*2.7.2 Fat grafting*

Volumes have been written about fat grafting. For the sake of completeness, it will be described.

Fat is the most convenient and likely inexpensive autologous, homologous volumizer available today. It is a natural product of liposculpting and contains thousands of times for regenerative cells and the accompanying milieu than bone marrow. Fat is a complex organ of metabolism and endocrine function as well as a physical and thermally protective tissue that makes our exterior contours more (or less) esthetically pleasing. The basics of fat grafting involve collection of Macro (structural) fat (1-3 mm) is collected via a small-holed suction cannula at lower pressures.

(12-20 mm Hg vacuum) into a sterile container. The fat is allowed to separate (it floats above the infranatant tumescent fluid and blood) from via sitting or sitting on a vibrating platform and/or some centrifuge fat. Many prefer to strain or wash lidocaine containing fluid and fibrous material out in some fashion. (Consider PureGraft and Wells Johnson systems or variations as "closed" to the air vs. open straining techniques). Oil (fractured fat cells and other inflammatory substances) should be removed from the top of the mix as well. Once macro fat is gently collected and processed, it is important to weave it into the subcutaneous space with as little trauma as possible to preserve as much viability as possible. Weaving of the fat can be performed in basketweave fashion with a larger (3-4 mm), single holed, blunt cannula, with the least effective injection pressure used, on the retrograde portion of the pass ONLY, to decrease the risk of fat embolization into an arterial vessel. Injecting fat into muscle is not recommended, despite the possible higher fat survival rate and greater effect on contour, it is not justified considering the increased and unpredictable risk of arterial injection and fat emboli causing pulmonary blockage and death from an elective esthetic procedure. Fat grafting is more successful if performed from several different insertion sites and not creating lakes or puddles of fat which may become a hypoxic, necrotic source of inflammation and fibrous induration.

After macro fat is placed in the subcutaneous plane to contour the buttocks and hips into the desired shape, it can be further infiltrated and smoothed with micro and nano (supportive) fat (less than 400 micron cells) obtained by sieving the fat through smaller holes (Hogue Surgical) of pushing through various sized screens or ball bearing (Tulip, NanoCube and others) and then metabolically supported with the patients' own platelet rich plasma in as nearly a 1:1 ratio as possible (it may go up to 1:20) injected into the same area. While it is likely that few of the initial fat cells injected survive (Yoshimora et al), it is estimated that 50–70 percent of the volume deposited may survive at a year. Recognize that the fat cells are disconnected from both their nutrient and waste removal systems when they are grafted. It is theorized that some cells "hibernate" until they are reconnected in their new location and then enlarge further as they thrive once again. Larger clumps of transferred fat cells die as they are poisoned by hypoxic inner core saponification leading to inflammation of the surrounding fat cells which are then more prone to macrophage attack. Tender, palpable "oil" pockets that can be found for o = months after a procedure should be removed when possible (Ultrasound directed I and D) or an area of fibrous scar tissue can result. It is more successful to plan for several sessions of fat grafting over the course of a year than to attempt ambitious volumes in one procedure that are prone to issues.

Fat grafted areas require some compression and support to help the fat "gel" and stay in position as it evolves into a long lasting volumizer. Compression garments generally supply 10-15 mm of compression to grafted areas and more to lipo'd areas. They are generally worn 23/7 for 2–3 weeks and when up afterwards, for a total of 4 to 10 weeks. We sit on our ischial tuberosities and move throughout our sleep cycle, so it is dubious that most fat grafted buttocks require the patient to purchase special foam wedges to sit on or adhere to caveats about excessive supine sleeping preventing circulation to most if not all the grafted areas.

Fat grafting should not be offered to current smokers, patients who are avid exercisers or who are or plan to actively diet. The original grafted fat does may not survive to any great extent anyway according to Yoshimura et al. [6, 7].

#### *2.7.3 Tissue tightening*

Over the last 2 decades, subdermal tissue tightening via bulk heating, (after debulking the fat compartment with lipo), has evolved from various 0.5 to 1.5 mm laser fibers of different infrared wavelengths that were run inside of cannulas and projected in non-columnated beams out the tip or side of the cannula, to monopolar 15 cm x 2 mm tubes (ThermiTight) that allowed for bulk heating with a tip the size of several grains of rice. None of these technologies were particularly successful for larger body areas because they produced too small an effect to cover the volume and surface presented. Further, they were fraught with risk of end hits, skin burns and uneven distribution of thermal effect. Lack of homogeneous effect resulted in adding undulations to the skin and tissue they were trying to smooth.

A newer technology available in the US for about 4 years, utilizing an RF generated helium plasma field (Renuvion by Apyx Medical) is proving itself to be a more useful and predictable tool for subdermal tissue tightening of the body as well as the face and neck. The plasma field influences tissue for several centimeters around its either in-line or side-firing tip and uses the interaction with and contraction of the fibro-septal network to tighten the tissue without bulk heating. The risk of burnthroughs caused by end hits is substantially reduced. The technology can be utilized to tighten skin envelopes that does not exhibit stria by 10–20 percent with a single treatment and treatments can be repeated over time. It can be used deeper in the tissue before fat grafting is performed more superficially.

A key to success with this technology is assuring that the helium flow, generally 1–3 liters/minute has adequate exit ports that are connected with the treatment area(s) and that periodic milking of the treatment area pushes excess gas out of those ports. Gentle suctioning of the treatment area(s) at the conclusion of Helium Plasma application removes additional gas, residual tissue and oil generated during the procedure, decreasing risk of sub-cutaneous crepitus which can take 3–10 days to resolve or inflammatory healing. Some physicians advocate external infrared thermal monitoring to maximize safety and homogeneous effect.

Another key to success with this technology is *not* over-treating an area. This technology is sometimes combined with ultrasonic fat sculpting (VASER) and or other RF skin technologies. The initial appreciated tissue tightening will generally continue to improve over several months. Excessive treatment with Renuvion alone or in concert with other Energy Based technologies, especially in thinner tissue areas like necks, can cause irregular contraction and fibrosis requiring steroid injection, massage, undermining and even redraping procedures. Grade 1 to 2 compression of treatment areas and weekly or more lymphatic drainage massage both improve the rate of return to full activities and esthetic outcome.

The current flexible, carbon fiber, single use handpiece is available in 15 and nearly 30 cm lengths and is only 3 mm in diameter. There is an original 5 mm

*Posterior Torso and Buttocks Contour Enhancement DOI: http://dx.doi.org/10.5772/intechopen.100529*

diameter (stiffer) in-line port, single use handpiece available in various lengths as well. The results of this technology have generally been predictable and sustainable, and they offer an alternative to surgical skin excision in appropriate cases with and without liposculpting and/or fat grafting.

Renuvion allows the clinician to offer less invasive procedures in select patients, that previously would have required more invasive surgery (Eg: J plazty® vs. a surgical neck lift). The company supports the exchange of information between providers with User Meetings and on-line forums. This has allowed the technology to be utilized more rapidly and more safely, worldwide [8, 9].

#### **2.8 Pre- and post-operative protocols and considerations**

ASA 1–2 patients who have maintained their current body weight, have BMIs under 35, are not stressed, have enough time, support, and appropriate nutrition to survive and prosper from this elective surgery are candidates. The pre and post op protocols and considerations are like traditional lipo-sculpting. The use of appropriate wound drainage, tissue support and compression of tunneled tissue without over compression of fat grafted or skin excision areas, and weekly or more often lymphatic drainage massage assures the best possible outcome long-term for these patients. Practices that do not supply all aspects of care to their posterior torso and buttocks contour patients may not enjoy as successful and trouble-free outcomes.

#### **2.9 Complications**

Issues are prevented by scrupulous planning, attention to detail, micro-management of the patient and team members involved in their care and personally seeing the patient whenever there is any concern. We cannot control or even imagine what patients do outside of our offices, so our duty to "first do no harm" is challenging to fulfill.

Caveats learned through the years are repetitive but true: anything that can go wrong, will; be extra careful operating on family and friends, they are both hard to come by and sometimes less understanding if there is an issue; frame expectations well, ahead of time (consider your consultation like speed dating and your consent is a pre-nuptial agreement); beware of pet owners, they will cuddle their pets and may get atypical infections weeks and months after their procedures.

#### **3. Summary**

#### **3.1 Pearls and pitfalls**

Doctors Robert Yoho and Jeff Klein gave me sage advice to start with manual techniques for more forgiving areas like torso lipo on more slim patient without skin laxity using a spinal needle for comfortable, though time consuming, tumescing and careful suctioning with smaller cannulas for my first 50 patients. Torsos are directly connected to axilla, pubic, hip and upper buttocks areas, so they were attempted next. Then move on to more complex and potentially challenging areas like neck and extremities. Gradually I mastered effective tumescense from deep to superficial planes with 12–16 gauge cannulas that did not overfill the tissue (prolonging recovery and masking the actual fat thickness) as well as the art of comparing the subdermal fat by palpation and skin pinch to achieve fairly symmetric results. Suctioning should be deployed from several insertion sites or adits to cancel out the grooves and irregularities that suctioning aggressively from one insertion

site almost always yields. When you get comfortable with manual techniques, consider adding Power Assisted technologies. I prefer rotary versus reciprocating power cannulas which seem smoother, more forgiving and faster, but perhaps best to try each technology for yourself. This journey is harder than it looks. It's time consuming and there are no shortcuts to sculpting the living human and developing your tactile skills and endpoints-much like learning a new instrument or competitive sport. Frequent sitting up, standing and positioning the treatment area(s) as they hang when standing, marking persistent elevations, divots and other contour asymmetries and progressively enhancing these contours will always give a better long term result than sculpting performed under deeper sedation in just a supine or prone position. Detailed op notes and critical examination of before, 6 week and 3 month or more photos will help perfect your skills and allow you to accomplish more precise contours in less time. Each patient is a new challenge of art, science and skill. Each one leads to better success, finesse and allows you to achieve the subtle nuances of depth and shadow, youth and age, masculine and feminine, and an appreciation that what you leave intact is at least as important as what you remove. The mature sculpture has insight of when to struggle and strive for further definition, contour and tightness and when the work is "done"-to walk away before the result is corrupted.

Suggestions and considerations are strewn and densely packed in this chapter. Use and modify them in your unique fashion. Perhaps the best advice is "life is short, learn from the mistakes of others". I have tried to openly share many of my most time consuming, brain-damaging and painful-for both patient and practitioner-lessons. I wish you luck, fulfillment and great success. Enjoy the journey!
