Many treatments have been touted over the years to create a facelift-like effect from topical creams to devices in lieu of having the actual surgical procedure. Today’s ‘alternative facelifts’ have taken on a very different approach and it is done through largely an injectable approach. These are all about adding volume to the face, plumping it out in select sunken facial areas. In many ways these are facial reinflation methods which work best for those patients who have lost volume and have a little loose or saggy skin.

These volumetric facelifts are comprised of two basic approaches. The first is the generic liquid facelift which completely uses synthetic injectable fillers and promises nothing more than a limited time period of benefit. The now more appealing, and the group that has caught the most press and is also heavily marketed, is the autologous injection techniques which promise more than just a short-term effect…they promise a rejuvenation of tissues as well.

These autologous injection techniques use either blood products such as platelet-rich plasma (PRP, e.g., the Vampire Facelift) or one ‘s own fat which is obtained by liposuction. Because our fat stores are now known to contain large amounts of stem cells, these type of liposuctioned-derived injections have become known as ‘stem cell facelifts‘. They have become heavily touted on the internet and many patient testimonials as to their rejuvenative benefits can be found online.

But what is a stem cell facelift actually? In reality, it is a bit of a misnomer. It starts with liposuction to harvest fat, usually from the abdomen, which is then processed during the procedure to get rid of most of its fluid contents. (blood, tumescent fluid, free fatty liquids) What happens next varies by the doctor doing it. Some will proceed to inject the fat concentrate while others may further process the fat to obtain a greater cellular concentrate of the material which presumably has more stem cells per injected volume.

For those just taking concentrated fat and injecting it (aka fat injections), any stem cells that are in the fat are inadvertently carried along with it. How many stem cells and how active they are after being injected into the face is anyone’s guess. This is a stem cell facelift in the loosest use of the term.

To those who do a stem cell preparation step with the fat (usually a mechanical process that separates the stem cells from the fat and then they are injected along with the fat), this is a purer form of a stem cell facelift. Such higher concentrations of stem cells are purported to induce skin rejuvenation allegedly because of the growth factors that are produced by the stem cells. But no one really knows for sure.

While the appeal of the stem cell facelift is undeniable, does it really work? The regenerative properties of adult stem cells has been vigorously studied for decades in a  wide variety of medical conditions. But their use in aesthetic medicine is very new and, as a result, the medical evidence supporting their effectiveness is presently very weak. The marketing claims are high, but almost all the clinical evidence of its effectivenss is anectodal….and very short-term.

To really answer the question of the effectiveness of stem cell facelifts, split-face clinical studies would have to be done. Patients would have to submit to one-half of their face being injected with fat and the other half with fat that contained concentrated stem cells with postoperative assessment of appearance and skin improvement. Such studies are hard to conduct although patient recruitment would likely not be difficult.

Stem cells have a lot of regenerative potential but whether that applies to aesthetic conditions like facial aging remains to be seen. I like the concept very much but it remains a clinical procedure that is in the earliest stages of development. And as often happens in many developing aesthetic techniques, the marketing and promotion of it gets way ahead of the actual science to support it.

Dr. Barry Eppley

Indianapolis, Indiana

Stem cells has understandably caught the imagination of both plastic surgeons and patients alike with their regenerative potential. This has led over the past few years to surgeons promoting their benefits to patients by so-called stem cell-enhanced or derived procedures. From facelifts to fat grafts, the moniker of the words ‘stem cells’ confers an improved method which leads to better or more long-lasting results. Such promotions have been done even though the FDA has not approved any stem cell therapies for cosmetic use.

Manufacturers of devices that can create stem cell concentrates have also emerged. This is usually done by taking fat obtained by liposuction, processing it through an on-site machine, and then a near immediate stem cell preparation obtained for patient re-introduction, usually by injection, is available. Laboratories also began offering services that will also take a patient’s fat, extract the stem cells, and grow them in cell culture to be available for use weeks later. The patient’s stem cells could also be stored and used in the future if desired.

Despite the initial tremendous enthusiasm and unregulated behavior when it comes to stem cell use, that has come to an abrupt end in the past year. The American Society of Plastic Surgeons and the American Society of Aesthetic Plastic Surgeons issued policy statements that their members should avoid offering and marketing stem cell procedures. This position is based on the scant human evidence in the medical literature to support the benefits of injecting stem cells into patients. While there may be real benefits to the use of stem cells, it is way too early to know what their actual benefits are, how they might work and what are the best indications for their use. Long-term controlled human studies need to be done for various plastic surgery indications to determine their efficacy…just like the approach used for drugs.

While plastic surgeons have been admonished by their own societies to cease stem cell therapies, the manufacturers and laboratories of stem cell-derived devices have received more stern edicts. Recent legal rulings have sided with the FDA that all companies processing stem cells or selling machines that extract and concentrate stem cells must do so through a formal FDA regulatory process involving controlled human clinical trials. There will no fast-tracking or short cutting to human use based on the comparative use of processing blood and blood-derived products. Basically the legal ruling is that fat is not blood and and large studies involving human participants is needed.

Adult stem cells are found in various locations throughout the body, but fat has the highest concentration of them. Obtaining stem cells from liposuction-derived fat has brought their potential use to quick fruition. But with this potential may come unknown risks that are more likely to be revealed (if indeed they do exist) in controlled human clinical trials than theoretical plastic surgery procedures that are highly marketed.

Dr. Barry Eppley

Indianapolis, Indiana

Stem cells are the rage in medicine and their potential application for cosmetic changes is no exception. Since fat has become discovered as a resplendid source of stem cells, it has become relatively easy to acquire one’s stem cells from liposuction harvests and grow them in great numbers. As a result, numerous private laboratories have emerged offering stem cell growth and storage. This has led to numerous doctors across the country offering so-called stem cell cosmetic procedures and injections.

The appeal of stem cells therapies to potentially improve aging, wrinkles and sagging tissues is understandably irresistable. But one of the stark realities of stem cells is that no one knows what they will actually do if implanted. While the understanding of the basic biology of stem cells is well known, how they interact with other cells and materials after being implanted is far from an exact science. There are presumed to have remarkable regenerative properties, but there is not one single scientific paper that has ever actually shown that to be true in human application. Quite frankly, stems cell for cosmetic applications in humans is really an experiment even if it is the patient’s own grown cells that being used.

This human experimentation of stem cells in cosmetic surgery is illustrated in a recent report that appeared in Scientific American. A California woman complained of a swollen eyelid, an inability to open it well and hearing a strange sound when she did months after having received a new cosmetic procedure months earlier. The procedure was a ‘stem cell facelift’ where stem cells obtained from her fat by liposuction and then isolated were injected in combination with an injectable filler around her eyes. In subsequent surgery on her eyelids, a different surgeon than the injector removed bone fragments around the eye which were the source of her swelling and eyelid motion restriction. The sounds the woman heard appeared to have been caused by bone fragments rubbing against bone fragments.

While the injectable filler used was not identified in this report it undoubtably was Radiesse, a particulated filler that contains calcium hydroxyapatite particles as part of its composition. The stem cell treatment appears to have been a concoction of Radiesse and stem cells with the theory presumably being that it would improve the longevity of the filler’s effects. What was not predicted was that some of the hydroxyapatite particles served as a nidus for stem cell conversion into bone. In hind sight, this potential reaction seems obvious. But the euphoria of using stem cells and the lack of any previous studies using this combination led to this one patient’s unprecedented iatrogenic affliction.

It is important for patients to understand that the FDA has not approved any cosmetic procedures which use stem cells…or at least so claims. The more common and widely popular use of fat injections undoubably contains stem cells but their incorporation into the injectable treatment is inadvertent and the stem cells are not altered. Extracting stem cells and isolating and manipulating them for re-injection for human cosmetic alteration is now unapproved and requires a controlled FDA-regulated study in which to do it.

Whether stem cells are the fountain of youth for humans, or at least offers some spot areas of physical improvement, will now await years of further study.

Dr. Barry Eppley

Indianapolis, Indiana

The desire to correct an aging facial appearance has been around as along as there is recorded history. Facelift surgery in various forms has been employed now for over one hundred years. Today’s facelift techniques are very diverse and use manipulations of all tissue levels down to the bone to achieve often dramatic improvements. Younger patients with very early signs of aging enjoy the benefits of facelifting albeit with more limited procedures geared towards the need for less dramatic changes.

But no matter how it is done, a facelift procedure is invasive and many patients want to avoid surgery if at all possible. Some patients are so opposed to surgery that they will choose any procedure  that simply isn’t surgery. With the widespread and growing use of injectable fillers and promising autologous therapies like platelet-rich plasma (PRP) and stem cells, newer methods of ‘non-surgical facelifts’ have emerged. Some of these have very catchy names and good marketing efforts behind them, which combined with the ability to do them outside of a traditional operating room setting, has caught the attention and imagination of people concerned about their aging facial appearance.

The basic concept of all of these techniques is that they are injectable. While the name ‘facelift’ has become attached them, this is not an accurate name for them. They do not achieve the same effect as a facelift nor should they be construed as having much other similarity to a facelift either. Their use of the facelift name is a marketing manuever. The only similarity between a true facelift and these injection techniques is that they treat the same problem…facial aging concerns. Therefore, the proper name for them should be Injectable Facial Rejuvenation (IFR) which signifies their non-surgical nature They may provide some degree of rejuvenation but they definitely don’t lift tissues in the conventional sense.

In reviewing the available options for Injectable Facial Rejuvenation, it is important to recognize that most of them are not standardized treatment methods and are not sanctioned by the FDA to be used in this fashion. Because these techniques have emerged largely from marketing and patient recruitment means, and not from scientific or clinical studies, there is no way to compare their effectiveness other than anectodal reports and patient testimonials. This is why how one practitioner performs one injectable technique may be different than another. Such provider variability makes it impossible to assess the effectiveness of one IFR method, let alone if one IFR method is more effective than another.

The Liquid Facelift uses either one or a variety of off-the-shelf FDA-approved injectable fillers. These could include any of the many hyaluronic-acid based fillers, such as Restylane or Juvederm, or the particulated fillers such as Sculptra or Radiesse. The concept is the select placement of them into volume-deficient or sagging facial areas that expands them, thus creating some degree of a lifting effect. This is more expansion than a lifting result. Its effects will subside as the filler absorbs. It is postulated but not proven that these fillers have a long-term collagen stimulatory effect.

The Vampire Facelift is the ultimate marketer in IFR because it is a company that sells its technique for use. Its foundation is the use of platelet-rich plasma (PRP), an autologous platelet concentrate extract which contains growth factors and cytokines. Such factors have proven laboratory performance of accelerated healing. When introduced under the skin, it is presumed that it may have some rejuvenative or stimulatory properties. This technique is also combined with injectable fillers. The theory is that the PRP and the fillers in combination may lead to an enhanced and sustained collagen response. Whether this is enough to wake up the living dead is speculative.

The Stem Cell Facelift primarily employs the injection of fat or allegedly concentrated extracts of stem cells. Stem cells have caught the imagination of the cosmetic surgery world with the belief that they will provide some rejuvenative effect. This concept is theoretically appealing but has little scientific proof that this really occurs. Most ‘stem cell extracts’ are just concentrated fat from liposuction harvests. As such, it is impossible to know how many stem cells and what their potential is in any fat concentrate. Because of the widespread uncertainty of the value and effectiveness of stem cells, the American Society of Plastic Surgeons has issued a position statement that any of its members promoting or marketing stem cell techniques as unethical behavior. In addition, the FDA has recently issued a ban on any company that grows patient stem cells for treatment. All stem cell therapies, even using the patient’s own stem cells, must be done under a clinical study protocol. This does not exclude the common use of fat injections in which stem cells exist amongst the fat cells and are incidentally injected. But promoting it as a stem cell procedure is not viewed favorably.

The Acupuncture Facelift employs the traditional Chinese technique of the introduction of needles to free up chi or energy. Allegedly, introducing needles into the face causes the production of collagen and elastin to plump up the skin. After a series of 10 treatments, wrinkles and deeper lines are purportedly reduced and skin is lifted. More likely, some mild swelling occurs as a result of the needles and results in some slight temporary skin fullness but no documented and proven lifting effect that is sustained as ever been studied or proven. This limited injection or needle approach to facial rejuvenation is the greatest stretch in calling it a facelift technique.

Injectable Facial Rejuvenation has a role to play in treating facial aging concerns but should be understood in proper context. They are not facelifts and will not lift up sagging facial tissues. They are principally plumpers or volumizers and achieve any wrinkle or fold reduction through this effect.

Dr. Barry Eppley

Indianapolis, Indiana

The field of stem cell research has spurned a lot of new potential medical applications. Enthusiasm is high as to what stem cells may do and many almost give them magical properties and disease curative capabilities. Much of this enthusiasm is at least partially warranted based on a large number of animal and cell culture studies which show some extraordinary results.

The allure of stem cells for plastic surgery applications has not gone unnoticed. Their use in plastic surgery is spurned by several driving factors. The first is their autologous nature and our familiarity of harvesting a fat donor source of stem cells through liposuction. Many problems in plastic surgery particularly of cosmetic concern is the aging of soft tissues, exactly what stem cells can theoretically help reverse. But the pivotal technology that brings stem cell use in plastic surgery a reality is that of commercial stem cell production. There are numerous companies that have emerged that offer to grow stem cells from patients in a timely manner and at a reasonable expense. Since these are cells that are being transplanted back into the patient from which they came, there is no objection yet to their use by the FDA.

Now that stem cells are available, the next question is exactly what in plastic surgery are they good for? Stem cells are different from that of injectable fat grafting in that volume is not being replaced. Fat injections add substantial volume which is why they have made facial volumetric enhancement and breast and buttock augmentation possible. While these fat grafts do have some stem cells in them, they are not really true stem cell injections. The stem cells are inadvertent passengers along with the much greater number of fat cells. The use of such monikers as ‘stem cell injections’ and stem cell-enhanced fat injections’ used by some surgeons are marketing terms and not indicative of scientific reality.

When thinking about how to use stem cells in cosmetic plastic surgery, one potential application is their use as an adjunct or supplement to an existing technique. This would be adding stem cells to enhance the effectiveness of an established treatment method. The obvious choice would be that of adding them to fat injections. While fat injections do naturally have some stem cells, their numbers are low and their viability in question. Adding a concentrate to fat injections would increase their numbers and one would be more certain that they were viable. The question is the ratio of stem cells to the fat injectate and what is a truly effective percent. No one knows but it would seem logical that fact injections into the face would be more appropriate given the lower amount of fat used and the higher ratio of stem cell volume that could be added. Stem cells could also be added to any of the available synthetic injectable fillers used for facial wrinkles, folds and volume enhancement as a theoretical alternative to fat injections. Or they could be added to grown autologous fibroblasts for injection creating the ultimate synthesis of cell culture technologies.

The other application concept is that of pure stem cell injections alone. It would be used by injecting the cell concentrate into the desired tissue target with the intent of creating a rejuvenative effect much like the way we use synthetic injectable fillers today. Whether they could serve as an alternative to injectable fillers creating a delayed volume effect through cell stimulation or conversion to adipocytes or fibroblasts is theoretically possible. Injecting directly into facial wrinkles and folds would be easy to do as stem concentrates would flow through very small needles. Could skin thickness and texture be improved by direct stem cell injections?

While stem cells are now available and their biologic appeal is obvious, the cosmetic applications for which they would be most beneficial is not yet known. This is sure to create a flurry of clinical activity in this area from many inventive and entrepreneurial cosmetic practitioners in the near future.

Dr. Barry Eppley

Indianapolis, Indiana

The use of stem cells in medicine has garnered much media and public attention. Because it is a natural component of human tissues and it is a pluripotent cell that has the capability of converting to many different adult cell types, it holds much promise for numerous medical therapies. While the quest for which medical diseases stem cells offers the best benefit is being investigated with much fervor, there is no question that anti-aging conditions are one logical application.

While not a disease in the truest sense, aging is a natural medical condition  that is degenerative of both cells and the substrates in which they exist. The use of stem cells and the factors that they may excrete would seem like they could offer some regenerative effects on one’s external appearance. Thinning and wrinkled skin, atrophy of fat and supportive connective tissues, and restoration of face and body contours have the potential to be enhanced with adjunctive stem cell techniques.

The promulgation of stem cells to the forefront of anti-aging treatments has been driven by the realization of their easy access. While stem cells have traditionally been thought of as existing largely in bone marrow, it is now known that fat is the richest source of adult stem cells. Estimates are that fat has 300 to 500 times more stem cells than bone marrow. Given that fat can be quickly harvested through liposuction, the acquisition of stem cells is now easy.

While plastic surgeons have trued numerous methods of isolating stem cells at the time of their harvest, the present reality is that it is not easy to obtain really true concentrates of them. Most so-called stem-cell therapies today in plastic surgery are nothing more than concentrated fat injections. While these fat injections do contain some stem cells, calling them stem cell injections or stem-cell enhanced fat injections is a stretch and more of a marketing concept that it is a true stem cell therapy.

To obtain stem cell in sufficient numbers from fat, it requires that they be isolated, grown and processed in laboratory conditions. It was only a question of time before a commercial laboratory became available to provide this service for plastic surgery and anti-aging applications. Cryo-Lip, a bio-tech startup laboratory based in Indianapolis, is now offering the service of cryopreservation of adipose-derived stem cells, fat, or both. It is now possible that patients and plastic surgeons can not only obtain viable stem cell concentrates but can have them stored and grown for future use.

While liposuction surgery is an obvious source of fat to be processed, it can also be done when one is not desiring body contour changes. The amount of fat needed for processing is in the range of between 25 to 50ml which can be obtained using a patented syringe system under local anesthesia in the office if desired. The sample is then sent to Cryo-Lip for processing and storage. The average turnaround time to obtain injectable materials is two weeks. The samples can be sent as either a fat or concentrated mesenchymal stem cell mixture. The existence of viable stem cells is confirmed by testing and analysis before being sent. If not an adequate number of viable stem cells is present in the sample, the provider is informed and the tissue is discarded at no charge to the patient.

The now easy access to stem cell concentrates allows them to be used for numerous potential cosmetic and regenerative medicine uses. Some of the well known current applications include their adjunctive use with fat for lipofilling for facial volume restoration and breast and buttock augmentation. When used as isolated stem cell concentrate injections, they have potential use for facial skin rejuvenation, wrinkle reduction and fold and crease filling.     

Dr. Barry Eppley

Indianapolis, Indiana

Stem cells have been well known for a long time and bone marrow has been the traditional source of their harvest. Stem cells have generated such interest because medical researchers believe that stem cell therapy has the potential to dramatically change how we might treat certain the human diseases. As stem cell science has continued to evolve, new approaches are being developed about how they might be better used in medical therapies.

One big change has been the awareness that fat has more stem cells than bone marrow. Bone marrow has been thought of for decades as the exclusive or most replete source of stem cells in the body. Even though it was known that other tissues had stem cells as well it was thought they were either too few or impractical to harvest. Then along came fat and its easy access from liposuction. This lead to the realization of the potential of its abundant stem cell source. How abundant?  I have read estimates that fat has 300 to 500X more stems cells than bone marrow. That is a lot more, not to mention the abundant supplies that are walking all around us.

Concentration of liposuctioned fat is now widely available by a variety of manufacturers and their devices. This concentrated pellet of uncultured fat tissue, known as the stromal vascular fraction (SVF), is what is believed to be a potent source of stem cell therapy. Traditionally the approach to the use of stem cells has been in the context of tissue engineering. The strategy is to have the stem cells convert and grow into the missing or damaged tissue such as bone, cardiac muscle, or new brain cells or neurons. But this more easy access to uncultured SVF from liposuctioned fat has led to its potential use for healing or regenerating tissues directly rather than using a cultured differentiation of stem cells. In essence, make the body heal directly rather than implanting tissues grown outside of the body. Some refer to this as autologous regenerative therapy or ‘heal thy ownself’.

How might this work? What is the magic of stem cells that would make them heal injured tissues? Some stem cells, known as mesenchymal stem cells, live within or are attached to blood vessels.  When injury occurs these blood vessels are disrupted or traumatized and some stem cells are released. This activates the stem cells which release a wide variety of chemicals, generically known as growth factors. These released factors attract the necessary cells and other elements for healing. One of its main functions is to promote new blood vessel growth which provides the highway for all healing elements to get to the site of injury In short, stem cells are a source of a new blood supply.

There are many ongoing clinical trials for stem cells which ranges from diabetes, heart attacks to spinal cord injury. In plastic surgery they include non-healing wounds and scar therapy. But of equal interest, although not a specific clinical trial, is in the improved or accelerated volume retention of injected fat grafts. Since we are injecting some level of concentrated fat aspirate, it must contain the stem cells from the disrupted blood vessels as well as those that resided in the fat itself. While this is undoubtably true, why does injected fat have such variable retention? Most likely there are not enough stem cells in our prepared fat concentrates or their amount is  highly variable. But injection technique and the recipient site has a lot to do with it as well.

The stem cells in fat and in prepared injectates present interesting possibilities and potential. But we have a long way to go to understand how they may be of benefit in the plastic surgery version of the ultimate version of ‘recycling’ or ‘green surgery’. 

Dr. Barry Eppley

Indianapolis, Indiana

The continuing evolution of fat grafting in plastic surgery has seen it become more dependable as well as new applications being developed. Popular target areas for fat grafting have focused on the face, breast, and buttocks. Some equate fat injections to that of synthetic injectable fillers. But beyond their injectability, there are used for entirely different purposes. Fat grafting is for larger volume problems and are used in the hope they provide some more permanent effect.

Fat grafting is not the equivalent of typical injectable fillers. Instead, it is less stiff and behaves more like a liquid…it has little substantative pushing effect on a specific tissue site. That is why if you try and use injected fat to lift up or diminish a fold or wrinkle, it does not work very well. Regardless of whether it even survives, it does not have a focused displacement effect. For areas that are very adherent, such as deep creases, folds, and lines, it just can not efface them. These commonly perceived areas of fat injections have high failure rates and that experience contributed to the perception that injected fat doesn’t work very well. Fat injections are best used as a volume fillers for the treatment of facial contour areas.

The biggest reason that fat grafting has become more accepted today is technology. Advances in harvest methods and processing (concentration) are the two main areas of improvement. Less traumatic harvesting methods that enable better quality fat to be obtained creates fat tissue that even looks better. Getting rid of extraneous liquids and debris, whether it be centrifugation or less powered purification methods, creates a more homogenous injectate material.

But the one thing that has really tipped the balance to wider acceptance and usage is that of stem cells. The realization that high concentrations of stem cells reside in fat has raised the potential that they can be used for better volume preservation and even promote healing in difficult wounds. The stem cell has been given magical properties even though whether it really has any benefit to a fat injection is far from an established medical fact. Many anectodal claims are being made about skin quality improvement and anti-aging tissue effects. While the science has yet to provide proven support of these observations, the potential of it has propelled injectable fat transplantation into one of the hottest topics in all of plastic surgery today. Once scourned and held in disrepute by most plastic surgeons, fat grafting today has undergone a complete reversal of medical acceptance…and the well known stem cell is helping it along.

In performing fat injections into the face and hands, I have observed some changes in the quality of the skin overlying grafted fat.  Sun-damaged and aging skin seems to improve in some patients (I didn’t say all patients) more than one would anticipate  just from the push of the volume from the fat under the skin alone. This newly injected fat appears to be contributing to improved healing into the areas where it is injected. From breast lumpectomy defects to facial scars, there does appear to be some healing benefits. Research suggests that these positive effects on the skin may be from exogenous factors from stem cells. Since fat has the greatest number of stem cells of any tissue in the adult human body, their potential influence is likely. The presumed effect is that they promote earlier and more abundant blood vessel growth into the surrounding and overlying tissues. This has been shown to be true when fat is injected under skin with severe radiation damage. With a new or more normal blood supply, severely radiation damaged skin becomes healthier.

How the stem cells in fat grafts may contribute to better volume preservation is more speculative. Earlier revascularization may play a role in helping some of the mature and intact fat cells survive the transplantation process. Stem cell conversation may also play a role. Once known as merely preadipocytes, some stem cells may be induced to differentiate into fat cells. That may explain the observation that injected fat volume may go down early on after surgery only to rebound months later.

Even though injectable fat grafting is rapidly becoming a common procedure in plastic surgery, there are a lot of very important questions we need to answer before we can conclude it is all that it is being touted. Currently, the marketing of it sometimes exceeds what is scientifically known about it. (e.g., stem cell facelift) We need to learn the optimal way of processing fat tissue and we really need to get some accurate information about how long fat grafts last. Much of the clinical work being presented  lacks quantifiable measurement. The good news is that injectable fat grafting is perfectly safe, we just don’t know yet the extent of its benefits or for what problems it is most effective.

 Dr. Barry Eppley

Indianapolis, Indiana

The long known presence of stem cells in fathas led to an exciting wave of scientific and clinical efforts to harness the potential of this ‘wonder’ cell.The real question is wondering what benefits stem cells can really offer.Why do we have cells that lie around dormant in our fat but yet has the potential to turn into any type of cell and grow new tissues if properly stimulated? The reason must be as a reserve for new tissue regeneration should that be needed.

Given the ease from which fat can be extracted through liposuction, whole new uses are being derived for what may be capable with stem cell-derived fat grafting. (SCFG) Fat is being injected all over the body by plastic surgeons, mainly because it is easy to do and perfectly safe. Injected fat has many body uses from body contouring to facial rejuvenation. For the body, buttock augmentation and breast reconstruction (lumpectomy defects) are being widely done. Fat breast augmentations are being approached more cautiously but is gaining some momentum also. The other good body use is that of hand rejuvenation, using the injected fat to fill hollows between the extensor tendons and to camouflage prominent veins.

The face, however, is the most widely implanted body part for fat injections. More recent research in facial aging has shown that we loss fat in our face as we age. This facial deflation is one of the reasons that we look old and contributes to skin sagging. This has led to younger people getting fat injections at an early age and fat injections being used as part of a facelift procedure for more advanced degrees of facial aging.

In the most contemporary spin of fat grafting to the face comes the Stem Cell Face Lift. The concept is that stem-rich fat grafts combined with skin tightening makes for a better facelift result. Proponents claim that the patient’s own stem cells provide a regenerative effect that gives a significantly better end result in face lift procedures with longer lasting results and has a youthful restorative effect on one’s skin. The skin is claimed to be changed with smaller pore size and less wrinkles and pigmentation.

While controversial, this newer Stem Cell Facelift uses an activation process that is believed to activate the stem cells once they are injected with the fat. While laying dormant in the fat donor site, they may only be beneficial if they are brought to life in their transplanted location. Various stimulation methods are being proposed including the addition of chemical stimulants and even low-level laser light therapy. This newer process is to be differentiated from just plain old fat grafting to the face (which is not that old) by applying amethod to trigger and activate the stem cells either during or after the fat transfer. It is claimed that patients receiving fat injections alone done the traditional way, without the advantage of activation, will see little to none of the actual stem cell’s regenerative effects on the face and skin.

How is a Stem Cell facelift done? A typical facelift operation is an outpatient procedure done in around two to three hours or longer if other facial procedures are done with it. The fat is removed by liposuction from a favorable location, usually the stomach from inside the bellybutton. The harvested fat is then concentrated and purified. Prior to injection it is “activated” or enhancers are added. My current method is to add a mixture of PRP (a platelet-rich concentrate) and Matristem collagen matrix. PRP is obtained as a blood extract from the patient once they are asleep. The high concentration of growth factors in platelets, is a known potent source of cell stimulation. Matristem is an extracellular matrix which comes in a powder form and is an off-the-shelf product. Mixed in with the concentrated fat graft, it adds a potential source of collagen stimulation and matrix onto which stem cells may attach and proliferate. Once all the elements of this elixir are obtained and mixed together as the final step, the fat is then selectively injected and the facelift completed.

With all of this being said, is the Stem Cell Facelift actual science or more science fiction? Is it hype or hope? At this point I would say a little of both. The real scientists of stem cells would most certainly tell us that the use of stem cells isn’t that simple. While stem cells have been extensively studied and their properties recognized, how to harness their potential and make them work is far less clear. While moving them from one place to another in the body just seems like it should work doesn’t make it so. This is the principle of what I call a ‘trueism’ . A trueism is anything on the surface that just seems so logical and natural that it is obvious that it works or is true. The problem with trueisms is that most of them, on closer inspection over time, are shown to be not true at all. Stem cells and their effects on facial aging has the potential to be a great example of a trueism. They certainly are associated now with a lot of hype.

Conversely, the hopeful part of a Stem Cell Facelift is that it is a perfectly natural procedure that has no harmful effects, an almost organic procedure if you will. It is all the patient’s own tissues and may exemplify the appealing concept of ‘heal thyself’. Because one’s own cells are being used (recycled?), it is not a procedure that requires FDA approval or that of any governing medical organization. (so don’t be misled that it is an FDA-approved procedure or technique) At the worst, one gets the benefit of fat grafting whether the stem cells really become alive or not. And the use of fat grafts to the face with our current appreciation of what happens as our face ages is a proven benefit.

Dr. Barry Eppley

Indianapolis Indiana

The use of the words ‘stem cell’ and ‘reconstructive surgery’ is a charismatic combination that brings to mind a simple and seemingly obvious biologic solution. With the knowledge that fat cells are an excellent source of adult stem cells and liposuction is an easy way to get them, the procedure of lipofilling or fat-stem cell injections is irresistible. This has prompteda wide range of purported stem cell procedures in plastic surgery from breast reconstruction to facelifts. The unfiltered dumping of promotional ‘stem cell’ procedures on the internet has understandably galvanized the public, sometimes traveling afar to get these procedures.

But despite the simplicity of reprocessing fat from one body location to another, the science offat grafting and the stem cells that it carries is extremely complex and very poorly understood. While stem cells in the laboratory in a petri dish can be reliably studied and quantified, what happens in human tissues is still largely unknown. I suspect the science of stem cell transplantation will one day be the equivalent of a complex chess game compared to the simple ‘checkers’ of the blood coagulation cascade.

In normal human tissues, which is the best of circumstances, we have trouble getting injected fat grafts to reliably survive and maintain volume. Numerous gurus in plastic surgery tout that the success of fat injections is technique-based and, if certain recipes are followed, good results are sure to follow. There certainly is merit in concentration processing and careful placement of the fat into the donor site but these steps are not the complete answer. Every plastic surgeon who has ever done fat injections in any numbers have had lips and faces which deflated rather quickly or whose buttocks never got much of a sustained augmented result. Technique accounts for some of these failed results but it can’t account for them all. I suspect that if an honest survey was done of plastic surgeons who have done fat injections, and they had actual long-term follow-up, the successes would still be dwarfed by the volumetric failures at this point in time.

With successful fat injection grafting, is it the fat cells which survive, the conversion of the adult stem cells, or some combination of both? Almost assuredly it is some combination of both but the why and how is unclear. One factor that appears to be critically important is the site of injection and the extracellular matrix (ECM) into which it is placed. The ECM of the donor site has been shown to have a very strong influence on the ultimate cellular behavior of the injected cells. In cosmetic applications, the ECM of the donor sites are almost always normal.

But what of that of damaged tissues where the ECM is clearly altered or abnormal? The irradiated breast lumpectomy site is a prime example. The collagen and the blood vessels in the tissues are scarred and less prone to normal healing. Yet anectodal reports and a few reported clinical series show an improved tissue quality and some volume retention even in the face of an abnormal ECM.

Fat grafting and the stem cells it may contain is going to continue to find expanded clinical uses. The appeal of an autogenous or natural solution to both cosmetic and reconstructive tissue problems is just too great. The axiom of ‘Body…Heal Thyself’ just seems like it should work, whether one views that from a biologic or religious perspective. My hope is that the fat/stem cell therapies today do not become the failed hype of the growth factor science from twenty years ago where much scientific effort has resulted in just a few scant healing products.

From a patient’s perspective, it is important to realize that fat grafting by injection today may contain stem cells, but it is not a true stem cell treatment…at least not just yet. Their presence in the injected fat is an ‘incidental’ by product of the process. What they do and whether they are of benefit may be good medicine by default. When touted as a ‘stem cell therapy’ however is purely promotional and is bad medicine by intent.

Dr. Barry Eppley

Indianapolis, Indiana