Medical Minute 4-11: Fat Grafting for Faces

By: Vanessa Welch Email
By: Vanessa Welch Email

Jeremy Feldbusch was just 23 -- and deployed in Northern Iraq -- when his unit came under attack.

"A piece of shrapnel about an inch by an inch and a quarter thick penetrated the side of my right eye. That was the start of a different battle for me," said Jeremy Feldbusch.

The attack left him blind, brain injured, and severely scarred. Doctor Peter Rubin is part of a University of Pittsburgh medical center team, researching new ways to precisely reshape injured faces using a patient's own store of fat.

"That's our best replacement tissue after trauma or cancer therapy," said J. Peter Rubin, M.D., Chief of Plastic Surgery at Adipose Stem Cell Center.

Rubin removes fat from a patient's abdomen or thighs. Then, it's processed -- separating tissue layers from other fluids. He then re-injects the concentrated fat into the injured area -- adding volume and smoothing it out. One potential side effect? Grafted fat may be re-absorbed by the body. Ultimately, researchers want to know if adult stem cells -- present in fat tissue -- will prevent that.

"We know that they will be stressed by the surgical procedure, and under the stress, they are capable of releasing different growth factors that can assist in the healing process."

For now, patients like Jeremy Feldbusch are reaping the benefits of the research-even without super-charged fat tissue. Jeremy's sunken forehead-and large facial scar- are less noticeable.

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500, jcherry@ivanhoe.com.

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MEDICAL BREAKTHROUGHS - RESEARCH SUMMARY:

BACKGROUND: According to plasticsurgery.com, fat grafting is a procedure where doctors remove a patient's own fat to re-implant it where it is needed. The fat is typically extracted from body parts like the abdomen, thighs or buttocks and injected into another area that requires "plumping," such as the face. When used as a facial filler, fat grafting can improve the creased and sunken areas of the face and add fullness to the lips and cheeks.

FAT HELPS SOLDIERS: A team of doctors at the University of Pittsburgh School of Medicine has received $1.6 million from the Department of Defense to help wounded soldiers recover from facial injuries by using technologies based on the biology of fat tissue. "As many as 26 percent of wounded soldiers suffer some kind of facial injury, which can have a huge impact on quality of life," Dr. J. Peter Rubin, Chief of plastic surgery and Co-director at the Adipose Stem Cell Center at the University of Pittsburgh, was quoted as saying. "While we can reconstruct bony structures very well, it is the surrounding soft tissues that give people a recognizable face. This project will investigate how soft tissue grafting can more precisely restore facial form and improve the lives of our wounded soldiers." The research program involves the treatment of 20 soldiers with facial injuries. The use of fat grafting for serious facial injuries, such as those resulting from roadside bombs, is performed by using specially-designed devices and instruments for harvesting fat tissue and implanting it into regions of scarred tissue. "Fat grafting, or moving fat tissue from one part of the body to another, has been used as a cosmetic procedure for decades," Dr. Rubin said. "We are now applying this technology for reconstructive surgery to accurately restore facial form after battlefield injuries."
(SOURCE: University of Pittsburgh Press Release)

HOW IT WORKS: Dr. Rubin first removes fat from a patient's abdomen or thighs. Then, the fat is processed. Tissue layers are separated from other fluids. Dr. Rubin then re-injects the concentrated fat into the injured area. This adds volume and smoothes it out.

STEM CELLS: THE FUTURE OF FAT GRAFTING? The research team would ultimately like to know if adult stem cells, which are present in fat tissue, will prevent grafted fat from being reabsorbed by the body. Dr. Rubin's team has separated stem cells from other fat tissue in lab studies. Their goal is to eventually re-inject stem cell enriched tissue for even better results. European studies have shown fat grafts performed with tissue enriched by stem cells shows promise. However, no studies in the United States have proven its effectiveness.

FOR MORE INFORMATION, PLEASE CONTACT:
Amy Dugas, Media Coordinator
University of Pittsburgh Medical Center
Pittsburgh, PA
dugasak@upmc.edu

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IN-DEPTH INTERVIEW WITH THE DOCTOR FROM THE STORY ABOVE:

J. Peter Rubin, MD, Chief of Plastic Surgery and Co-Director of the Adipose Stem Cell Center at the University of Pittsburgh discusses how fat is helping restore faces for some.

What is fat grafting?

Dr. J. Peter Rubin: Fat grafting is a procedure that involves moving fat from one part of the body to another. The reason we use fat tissue is because that is our best replacement for lost or damaged tissues after trauma or cancer therapy.

Why is that the best?

Dr. J. Peter Rubin: It’s the best replacement because most of the soft tissue in our body that gives us the most recognizable human form is actually composed of a high percentage of fat tissue.

This is something that we have heard about in plastic surgery before. We hear about liposuction, that’s fat removal. I’m speaking in consumer terms. And certainly some facial areas where fat is added. How does it differ in medical terms?

Dr. J. Peter Rubin: As liposuction evolved, plastic surgeons had the thought that perhaps we could take some of this fat that we were removing from the body and we could re-inject it to another part of the body and that was the birth of this process of fat grafting. So, we will actually remove the fat tissue with a liposuction cannula, specially-designed for fat grafting in that it’s smaller and collects smaller parcels of fat, and then we’ll process the fat tissue in the operating room by separating the fat cells from the different fluid layers and oil layers so we have a more concentrated form of the fat. The fat is then re-injected to other areas of the body using very specialized instrumentation.

What role do the stem cells play in all this?

Dr. J. Peter Rubin: The field of fat stem cells is actually very exciting in plastic surgery and in the field of medicine as a whole, because within our fat tissue is actually a very rich population of adult stem cells that then have very powerful bioactive and regenerative properties. These fat cells can be separated from fat tissue and we are working with those cells in the laboratory along with many other groups around the world, but every time we transfer fat tissue that’s removed from the body by liposuction we’re also moving these fat stem cells with the fat. Most scientists believe that many of the properties of the fat graft that allow it to persist and heal over time are-related to the stem cells that reside within the fat tissue.

One of the problems is that the body can reabsorb the fat. How do you keep that from happening when you do the graft?

Dr. J. Peter Rubin: One of the major challenges with fat grafting is re-absorption of the fat, or the fact that it can lose volume over time, and that remains a challenge and while fat grafting has been used for many decades in cosmetic procedures, it’s never been well characterized or well measured about how much of this fat persists. And ,in the work that we’re doing with wounded military personnel, we are, first off, applying this technology of fat grafting for patient trauma and secondly, we’re very methodically measuring over time how much of the fat remains and how good our results will be with this technique. We are using that as a foundation to develop new technology that can make this therapy even better.

Do the stem cells signal automatically when they are re-injected, or is there something else that has to be done to signal them to grow or signal them to stop at a certain point?

Dr. J. Peter Rubin: Most of the stem cells in the tissues within our body remain fairly quiet; they are not very active and when we transfer stem cells that are within the fat tissue we know that they will be stressed by the surgical procedure and under this stress they’re capable of releasing different growth factors that can assist in the healing process.

Can you transfer fat from one person to another, or does it have to be the patient’s same cells?

Dr. J. Peter Rubin: The great thing about technology is in therapies that involve moving fat cells is that we can do that with the person’s own tissue and that we don’t have to use tissue from another person because we can always find enough fat tissue in a given patient that we can easily remove that and work with that and use it for these new therapies.

What about rejection? Is it less likely since it’s coming from the patient’s own body?

Dr. J. Peter Rubin: Rejection with tissue from your own body is really not an issue.

How long is the procedure? Where are the tissues taken from?

Dr. J. Peter Rubin: A typical procedure will take approximately two to three hours and during that procedure we will remove fat from another part of the body, usually the abdomen or the thighs, and we will remove the fat using specialized hollow tubes that are designed just for that purpose. Once the fat is removed from the body, we will do processing steps in the operating room that will separate the fluid layers, separate free oil layers from the fat and have us be able to get a very concentrated form of the fat tissue that consists of very small parcels of the fat and then, also using specialized instrumentation that is designed to get the fat into very tight spaces, especially injured tissue or in scarred areas we’ll inject very small amounts of the fat at a time, almost very small droplets of the fat that we will place in between the existing tissue plains because we want the fat tissue to be very close to the existing blood supply so that it has the best chance of healing.

Talk to me about Jeremy’s case.

Dr. J. Peter Rubin: Jeremy’s case is very typical of the injuries that we see after combat trauma and even after civilian motor vehicle trauma. He has undergone previous surgical procedures. We have wonderful techniques in plastic surgery that have evolved over many decades to restore facial form. However, even with the best of these techniques, we still lack precision in our ability to very accurately reshape facial features. Many of the other surgical procedures are also quite invasive and require more time and more recovery and more scarring. So, in Jeremy’s case as in many other trauma patients, we were able to use this technique of fat grafting as a final step, as a complimentary procedure along with the other procedures that he has already had performed in order to do that fine tuning and very precise shaping of his facial features.

Does it change over time or when you are done with the procedure is that pretty much how Jeremy’s face will look?

Dr. J. Peter Rubin: What we know historically is that there is always some loss of volume of the fat tissue to some re-absorption of that fat tissue and we know that what we place will decrease somewhat over time and one of the main goals of the work that we are doing under the Department of Defense funding mechanism is to accurately measure how much of the fat persists and what conditions may favor better results.

So he’ll come back over a period of time?

Dr. J. Peter Rubin: We’ll see Jeremy over the next nine months.

How do you go about measuring?

Dr. J. Peter Rubin: We do that through a variety of techniques. We use a special three-dimensional camera that takes surface images of the face, and can be used for very precisely measured contour and volume changes. We also use a very high-resolution CT scanning technique that allows us to very precisely measure the volume of the tissue that we placed and track that over time.

Working with wounded service men and women, you see before and after pictures what comes to your mind?

Dr. J. Peter Rubin: Well, you know, this is obviously a very rewarding area of work for us. These are people who have sacrificed so much for us and they are putting their lives on the line and we really have an obligation to do what we can to advance the frontiers of medicine to help them as they recover from their injuries. Interestingly, many of the great advances in reconstructive surgery have been born out of the unmet needs that we see in wartime conflicts. And that’s been the case from WWI, from WWII, from Vietnam. Every time we have a major armed conflict we have new challenges in trauma reconstruction. And we need to meet these challenges with new innovations.

What is the potential down the road?

Dr. J. Peter Rubin: The whole concept of very precise, minimally invasive soft tissue reconstruction is an area that has a very bright future in reconstructive surgery. The work that we are doing clinically now is harnessing the best that we are able to do in 2011 in terms of operative technique, instrumentation, and assessing the results. This gives us a very strong foundation that we can build upon. Right now one of our biggest challenges is the fact that the tissue that we add in will go away over time to a certain degree. While we are doing this clinical work we have a great deal of laboratory work going on at the same time exploring the next phase of technologies for our next trials that will allow us to make the results even better. So, right now, fat transfer involves removing the fat, processing it in the operating room and injecting it into the patient. Through an understanding of the biology of the fat stem cells and even being able to separate those fat stem cells and apply them in greater numbers with a fat graft may allow us to get better results and that’s something that we are studying. The next phase that we are doing actually involves removing the fat stem cells and adding them back in to the fat graft to have sort of a super charged fat graft and then examine the results. That’s something that people may have heard about in the media, but it’s something that has not been well proven in human patients yet.

Are you now able to separate the stem cells, or is that something that’s coming?

Dr. J. Peter Rubin: Technically, in the laboratory we are able to do that and we are just starting a clinical trial where we will be separating the fat stem cells and adding them into the fat and assessing whether or not that will give us better results.

So, it’s not part of the procedure now?

Dr. J. Peter Rubin: It’s not part of the procedure now. So, that’s something that we are doing under appropriate regulatory approval.

How many people will be affected?

Dr. J. Peter Rubin: I work very closely with military surgeon in this work. This is not a unilateral effort on my part and we have surgeons in all branches of the military and scientists in all branches of the military who are working closely with us on these projects. My colleagues in the military tell me that as many as 26% of our service members who have been evacuated out of the Middle East theater over the last year have facial injuries. When you combine that with civilian injuries to the face and to the skull you are talking about many thousands of people. Now the technology that we are developing for soft tissue reconstruction is not only applicable to trauma but also applicable to cancer reconstruction so everything that we are doing in this work with facial trauma also has application for breast cancer patients and in developing ways to make breast cancer reconstruction less invasive and more effective with minimal risk. As we explore the biology of stem cells and their applications for plastic surgery, we have to bear in mind that this technology is very promising and it’s also very early. We are in the early phases of investigation. Our understanding of the biology of stem cells is very likely to result in more effective treatments for our patients. We’re absolutely still in a phase where we are collecting the evidence and the data that we need to show effectiveness.


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