Facelift Series #11: Fat Facts w/ Dr. Jason Bloom

Summer Hardy (00:01):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Summer Hardy, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. The title of today's episode is Fat Facts, part of our facelift series. What does fat have to do with the facelift, Dr. Bass?

Dr. Lawrence Bass (00:28):
That's a great question, Summer. Fat is the layer immediately beneath the skin. A lot of face shape as well as the fullness and youthful qualities of the skin are a consequence of the underlying fat. So we're going to talk about fat, all kinds of things about fat, how we shape it, how we move it around, how we transplant it, fat's biological properties, and how we take advantage of those biological properties. Fat's a big part of what shapes the face and it helps support the fullness of the skin. What we call skin turgor is partly a character of the skin itself and partly the support of the fat underneath. To discuss these issues with us, I've invited Dr. Jason Bloom back to the podcast. He's a frequent flyer with us here on Park Avenue Plastic Surgery class. And in this episode of the Facelift Series, he's going to discuss fat with Dr. Edinger and with me. Dr. Jason Bloom is a facial plastic surgeon in Bryn Mawr, Pennsylvania. He's the co-director of the Facial Plastic Surgery Fellowship at the University of Pennsylvania. Welcome back, Dr. Bloom.

Dr. Jason Bloom (01:49):
Well, thank you for having me. It's always nice to talk to you guys. And this is one of my favorite topics, facial fat grafting and how we use it separately and in conjunction with a lot of the aesthetic surgeries we do. So thanks for having me back.

Summer Hardy (02:06):
Welcome, Dr. Bloom. Welcome, Dr. Bloom. Thanks for being here today. So why is fat part of facelifting?

Dr. Lawrence Bass (02:14):
Well, as we said, fat is the layer immediately underneath the skin. In fact, more of a fibro fatty network, and that helps support the skin. We lose some of that fat with aging, and facelift is about repositioning, lax or loose skin, but it's also importantly about a youthful facial shape because shape changes as we age, largely because of volume loss, fat loss initially, and so that's how fat gets involved.

Summer Hardy (02:50):
Okay, that makes sense. So what are areas that typically get fat grafted?

Dr. Jason Bloom (02:55):
This is probably different depending on each surgeon that you ask, but most commonly when we're doing fat grafting, especially during a procedure like a facelift, we're augmenting it by putting a little fat in the areas such as the cheek, sometimes the nasolabial folds, kind of feathering things laterally along the zygobatic arch. Sometimes we put fat in the lips and then the temples and earlobes or other areas that are commonly fat grafted in the facelift.

Dr. Lawrence Bass (03:18):
And the pre-gel sulcus or that area in front of the gel and behind the chin, and we may try to augment the chin a little bit. And certainly any dips or sags in the jawline, that's not only the result of skin laxity, but there's actually, particularly in the 60s and beyond, even the late 50s, there's muscle and bone volume loss. And so building back and down the angle of the mandible and some of the dip along the body of the mandible can be part of that as well. And finally, the temporal areas are another part. And Dr. Bloom, any other favorite areas for you?

Dr. Jason Bloom (04:05):
Yeah, I mean, I definitely agree with that kind of pre-jowl marionette area. Now, a lot of the marionette gets improved surgically when you're doing a facelift and kind of lifting the jowls. But at least in my hands, I went from years ago releasing what we call the mandibulocutaneous ligament in front of the jowl and releasing that subcutaneously to now I do a lot of just some fat grafting under the skin in that area. And like you said, Dr. Bass, along the anterior jawline to shadow that. Additionally, about 80% of my facial rejuvenation surgeries or facelift surgeries involve some kind of periocular surgery. And I think fat grafting in combination with lower or upper eyelid surgery is extremely common in my practice. Every lower eyelid blepharoplasty that I do incorporates some form of fat grafting.

Dr. Lawrence Bass (05:08):
And that's a really important point, actually. I agree with you completely that in lower lid blepharoplasty, we're typically taking out some of the orbital fat that may contribute to bulging in the lower lid area. But even if you nicely level the lid proper, the tear trough area is not likely to be fully corrected and grafting fat into that depression, that demarcation line between the eyelid skin above and the cheek skin below is an important part of amplifying the overall degree of rejuvenation in the periocular area.

Summer Hardy (05:50):
So can you tell me a little bit about how fat grafting is done? What's the process?

Dr. Jason Bloom (05:55):
Yeah, we typically harvest fat from somewhere on your body as a donor site. It's commonly done in the thighs or the abdomen. We process it, which is a process where we separate out the layers of the lipoaspirate, what we call it. Basically, it's a layer of fat and oil and some water and some blood. And so we separate out those layers to isolate those fat cells and then the stem cells in there. And then we take that and we inject it back into the areas that we want to reestablish some volume in the face.

Summer Hardy (06:20):
So what are some of the important points for harvesting then?

Dr. Jason Bloom (06:24):
I would say for harvesting, like I said, the most common areas that I'm typically harvesting are either in the medial thigh or along the lower abdomen, wherever the patient really has fat to give is where we will harvest it from. Typically, we try to use a little bit of a larger cannula just because that's a little bit less sheer stress on the fat cells themselves. And then before we harvest, we actually inject fluid, which usually is a combination of saline, some epinephrine, and then some local anesthetic like lidocaine to help with discomfort into that area first so that when we harvest, we get back, like I said, the slurry of fat cells and stem cells and fluid and blood and some oils that we then separate out of the later portion.

Dr. Lawrence Bass (07:05):
And so this is basically a liposuction-like technique, but typically we use some modified cannulas to harvest the fat in an attempt to avoid a lot of trauma to the fat cells. We're typically trying to keep the fat cells hydrated. We often use syringe suction rather than a vacuum aspirator or a liposuction machine, again, to avoid any unnecessary trauma. But one of the challenges in fat harvest, and especially nowadays with Ozempic and other medicines around is some patients are very slim and it's hard to find fat on their bodies. They just don't have a lot of extra. I recently did a facelift and we needed to do a bunch of fat grafting. And the patient asked me, "Well, how are you going to get fat? Because I'm pretty slim." And she was right. She was very slim, not even an ounce overweight, but there are still some deposits of fat on the body.

(08:10):
And particularly for facial fat grafting or other processes where we're going to use fat as a source of biological material, the amounts that we need typically in the face are relatively small. So we were able to find a little bit of fat at her waist. If there was no fat there, there's sometimes a little bit of fat even in very slender people in the inner thigh areas. There's often a little bit of fat on the back of the arms up by the armpit. So there are a few places that we can usually scavenge enough fat for what we're trying to do in treating the face.

Dr. Jason Bloom (08:56):
I'll agree with that. I think there's usually always a little bit along the inner thigh area. And interestingly, the quality of inner thigh fat, especially for facial fat grafting, just tends to, we say it hits different. It just is really good for that area. And I think also it's important to listen to the patient and actually things like they may have had liposuction in the past or some kind of device liposuction like laser liposuction. If they've had that, for example, on their abdomen and then you're harvesting from that area, the fat is just not as good when you're harvesting it and processing it. I will talk a little bit about the processing, but it's very interesting. Also, you can tell exactly what the patient, sometimes their diet is like when you harvest the fat and you see it's just oily or fibrous. Depending on the makeup of the patient and their diet, you can really predict a lot about what is going to happen and what their fat is going to look like afterwards.

(10:04):
How are you processing your fat, Dr. Bloom, speaking of that?

(10:07):
So this has really been interesting, and I speak a lot about this on a national and international level at a bunch of different conferences. And I typically in my practice use a closed membrane system. So I've gone back and forth using helpha and spreading it back and forth. I've used centrifugation and I've used strainers and a gravity method. But the nice thing that I've come to find is that there are great papers, one that was done in PRS that shows the use of a closed membrane system, which basically looks like an IV bag. And from the moment you suction the fat out, you then inject it into this bag, wash it with lactated ringers two different times. And then actually you're pulling out all the lyced fat cells or the triglycerides. You're pulling out the red blood cells that cause bruising. You're pulling out the white blood cells.

(11:19):
And what you're left with is a 97% purified fat product when you use a closed membrane system. And then the interesting thing is when they compared that to centrifuging the process, that process and looking at the fat, there was absolutely no difference in the actual things that matter to give some of the growth factors, the VEGF, the adipose-derived fat stem cells, things like that that are in the fat. There was no difference between using that closed membrane system and centrifuging the fat. So that has really been my go-to in the practice because the nurses love it because it's not a big mess. It's easy to use, and it's never outside of the syringe from the time you aspirate it to the time you inject it. It's always in a closed system. So those are the benefits that I've found with using that system.

Dr. Lawrence Bass (12:27):
And that's really important because how the fat is harvested, processed, injected, but particularly processed is really important to preserving fat viability. Fat cells are not the hardiest cells in the body, and if they get abused enough, they die. And if they die, they're not going to do the job that we want them to do. So high vacuum and in the processing phase, desiccation drying out is really bad for fat cells. And having fat cells sit and settle in a picture or get mashed about on a telfa to squeegee out fluid is definitely a traumatic experience for fat cells. And sitting hydrated in ringer's lactate solutions, sterile IV solution in a closed system minimizes the chances of desiccation. And that process of removing the liquefied fat or triglycerides, basically the broken open fat cells, which will only produce inflammation. And the blood, which seems to diminish fat take, we want to wash any red blood cells out of the fat graft because that diminishes the percentage of fat cells that will heal in and get a blood supply.

(13:53):
So steps like this are important. Everyone does it a little differently. The important thing is to have a consistent process that protects the viability or survivability, if you will, of the fat cells.

Dr. Jason Bloom (14:10):
And if I could add one other thing, I think one step that is commonly missed and not as talked about as much with facial fat grafting is sizing. And when you're doing, for example, high volume fat grafting, whether it's to the, and I don't do any of this obviously, but to the buttocks or to the breast or high volume to the temples or something, the size of the fat injected is not as important. But for example, when you're injecting it in the periocular area where the tissue is very thin, we're injecting it underneath the orbicularis muscle, lumpy bumpiness is really, it's important to avoid that. So one thing that I do in taking it a step further is I size the fat down. So it's important when you're thinking of a microns of fat. For facial fat grafting, the optimal is about 1500 to about 700 microns.

(15:16):
That's the sweet spot when you're using it for facial fat grafting. Because we know anything below 700 is nanofat. And I hate this term because nanofat isn't fat. There are no viable fat cells. It's just the adipose-derived stem cells. It's the growth factors that you get from the fat. There's no volumization there. But I use something like a 1200 or 1000 micron. It's like basically a screen that allows me to pass the fat back and forth through this screen where it will size the fat up into these small parcels that allows for more kind of easy fat grafting.

Dr. Lawrence Bass (16:05):
Even distribution.

Dr. Jason Bloom (16:07):
Totally.

Dr. Lawrence Bass (16:07):
Because

Dr. Jason Bloom (16:08):
I've seen it all. I've had the lumpy bumpiness. I've had all these things. And ever since I've used that, the rates of those kind of issues have really diminished.

Dr. Lawrence Bass (16:18):
Yeah. I think using smaller parcels or little shavings of fat, and when I'm grafting in the lids, I use different harvest cannula that harvest at a smaller size. And then I go from there to do other things to get a smaller size. And so that fat is special for the lid because it's so easy to get a lump. The fat needs to be small and it needs to be evenly distributed or there's mischief at a much higher rate than we consider acceptable. Basically lumps, which are notoriously hard to get rid of. But by using these techniques, fat grafting in the lid areas has really come into its own, I think.

Dr. Jason Bloom (17:08):
Are you changing cannulas how you harvest depending on where you're putting it?

Dr. Lawrence Bass (17:12):
Well, yeah. I mean, I use a cutting microcannula. It's almost like it's circular, cylindrical, but it's almost like a vegetable brater that you might use in the kitchen, except on a much smaller scale. And that fat is special for the lids and I harvest for the rest of the face separately and they get processed separately.

Dr. Jason Bloom (17:41):
Do you do something similar, Dr. Bloom?

(17:43):
I typically use a Miller harvester for most of my fat grafting, and then I size it after I've processed it. But I used to use what Dr. Bass is describing as a Tenard or a Sorensen harvester with a kind of barbed, it's more kind of a cylindrical circular, and that does start at smaller parcels. So you can do it either way. This has just been my kind of thing is that I just harvest it all at once and then I divide up the sizes based on where I'm going to use it. And then I sometimes even go smaller below 700 if I do want to use quote unquote nanofat, and that would be for skin rejuvenation.

Dr. Lawrence Bass (18:31):
Right. So we're coming to nanofat in a bit and we're going to talk about that. And interestingly enough, I got asked that question today in the office. So something that patients definitely want to hear about.

Summer Hardy (18:44):
And then what about injecting? What's important there?

Dr. Lawrence Bass (18:48):
So again, we were talking about distribution. So it's important that the fat not be sitting in a big lake somewhere because those fat cells need a blood supply and blood supply can only grow in if the fat is separated, distributed in tiny amounts. So we typically do multiple passes and multiple depths. In facial fat grafting, we use blunt needles because this produces less bleeding. We said bleeding again, blood around the fat graft impedes some of the survival of the fat graft. And we want the little parcels of fat to be within that size range that Dr. Bloom was talking about because if you have a two or three millimeter, two or 3000 micron glob of fat, blood supply isn't going to grow all the way through that. That fat almost certainly is going to die. And if you have an actual lake of fat, that's going to be an area of fat necrosis and potentially a lump.

(19:53):
So technique is really important in order to get survival of your meticulously harvested, delicately processed fat graft.

Summer Hardy (20:05):
And you mentioned a little bit just then, but how exactly does fat heal?

Dr. Lawrence Bass (20:11):
So the fat, as I said, has no blood supply. It drinks fluid from the interstitium, from the area around the cells in the tissue in which it's placed. That fluid contains things like oxygen that cells need to metabolize and respire. It contains glucose, it contains other nutrients and things, and the fat cell limps along for a while that way. But starting by a few days and towards the end of the first week, some circulation is starting to try to get back into the areas that had surgery, the areas that are healing, including the fat grafts. But it takes longer for a fully restored blood supply. So what that means is a portion of the fat cells die and a portion succeeded getting a blood supply and they will now live in the new neighborhood wherever they were placed. So that portion that dies, again, by being in tiny amounts distributed doesn't cause mischief as a general rule and is absorbed by the body.

(21:26):
We have cells that are becoming senescent senile in them being absorbed all the time, and the body knows how to scavenge those up and get rid of them. So as long as it's not too many all in one place, the body can deal with it without having any kind of a clinical problem that we observe. And studies show almost with any of the accepted techniques, survival runs somewhere in the 50 to mid 60% range. There are a lot of attempts to try to amplify that percentage of survival, but that just controls how much you inject knowing that you have to over-correct a little bit.

Dr. Jason Bloom (22:09):
That was very eloquently said. I think I have just a couple comments about that. Also, when I'm doing fat grafting, I have seen just over the years in doing this for now 15 years, probably somewhere in the 60 to 70% range of viability based on my eye. I haven't done any true vector studies, but there have been some studies looking at that in the breast as well as in the face. The Glassgold group looked at facial fat grafting using Vectra and saw maybe about a 70% uptake. So I tend to overcorrect by about 30% or so knowing that I'm going to lose about 30% of the fat. And so I'm kind of at a net equal. I tell patients that it is approximately healed or things are what they're going to be at around three months. At that point, I kind of feel like the amount that's grafted is going to stay there.

(23:18):
They're not getting any kind of fluctuations at that point. So I kind of assess that at three months, the amount of fat that is grafted is going to be what it is going to be. And then the last thing is I think that fat is interesting. We don't know really what. It's a graft all itself. So doing things like this is the future, but doing things like hyperbaric oxygen and things to increase the survivability of these fat cells. People have talked about maybe doing things like that to help fat grafts improve and survive when you're doing these procedures.

Dr. Lawrence Bass (24:08):
Yeah, that's an interesting point. And in addition to oxygen boosting the oxygen level in the tissues, people have looked at mixing the fat grafts with nutrients with cytoprotective chemicals, things that stabilize cells so they're less sensitive to damage to help the fat cells limp through the avascular period and make it to neovascularization. None of that is currently on the market, but there's a lot of research in that area. So there's potential for fat grafts going forwards to become super fat grafts, much more powerful, much more predictable than they are today.

Summer Hardy (24:53):
Are there any risks to fat grafting?

Dr. Jason Bloom (24:56):
Yes, there are. We just talked about a little bit about the asymmetry that can happen or really the amount of fat that you're hoping will take. You can undercorrect someone if how much you put in didn't stay, and if you can over-correct them if you put a little bit too much in and they actually take more than you anticipated. Some of the other things we had already mentioned are some of the little lumps and bumps. If you don't have that smooth fat, like Dr. Bloom was talking about filtering out those larger pieces when you're putting it, especially around the eye, you can get some of those lumps and bumps. There are bigger risks. Anytime you inject fat or e-filler or anything like that, you're near blood vessels as though if any of that fat were to get in one of those blood vessels, it can occlude one of those blood vessels and cause any sort of problems ranging from skin death of the area that that blood vessel supplies normally or traveling into other blood vessels.

(25:42):
They're very interconnected in the face and causing an issue like blindness in the eyes.

Dr. Lawrence Bass (25:47):
And that's the really dangerous complication of fat grafting, which fortunately is quite rare. That's another reason why the fat is typically placed, not using sharp needles, but blunt tipped cannulas so that if you poke near a blood vessel, that blunt tip won't go into the blood vessel and introduce the fat, but will slide past the blood vessel more often than not. So fortunately that risk is very rare. And overall the tendency with fat grafting is towards undercorrection. We typically get a natural look and less than what we were hoping for rather than an overbuilt look, which is so easy to produce with filler. So that natural look and the fact that it's living fat cells is an advantage to counterbalance that risk, and that gives you durability as well.

Dr. Jason Bloom (26:48):
Yeah. I mean, in doing facial fat grafting for quite a long time, I've run into all of these minor risks, the lumps and bumps, the oil cysts, the issues with fat viability, the fat necrosis in certain areas. And I think the biggest thing, as I was mentioning, that has really changed the ability to decrease complications with the fat itself has really been the way that I process it and the way that I size it. And doing that has really given me a purified and uniform fat product that has allowed for consistency. And everyone that's doing it out there, you're going to find what works for you the best. But now over years of doing it and running into problems, we've coned down our best techniques now.

Dr. Lawrence Bass (27:44):
And I think it's very appealing to have that reproducible kind of process. If you are using a processing kit or a processing machine, the fat product that you end up with for injection is much, much more uniform, much the same case after case after case, because how you inject the fat and what results you get is going to vary depending on what fat product you're starting with. I personally believe if you are squeezing fluid out of the fat by rubbing the fat back and forth on a telfa, you are starting with a much drier fat graft than if it's centrifuged. And I think that's a drier fat graft than if it's dialysis membrane separated as you are doing. And I'd use a settling technique and that's an even wetter fat graft. And so I volitionally plan to inject more fat, more volume, if you will, to get a certain amount of correction because I know I'm working with a very wet product.

(28:54):
And I like the wet product because I think it helps it distribute. And I like the wet product because I think it helps fat graph viability that it has a big reservoir of fluid with nutrients, at least the rudimentary lactate that can be metabolized by the adipocytes. But it's not the best way. It's certainly not the only way, but it's just a way that works for me with my process. And I think you quite correctly said every surgeon's got their own process. And the important thing is to get that reproducible and a kit-based or device-based processing of the fat helps you do that.

Dr. Jason Bloom (29:38):
I like exactly what you're saying. In doing what I have been doing in my processing, it's interesting because it does get a little bit more dehydrated. And I feel like when I'm injecting the fat after the kind of processing I'm describing, it injects a little bit more like filler than when I was It's using more of a wet kind of process where it injects a lot smoother and easier. So when you're trying to get a smooth, consistent injection, yes, something like Dr. Bass is doing is preferred. When I do it, it is definitely more dehydrated. And so it injects very similar to a hyaluronic acid filler product in the way that it comes out of the cannula. So it's just you notice that when you're doing this kind of processing.

Dr. Lawrence Bass (30:37):
Yeah. And I bet it's the sieving that really dries out your product and not the dialysis processing, which usually keeps it pretty hydrated.

Summer Hardy (30:47):
And then we've alluded to this earlier, but what else should we know about fat?

Dr. Lawrence Bass (30:52):
So as I was saying, you're basically transplanting living adipocytes or fat cells from wherever you harvested them to this new part of the body. And that gives us volume or shaping effects, but it also gives us some of the other biological properties of the adipocytes and some of the other components that are in that lipoaspirate. So we've already heard that lipoaspirate contains adipose-derived stem cells, basically a mesenchymal or multi-potent stem cell, not a pluripotent stem cell. And that stem cell has a lot of biological processes. And if you create other modified versions of the fat graft with your processing, you can exploit those properties. So Dr. Bloom, what can you tell us about some of these more advanced approaches that aim to use the fat to change skin or to improve healing or rejuvenate the skin's metabolism in the face?

Dr. Jason Bloom (32:02):
Yeah, so when we're doing facial rejuvenation surgery, first of all, we know that patients want everything. And what I mean by that is they want the lifting procedures that we're doing surgically and we're modifying and tightening the muscle layer. And they want, as we said, fat to give them some volume and more youthful effects of the tissue. And then also you can't forget about the skin. So we have all that ability when we're processing the fat and using it, for example, for fat grafting, to take some of it and harvest the real bioregenerative components of the fat, which are some of the growth factors such as platelet-derived growth factor and adipocyte-derived growth factor and angiogenin and VEGF, all these things that actually help give the skin its bioregenerative capacity. So commonly I'll take the fat and then bring it down or size it down below 700 microns into basically a topical that sometimes I apply after a laser and kind of creating a drug-assisted drug delivery where I'm creating a blade of holes in the skin with a fractionated laser, and I will apply that topically.

(33:30):
Sometimes I take a 27-gauge needle and inject that same fat into the fine lines around the mouth. I think it really helps to rejuvenate the skin, especially in perioral lip lines and things like that. And then some of the actual companies, a lot of the skincare companies that are using things like exosomes, which are the signaling molecules that carry a message from one cell to another, are getting these bioregenerative exosomes from fat. So they're actually taking adipose derived exosomes and putting that into skincare or topicals that you can apply after some of the procedures you even do in your office.

Dr. Lawrence Bass (34:17):
And that nanofat, if we can use that term for a moment, I know not your favorite term, but basically is the broken down adipocytes. And so it is a biostimulative product or a regenerative product. It signals the skin with a lot of messaging, and that's partly growth factors, but partly exosomes and other subcellular components, which as you said, companies are harvesting, purifying and selling as moisturizing lotions or as products for microneedling or topical application after. What you're describing with the fractional lasers goes under the broad term nowadays of channeling. And there are a whole bunch of ways of channeling the skin by using a fractional ablative laser. A fractional non-ablative laser creates channels. Microneedling with or without energy creates channels. The quality of the channels, the size of the channels, the durability of the channels varies depending on the technique, but all of these interrupt the skin's barrier so that you can get these large molecules or little organelle-like packets of information like exosomes into the skin and injecting nanofat or ruptured fat directly into skin features allows you to concentrate a lot of those messages right in a targeted area where there's an aesthetic feature that needs correction.

Summer Hardy (35:52):
And is this all just about building fat or is there also a need for fat reduction?

Dr. Jason Bloom (35:58):
Well, that depends on the patient and the area that we're talking about, but oftentimes patients have a lot of excess fat, especially in the contour along the neck. Whether we remove this or not depends on each patient, but I would say not uncommonly. I'm removing some fat along the neckline with liposuction or other modalities directly in a facelift at some point.

Dr. Lawrence Bass (36:18):
That's right. I mean, a lot of patients get some heaviness, build up some fat in their neck with aging, but not everybody. And it's about shape, balancing the neck shape with face shape. So the trick is ensuring that you take the right amount, not too much or too little, because we don't want hollowing. We don't want an over-skeletonized neck that looks obviously surgical or that looks spindly and thin.

Dr. Jason Bloom (36:49):
I think it's important also for patients to know kind of two things. I think one is that it's not just about fat on their neck, for example, because more important than I think the fat, you could take a woman in her 60s and liposuction the subcutaneous fat on their neck and actually make the neck look worse because it's the presence of loose muscle and loose skin. And having a little fat there sometimes to fill out the neck actually looks a little bit more youthful than taking out all the subcutaneous fat, and then they're left with the loose crepiness that exists with the muscle and the fat. So sometimes you get women coming in and they're like, "Well, can't you just liposuction my neck?" And I said, "Sure, I can liposuction in your neck if you want it to look worse." And they don't understand that the underlying muscle and overlying skin needs to be addressed.

(37:51):
And the second thing is it's important, and I'm sure all the doctors here have seen these patients in their practice where they have deep subplatysmal fat in their neck, and you could liposuction their neck and the neck contour will not change one bit. And I have to explain to them that the subcutaneous fat, the fat under the skin is really the target for things like liposuction, chibella, CoolSculpting, and that is just below the skin. But if you sometimes really need to address the deeper fat below the platysma muscle, that can only really be contoured directly with direct excision. And so I am just in my practice, I'm doing way more what I call deep neck lifts where I'm actually removing deep subplatysmal fat and tightening the platysmal bands and deeper neck layers through a small incision under the chin rather than doing a simple neck liposuction because it actually gives better contour sometimes.

Dr. Lawrence Bass (39:06):
I think those are really important points and a very important part of this discussion. So it goes back to what we said at the beginning, a lot of youthful face shape and youthful skin appearance is a consequence of the presence of fat. So we're Americans, we think fat is bad. The less fat, the better, but eliminating fat will not give you a healthy or youthful look. And I just in a lot of facelifts, I'm on the relatively aggressive side at taking fat out. I have a lot of slim ladies with defined faces and a slim neck looks good on them, but I just did a facelift on someone. It was a secondary facelift. I know the surgeon who did the first one, and I know he took a lot of fat, and this lady is super slim. And I got in her neck and there's fat there, but I didn't take out a drop of the fat.

(39:57):
I positioned the muscles, I repaired the muscles, I re-draped the skin, but she's already slim enough in her neck. To your second point, the place that I see the example of the deep fat, you can see it in the facelift because you look in the neck and you take out the superficial fat or you contour it to the extent you want, and you see that they're not flat yet, and you know you have to go and start chasing subplatysmal fat and maybe other deep neck structures. And I've got a question for you about that in a second, but I see it sometimes with the young patient. They're 30 or 28. They got a liposuction in the neck, but they still have submental fullness. Why? Because they have subplatismal fat and liposuction is only going to get the subcutaneous fat. So you have to go in and do that.

(40:51):
Now, interestingly, some of the non-surgical devices will hit subplatysmal fat. CoolSculpting will reduce subplatysmal fat. In the Kybella study, we saw subcutaneous fat, not subplatysmal fat. I was an MRI site in the Kybella studies and we did not see subplatysmal fat because you're not supposed to be injecting it that deep because there are other things down there. But one of the virtues of Sculpsure or CoolSculpting is that they can contour that, but you have much more control over the shaping if you do that surgically and that's done through a small incision under the chin that nobody can see unless you're literally basketball player height.

Dr. Jason Bloom (41:38):
I say only dogs and lovers can see it.

Dr. Lawrence Bass (41:40):
Right. I gave the rated G version, you gave the X-rated version.

Summer Hardy (41:47):
Are there any other areas where fat is reduced?

Dr. Lawrence Bass (41:50):
So sometimes we go in the gel area and most of that gets re-draped when we do the lifting, we do the SMAS layer repairs or composite lifting, however it's being done. But some skin release in that area, some fat grafting in front of the gel, but sometimes some modest fat reduction of the gel itself is done. That has to be done very conservatively so you don't end up with a hollow, which really looks unnatural along the jawline, but with a very chubby gel, if you will, in someone who might be a little bit heavier. Sometimes we do that just to touch. And sometimes as people age or after a previous facelift somewhere, they will have some prolapsing buccal fat that's creating bulging by the corner of the mouth or just above that at the bottom of the area under the cheek and teasing down that fat, teasing out a little bit of that fat and trimming it down and closing the access to the deep buccal fat is something that occasionally is called for.

Dr. Jason Bloom (43:06):
Yeah, I think when you look at a patient and the buccal fat is contributing, like you were saying, to the jowling, I will typically remove some of it through the deep plane when I'm in there for a facelift. And we're in that area anyway, and sometimes the buccal fat is just herniating into the field.

(43:28):
It's looking right at you. It's looking right at you. So those kind of cases, I will reduce it. One thing that I will say that I don't do, and I've just seen many patients for this is I don't like to liposuction the face. I don't like to liposuction the jowls directly because if you're doing that, the risk of asymmetry, lumpiness, just like I've seen banding across the jowl area. And some of these RF injectable RF devices, people are using that and liposuctioning the jowls externally. I've really, really tried to stay away from that just because some of the things that I've seen.

Dr. Lawrence Bass (44:20):
Yeah. I mean, with energy, it's treacherous because sometimes you're trying to get energy in there, something like these little RF probes, and you're trying to create some coagulation injury to get the skin to tighten up a little in that area that doesn't always totally tighten and flatten with a facelift, or you're not doing a facelift and that's just a local trouble area on that patient's face. And so it's important probably in those circumstances not to suction any fat because you're already going to coagulate some fat. And if you do both, you're almost certainly going to be overcorrected and have a problem. I don't have an absolute prescription against doing it. I do it, but one out of 20 patients would be a lot. It's probably more like one out of 50. And selectively, again, in patients that are doing lipo only of the neck in an occasional selected patient, and it has to be very conservative and very minimal.

(45:26):
And you have to volitionally under-correct. If you correct with tumescent fluid in there to what you think is going to look good, you're going to be over-corrected for sure. So it's like everything. If you get the right touch for it in the occasional patient who might benefit, it just takes them from an A to an A+, but that's not your workhorse of how you get that area to look good. That's the icing on top minimally, minimally, minimally.

Summer Hardy (45:57):
And Dr. Bass, can you share your takeaways?

Dr. Lawrence Bass (46:00):
Absolutely. As we discussed, facial aging is manifested as skin laxity change, skin quality change, and changes in deeper tissues, especially fat. That loss of fat alters facial shape and projection. It's a loss of volume. So restoring fat in the face goes a long way towards restoring youthful face shape. That's part of facelifting. It's what we do in standalone fat grafting treatments for the face. Sometimes in people who previously had a facelift don't need another facelift, but have had additional volume loss. Many patients tell me they don't want fat. They're trying to get a thinner face. But with the exception of significantly overweight people, the face is usually emptier and hollower as we age, and this is progressive. The older we are, the more of that hollowing we get. It's amplified by muscle and bone loss in the late 50s or 60s and beyond. And some of what looks like widening and thickening of the face is simply skin laxity, which will be treated with the facelifting to reposition the skin and tailor out any redundancy.

(47:17):
Fat grafting has a number of advantages compared with off-the-shelf filler, including durability and a number of associated biological effects. And it's generally the treatment of choice when we're trying to do global re-volumization of the face. Still, sharp contours and small precise shapes are less predictable and the overall survival of the fat varies, although generally somewhere in the range of 60 or in Dr. Bloom's hands, 70%. And fat removal is extensively used to define neck contour, but that's wholly in the proper degree. You have to hit the right balance point to avoid a non-natural look or unbalance the neck contour compared to the face. Fat in facelifting has become a major adjunct to help maximize the rejuvenation. As Dr. Bloom said, we need to get it all, not just the loose skin, but the shape, the quality of the skin. All of these things need to be maximized so you get the most out of any facelift procedure.

(48:29):
I'd like to thank Dr. Bloom for coming back on the podcast once again, joining Dr. Edinger and Summer and me and sharing some of the latest advances in the arena of fat and his insights about how these things fit in.

Dr. Jason Bloom (48:45):
It's always wonderful being here, and I appreciate the invite as always.

Summer Hardy (48:49):
Thank you, Dr. Bass and Dr. Bloom.

(48:51):
Thank you, Dr. Bloom. It's been a pleasure to have you back on the podcast. Thank you for listening to the Park Avenue Plastic Surgery Class Podcast. Follow us on Apple Podcasts, write a review, and share the show with your friends. Be sure to join us next time to avoid missing all the great content that is coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.