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Facial Fat GraftingFacial Fat Grafting For the Ophthalmologist & Oculofacial SurgeonFor the Ophthalmologist & Oculofacial Surgeon

William W. Ehrlich, M.D., FAACSWilliam W. Ehrlich, M.D., FAACSBaker, Holloman & EhrlichBaker, Holloman & Ehrlich

Oklahoma City, OKOklahoma City, OK

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Fat Grafting Fat Grafting Technique:Technique:

Patient Selection:Patient Selection:Non-smokers with BMI > 20Non-smokers with BMI > 20

Harvesting:Harvesting:Gentle, low pressureGentle, low pressure

Harvest fat below sternum Harvest fat below sternum Processing:Processing:

Minimize exposure to airMinimize exposure to airRemove oil & impuritiesRemove oil & impurities

Centrifuge?Centrifuge?Grafting:Grafting:

Within 0.5 mm of blood supplyWithin 0.5 mm of blood supplyTiny aliquots, maximal surface areaTiny aliquots, maximal surface area

Three dimensional placementThree dimensional placement

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Myth vs. Myth vs. FactFactLess than 35% of grafted fat survives.Less than 35% of grafted fat survives.

With proper technique, at least 70-80% of grafted fat With proper technique, at least 70-80% of grafted fat will survive. will survive.

The fat is gone in 6-8 monthsThe fat is gone in 6-8 monthsFat often “lasts” more than 10 years. Fat often “lasts” more than 10 years.

Fat grafts increase the incidence of cancer.Fat grafts increase the incidence of cancer.In 108 years of fat grafting, not a single paper or In 108 years of fat grafting, not a single paper or physician has ever reported that fat grafting is physician has ever reported that fat grafting is

carcinogenic.carcinogenic.Fat grafting success is independent of surgeon Fat grafting success is independent of surgeon

technique.technique.Fat survival is extremely dependentFat survival is extremely dependent upon the surgeon’s upon the surgeon’s

ability to harvest and graft fat cells correctly. ability to harvest and graft fat cells correctly.

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B.S. Zoology, M.D.B.S. Zoology, M.D. University of Michigan University of Michigan

Ophthalmology ResidencyOphthalmology Residency Henry Ford Hospital Henry Ford Hospital

Fellowship Orbital Surgery Fellowship Orbital Surgery Albany Medical Center Albany Medical Center

Preceptorship Orbital Surgery Preceptorship Orbital Surgery Moorfields Eye Hospital Moorfields Eye Hospital

Assistant Clinical Professor of SurgeryAssistant Clinical Professor of Surgery Michigan State University College of Michigan State University College of

Human Medicine 1985-PresentHuman Medicine 1985-PresentCO2 Facial ResurfacingCO2 Facial Resurfacing

Baker 1995Baker 1995True Tumescent Liposuction of Body & NeckTrue Tumescent Liposuction of Body & Neck

Klein 1997Klein 1997Small Incision Facelift Small Incision Facelift Hopping & Zylan 2000Hopping & Zylan 2000

Facial Autologous Muscle Injections (FAMI) Facial Autologous Muscle Injections (FAMI) Amar 2001Amar 2001

Trans-Axillary, SubfascialTrans-Axillary, Subfascial Breast Breast AugmentationAugmentation

Multiple Surgeons 2004Multiple Surgeons 2004Natural Fat Augmentation of Breast, Hands, Natural Fat Augmentation of Breast, Hands,

Buttock Buttock Caruth 2011 Caruth 2011

I began fat grafting 11 I began fat grafting 11 years ago.years ago.

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I’m an I’m an ophthalmologist.ophthalmologist.

(so am I)(so am I)

Why should I Why should I care about fat care about fat

grafting?grafting?

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Complete peri-Complete peri-orbital volume orbital volume

rejuvenation and rejuvenation and enhancement enhancement

require require at leastat least 10- 10-12 cc of volume 12 cc of volume

increase. increase.

Brow lift & fullnessBrow lift & fullnessLower lid Lower lid

Upper lid hollowingUpper lid hollowingTear trough Tear trough

Temporalis fossa Temporalis fossa Glabellar & frontalisGlabellar & frontalis

Nasal bridgeNasal bridgeCheeksCheeks

Skin RejuvenationSkin RejuvenationOne year after 25 cc to peri-One year after 25 cc to peri-

orbital areaorbital area

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For many For many patients , peri-patients , peri-orbital and lid orbital and lid

volume should be volume should be increased increased

(not decreased) (not decreased) to create a more to create a more

youthful look.youthful look.62 year old after 74 cc of fat to whole face. No other 62 year old after 74 cc of fat to whole face. No other

surgery was done.surgery was done.

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A 59 year old achieved A 59 year old achieved not only cosmetic not only cosmetic

peri-orbital peri-orbital enhancement, but enhancement, but

wonderful skin wonderful skin improvement. Almost improvement. Almost

all patients note all patients note marked skin marked skin

improvement that improvement that begins several months begins several months

after grafting.after grafting.

After full face fat grafting of 80 cc. No other surgery was done.After full face fat grafting of 80 cc. No other surgery was done.

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A 58 year old 3 A 58 year old 3 months after full months after full

facial fat grafting. facial fat grafting. Her improvement Her improvement should last many should last many years, assuming years, assuming

that she maintains that she maintains a body mass index a body mass index (BMI) above 19-20.(BMI) above 19-20.

75 cc to whole 75 cc to whole face.face.

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Orbital Fat Graft Orbital Fat Graft 18931893

NeuberNeuber Face & Breast Face & Breast

19101910 HollanderHollander

Liposuction Liposuction 19821982

Fournier/Illouz Fournier/Illouz Skin Rejuvenation Skin Rejuvenation

19891989Chajchir/Benzaquen Chajchir/Benzaquen

Face & Body Face & Body LipoSculptureLipoSculpture

20002000Amar/Coleman/Toledo Amar/Coleman/Toledo Adipose Derived Adipose Derived

Stem Cells Stem Cells 20012001 ZukZuk

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The usefulness of fat grafting is not The usefulness of fat grafting is not limited to the periorbita. Fat grafting limited to the periorbita. Fat grafting

can also be used for:can also be used for:

Whole facial sculptingWhole facial sculpting(“Stem cell facelift”)(“Stem cell facelift”)

Breast augmentation & rejuvenationBreast augmentation & rejuvenationCorrection of specific facial areasCorrection of specific facial areas

Facelift enhancementFacelift enhancement(“Volumetric facelift”)(“Volumetric facelift”)

Nasal changesNasal changesHand rejuvenationHand rejuvenation

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A 48 year old marathon runner after two sessions of facial fat grafting. A 48 year old marathon runner after two sessions of facial fat grafting. 88 cc of total fat was grafted.88 cc of total fat was grafted.

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Natural Breast Natural Breast Augmentation with Augmentation with

autologous fat:autologous fat:

300 cc per breast grafted from 300 cc per breast grafted from the thighs and hips during the thighs and hips during body liposuction : 100 cc body liposuction : 100 cc

intra-pectoral, 200 cc intra-pectoral, 200 cc subdermal. Mammary gland subdermal. Mammary gland

tissue was not disturbed.tissue was not disturbed.

In several studies, MRI In several studies, MRI volume analysis volume analysis

indicated that, on indicated that, on average, 85% of average, 85% of

grafted fat will survive grafted fat will survive beyond 1 year.beyond 1 year.

BeforeBefore2 Months2 Months

AfterAfter

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After a chin implant, Gortex lip implant, rhinoplasty, and facelift After a chin implant, Gortex lip implant, rhinoplasty, and facelift performed “elsewhere,” this 45 year old was unhappy with her “Calista performed “elsewhere,” this 45 year old was unhappy with her “Calista

Flockhart” look. Her facial features were softened with 54 cc of grafted Flockhart” look. Her facial features were softened with 54 cc of grafted fat. No other surgery was done. fat. No other surgery was done.

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48 year old one year after a minimal incision facelift, neck 48 year old one year after a minimal incision facelift, neck liposuction, liposuction,

and facial fat grafting of 54 cc.and facial fat grafting of 54 cc.

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47 year old 47 year old after minimal after minimal incision face incision face

lift, neck lift, neck liposuction, liposuction,

and facial fat and facial fat grafting of 60 grafting of 60

cc.cc.

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Nasal changes, both actual and perceptual, can be both expected Nasal changes, both actual and perceptual, can be both expected and planned.and planned.

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Adult fat cells contains 3-5 million adult Adult fat cells contains 3-5 million adult mesenchymal stem cells (AMSC) per 10 cc of mesenchymal stem cells (AMSC) per 10 cc of

fat. fat.

Adipose derived adult regenerative cells Adipose derived adult regenerative cells (ADRC) and adult mesenchymal stem cells (ADRC) and adult mesenchymal stem cells

(AMSC) may someday safe your life, or the life (AMSC) may someday safe your life, or the life of someone you love.of someone you love.

CosmeticCosmeticBrow ptosisBrow ptosis

Glabellar furrowsGlabellar furrowsCheeks & Nasolabial foldsCheeks & Nasolabial folds

Marionette linesMarionette linesChin lineChin line

NoseNoseLip volume & textureLip volume & texture

Tear troughTear troughSkin texture and colorSkin texture and color

FunctionalFunctionalBreast reconstructionBreast reconstruction

Vocal fold augmentationVocal fold augmentationDupuytren’s contracturesDupuytren’s contractures

Burn injuriesBurn injuriesRegeneration of irradiated Regeneration of irradiated

tissuetissueMyocardial incompetenceMyocardial incompetence

Lower extremity Lower extremity reconstructionreconstruction

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Adipose derived adult regenerative Adipose derived adult regenerative cells (ADRC) and mesenchymal stem cells (ADRC) and mesenchymal stem

cells (ADSC) are much more cells (ADSC) are much more “plastic” than anyone imagined. “plastic” than anyone imagined.

They are autologous cellular They are autologous cellular “building blocks” that are readily “building blocks” that are readily available to produce long lasting available to produce long lasting

functional and cosmetic functional and cosmetic improvements.improvements.

AdipocytesAdipocytesOsteoblastsOsteoblasts

CardiomyoctyesCardiomyoctyesChondrocytesChondrocytes

Endothelial CellsEndothelial CellsEpithelial DifferentiationEpithelial Differentiation

NeurogenesisNeurogenesisHepatic DifferentiationHepatic Differentiation

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FDA approval is not required to relocate cells removed from, then FDA approval is not required to relocate cells removed from, then returned to, the same person in a single procedure.returned to, the same person in a single procedure.

Presently, there are at least two commercial facilities (Dallas & New Presently, there are at least two commercial facilities (Dallas & New Jersey) that will isolate, cryopreserve, and store patients' adult stem Jersey) that will isolate, cryopreserve, and store patients' adult stem

cells.cells.

In the past 2 years, mesenchymal stem cell isolation, In the past 2 years, mesenchymal stem cell isolation, banking, banking,

and tissue scaffolding/engineering have begunand tissue scaffolding/engineering have begun..

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Final Thoughts on Fat Final Thoughts on Fat Grafting:Grafting:

Is a wonderful, versatile technique for Is a wonderful, versatile technique for peri-orbital and facial rejuvenation. peri-orbital and facial rejuvenation.

Unlike other fillers, adult fat Unlike other fillers, adult fat simultaneously provides volume simultaneously provides volume enhancement, skin rejuvenation, enhancement, skin rejuvenation, longevity, and stem cells.longevity, and stem cells.

The potential functional and cosmetic The potential functional and cosmetic uses of adult adipose tissue and its uses of adult adipose tissue and its mesenchymal regenerative/stem cells are mesenchymal regenerative/stem cells are remarkable.remarkable.

Someday very soon, the much maligned Someday very soon, the much maligned and misunderstood adult fat cell may be and misunderstood adult fat cell may be the principal ingredient of engineered the principal ingredient of engineered tissues that enrich and save lives.tissues that enrich and save lives.

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Fat Injection: From Fat Injection: From Filling to Filling to

RegenerationRegenerationColeman & MazzolaColeman & Mazzola

Quality Medical Quality Medical Publishing 2009Publishing 2009

ISBN 978-1-57626-284-9ISBN 978-1-57626-284-9

Complementary Fat Complementary Fat GraftingGrafting

Lam, Glasgold, & GlasgoldLam, Glasgold, & GlasgoldLippincott, Williams & Lippincott, Williams &

Wilkins, Wolters Kluwer Wilkins, Wolters Kluwer ISBN 978-0-7817-6424-7 ISBN 978-0-7817-6424-7

20072007

csehrlich@hotmail.com