and in addition tighten the free border of the lid to lateral edge of the orbit with what is called a canthoplasty stitch.

You can see from the above that a LOWER blepharoplasty is much more complex than an UPPER one which can be done under local anaestheic whereas  the former requires a general anaestheic or at least intravenous sedation for it to be comfortable for the patient and provide optimal conditions for the surgeon to get the best result.

A  TRANSCONJUNCTIVAL blepharoplasty  does not take care of skin excess causing  the wrinkles. The skin excess can be reduced (shrunk with a CO2 or erbium laser but this runs the risk of over shrinkage and scleral show,even pallor of the lid which is ageing in itself, so it is safer to just take a pinch of the  excess skin off along the lash line. The skin is the smoothed up without tension and trimmed off exactly under the lashes so that it heals with an almost invisible scar.

Dynamic wrinkles around the age give character and  a pleasant expression to the face and dont really give it a tired or aged appearance.

Regretfully it is common to see celebrities  and others  looking expressionless and somewhat stunned from  the injection of too  much neuro-muscular modifier into the orbicularis muscle.      But early judicious use of the injections can  slow down the onset of permanent wrinkles  appearing around the eyes  when one’s face is relaxed.

In some older patients the orbciularis muscle is hypertrophied, hanging in festoons and has to be trimmed too. You may recall  there was once  a fashion popularised by dermatologists for cutting the skin  and fat off with a LASER claiming that there was less bleeding and swelling.  We found that the scar was always thicker whiter and more obvious if the skin was cut with a laser. Careful expert surgery with a scalpel and pinpoint diathermy, which will shrink the fat just as easily as the laser, gave a better and more predictable result.

DOWN TIME is always dependent on the quality of the tissues, the expertise of the surgeon  and the ability of the patient not to ooze or bleed excessively. Thus all drugs that may increase bleeding should be  avoided for at least a week before surgery.  Most importantly anti coagulants such as warfarin and all anti inflammatory  drugs including most vitamins and health supliments ; although the latter may only have a marginal effect.

Down time is also dependent on the patient following post operative instructions closely. these include keeping the head elevated for the first week and not exercising so as to raise the blood pressure which would obviously increase the risk of bleeding but you can walk round normally wearing sun glasses to disguise  the inevitable evidence of surgery in the first ten days.  Cold compresses are helpful for a few days.

Because the eyelids and brow are independent mobile asymmetrical units  it is very difficult to get them precisely symmetrical in the one operation so  you need to accept minor asymmetries while the lids are slowly continuing to improve over three months or so.. Only then can a true assessment  be made of the need for a FINESSING procedure.. Also you must realise that no one has identical  orbits , eyelids  and eyebrows. These discrepancies must be recorded and photographed beforehand.

COMPLICATIONS are thus very rare in experienced hands and always correctable with a fine-tuning procedure. In the upper lid minor asymmetries are the most common whereas in the lower lid it is not uncommon to have to adjust the tension along the free border to correct  a feeling of air getting under the lid even when it sits nicely on the globe with no scleral show or to go back and correct a persistent minor bulge.

The COST  is best found out by contacting the surgeon’s office, An accurate estimate cannot be given without first seeing the patient and establishing the most suitable teqcnique, the best venue  and whether or not local or general anaesthesia is required.

Cheap is not good. Costs to add up are the anaesthetic fee. the theatre fee and the surgeon’s fee.

The UPPER EYELIDS  can be done comfortably under local ansaesthesia  usually with oral sedation but the LOWER EYELIDS are  better done with local anaesthetic, and IV sedation or general anaesthetic.

The surgeon’s fee should relate to his  known expertise in this field, his experience, his aesthetic eye, the precision of his operating  and the care that he and his staff will give  you before and after the operation. Also you should find out if there will be further cost if finessing is required.

Some people who would benefit from  blepharoplasty are tempted to try to combine a holiday overseas with the operation.   This is known as COSMETIC TOURISM.     Whatever the  expertise of the  overseas surgeon he or she  is operating under three disadvantages.

1  There is no proper consultation before the patient and surgeon are  committed to the operation

2  The surgeon will not be able to look after delayed complications because you will be home by then.

3 The surgeon seldom sees his results so how can he know if  he has done a good job and how can he improve.

We see a steady number  unhappy patients coming to us to fix poor results or complications.

Prevention is always better than cure. Some women have better  anatomy and genes for delaying the visible onset of ageing. All can benefit from living a healthy life style, a good diet, not smoking, staying off the booze, protecting their skin from the sun and getting plenty of sleep.

ASAPS. Port Douglas Queensland August 2013

Stephen Gilbert attended the master class in volumetric face lifting presented by Tim Marten from San Fransisco at the meeting of the Australasian Society of Aesthetic Plastic Surgeons.
Stephen and Dr Marten both follow the same principles laid down by that Doyen of Facelifting Bruce Connell and have both enhanced their results by adding the patient’s own fat to give a more youthful fuller look without any signs of skin tension
Placed with precision fat can last permanently where it matters.

Mr Gilbert then presented his concept of ‘Arcs of Beauty’ during the meeting proper, using anatomical guidelines from recognised beauties to assist in placing the fat to enhance the patient’s own natural beauty as well as give a look of youthful vigour
Having restored volume and excised excess skin Mr Gilbert insists that the patient have the appropriate skin care to compliment the surgery.
He says it is no good having a youthful shape if the skin looks tired and lifeless.

ICAPS Meeting May 2013 – Singapore

Mr Stephen Gilbert was the scientific convenor for this annual meeting of the International Confederation of Aesthetic Plastic Surgeons. A full account can be found on the Icaps web site.

Mr Gilbert presented a paper showing his technique for facial restoration which enhances beauty as well as youth by volume replacement with the patient’s own fat at the same operation as a high extended smas multidirectional face and neck lift.

Woffles Wu presented a paper outlining how Asians are usually looking for a narrower more oval face. The modern concept of Asian and western beauty is merging both seeking high but not too wide cheek mounds set off by a mild cheek concavity I and trim jawline.

FROM THE ICAPS WEBSITE

“Stephen showed his surgical approach with fat first being placed radially from a a point on the malar prominence to emphasise the soft female facial curves and then securing the foundation with a high extended multi directional biplanar smas lift but both emphasised the need to raise the maximum projection of the cheek in three quarter view (the ogee curve) to meet present ideas of beauty in Eastern and Western cultures.”

A highlight of the social program was a visit to Dr Wu’s personal night museum where amongst other lively art works he has a number lampooning Mao Zedong. Ironically, once the antithesis of capitalism, Mao has become a marketable commodity.

Stephen Gilbert is a member of the International Consortium of Aesthetic Plastic Surgeons.To access their website, please click here.