During the course of any day, I am asked why fat isn’t the “same” throughout the body. Consider that fat has been grossly underappreciated and in fact deplored, however this connotes a fundamental misunderstanding of the multiple roles fat plays. Structure and protection are critical reasons why fat surrounds critical structures: the kidneys, the extraocular muscles, even the heart. However, as America struggles with obesity, global fat expansion threatens not only our aesthetic sense of self but also our health by causing fatty degeneration of the liver, atherosclerotic coronary artery disease, peripheral vascular disease, stroke, etc. While these disease states are beyond my scope of practice, here’s a Plastic Surgeon’s perspective on fat.

Like any organ, fat is genetically programmed to develop, expand, atrophy and die; the extent to which any anatomical zone follows its ontogenetic potential can also be modified by environmental factors, such as overeating, trauma, illness. Consider the contours of a baby’s face and body: everything is round, soft and smooth. Fat aging has a bimodal pattern: expansion or wasting but it also has a more diabolical variant, cellulite. Facial lipoatrophy has been well studied by Rohrich and Pessa in postmortem dissection specimens. Fat loss is fairly consistent and this serves as the “map” for repletion by fillers. By contrast, fatty degeneration or accumulation in the neck can be addressed by surgical excision, liposuction, nonsurgical RF and Kybella (injectable bile salts). After fat reduction, the next priority is ensuring satisfactory skin retraction or drape and this may require additional skin tightening modalities such as Thermi, Thermage, Ultherapy.

Fat is definitely influenced by hormonal fluctuation, as evidenced by the sequela of pregnancy and lactation. Many women despair the expansion of compartments of fat in the armpit and bra “boobs”, belly and “FUPA” (=fat upper pelvic area). The firm, high and tight structure of the young female breast sags shapelessly after lactation and seemingly expands upon menopause. Lacking any methods of “rejuvenating” these structural compartments, we can only resort to reducing the thickness, hopefully maintaining an attractive shape, hence liposuction, breast reductions, mastopexy, brastrap excisional lifts, abdominoplasty, brachioplasty (arm) and thigh lifts have become accepted and continually refined.

Conversely, unwanted fat has now become a virtual “goldmine” for regenerative medicine owing to the actual but limited availability of stem cells in mature adipose. Does it mean that we can now offer “stem cell” facelifts or breast augmentations? At this time, such scifi concepts are premature as the physiology and growth requirements are still under definition. ASPS has recently created a registry, GRAFTS, in which fat grafting cases may be analyzed in order to systematize methods, ensure safety and make results more consistent. Current accepted indications include fat grafting for breast reconstruction, facial rejuvenation and other reconstructive needs. Growth factors” have been permutated into “vampire facelifts”, a concoction of platelet derived growth factor and a patient’s own blood, HCG (Growth Hormone) diets and skin cosmeceuticals. A technique is valid when it can be independently replicated, otherwise it is merely one physician/surgeon’s experience and should not be considered a highest level of evidence based medicine.

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