Fat is GOLD now?! How we use fat in plastic surgery is totally changing [Matthew Nykiel, MD & Mark Epstein, MD]

Eva Sheie (00:00):
You're listening to Where Before Meets After. I have a butt question. Are there patients now who've lost a ton of weight, who maybe previously would've never considered having an aesthetic procedure to reshape their butt who are now in that market? Is it completely different person than the butt patient of the previous decade maybe?

Dr. Epstein (00:23):
I think it is a different patient because the tissues are often very compromised, very damaged. A lot of them who are coming in for surgery are having surgery because they've lost so much fat that they now have all this extra skin, and some of 'em don't even have enough to harvest to make that adequate butt. And the scaffold, the infrastructure to the butt is just not there. It's not what it is in the other patients. So you're not going to get the same results.

Dr. Nykiel (00:52):
I would add onto that, I'd say in general, when we're talking about body contouring, rebalancing the body, we have one or two problems. We either have too much fat or we have too little fat. And it is interesting to see that shift with the GLP-1s that we're more and more coming into the issues of now we have too little fat, we're needing to add fat back. We're needing to give volume back to help balance that body more towards that ideal shape that we're going for. And that's a huge change from four years ago, right? Four years ago it was, we need to take away as much fat as we can to then almost like taking a stone. How do we carve that stone into a final statue? And now it's very different. Now it's like more to Dr. Epstein's point, a rehabilitation reconstruction. We've got the finished statutes, just parts of the stone have cracked off. We've got to figure how do we add it back on?

Eva Sheie (01:45):
So there are people who have just enough fat, but they're not coming to see you. They don't need to have more or less fat.

Dr. Nykiel (01:52):
And that's a good point. Right now, you can have just the right amount of fat, but what if it's not in the right spots? I think one of the best examples, even in this GLP-1 era is bra rolls, right? I think bra and back rolls have become a much bigger issue for people because you can cut your weight down to almost anything and had a back and bra roll there. It's very hard for it to go away with diet, exercise, and loss.

Eva Sheie (02:18):
Why is that?

Dr. Epstein (02:19):
Because the skin is bound to certain fixed points like the ribs. That's what creates the roll. The fat expands the skin between two fixed points horizontally, and that expands a roll. And then now that the skin has been deflated, it's just like a sagging breast after pregnancy. It doesn't have the recoil. So now you have all this extra skin and lipo isn't going to help. And if the extra skin is beyond the point of radio frequency, skin tightening, then you're faced with doing a back lift.

Dr. Nykiel (02:50):
Do you do many back lifts?

Dr. Epstein (02:51):
I wouldn't say many, but I do do them. And when I do do them, the patients are very, very happy. But it takes a lot to push me to do one. It's a big operation and it's a big scar, albeit you can hide it with a bra. It's usually massive weight loss patients where they don't care about scar, they're just more interested in the contour.

Dr. Nykiel (03:09):
The other thing I'd like to jump back on that and just say in those people that we're talking about sort of just enough fat, whether or not diet and exercise, whether or not that's just how they were born or whether or not they're post GLP-1, right? I think, and GLP-1 for anybody listening, semaglutide, tirzepatide, although I feel like now you can just say GLP-1, and anybody that's listening probably knows, right?

Eva Sheie (03:29):
Yes, thank you to the pharma companies for forcing us to call it by the category name, right?

Dr. Nykiel (03:35):
The bra roll. You'll always have a little bit of posterior flank fat no matter what you try to do, get rid of it. So we can just take those areas and balance that down to whether that be the hips, the hip dips, maybe it's a little bit of upper buttock volume that got lost. And those subtle changes, I think just really restructure somebody. We're not trying to do what we were doing five years ago where it was just such the bigger the better. I mean the curvier, it's just how do we balance you back no more naturally, aesthetically appealing.

Dr. Epstein (04:03):
Yeah. You can talk in generic sense about all the different options we have, but it really comes down to when you see that individual patient, ask 'em what it is that they want, assess their tissues, look at the quality, how much extra skin, how much fat do they have, what are the options? And there's oftentimes more than one thing that you can do. You present the options to the patient and let the patient decide based on what you tell them, what is best for that patient.

Eva Sheie (04:27):
Close out the fat thing. I have one last question there.

Dr. Nykiel (04:29):
Oh, I got something for you on fat too.

Eva Sheie (04:31):
Throughout your body, the fat is not the same everywhere. Is it accurate that you could take fat from one part of your body and you probably shouldn't put it in the face because it's not the right kind of fat or?

Dr. Epstein (04:42):
Well, with the face, the fat in the face is of different size. Call it different parcels. And as you go, more superficial, the parcels get smaller and smaller. So when you're harvesting fat for facial fat graft, and you can take it from the abdomen or the inner thigh or the flank, and then you put it into a device called the lipo cube or an equivalent device that cuts it into different sizes. So when you harvest the fat, it'll come out as what we call milli fat. The particle size is one size, then you can cut it into micro fat, and then you can even make nano fat. So in the face for structural things, you can put in the milli fat. And then as you get a little more superficial, put in some micro fat. And then the nano fat actually has regenerative capabilities, so you can inject it right into the dermis and reverse the aging on the skin.

Dr. Nykiel (05:30):
Mark stole my thunder there. That was my,

Dr. Epstein (05:32):
Oh, I'm so sorry, Matt.

Dr. Nykiel (05:36):
When we talked about new things with fat. Fat and we went to the synthetic fat, and that's what I said. There's actually some cool things going on with fat itself. Nano fat is obviously one of it. And that was my first branch there. And then the second thing I think is cool, again, coming out of South America is they're taking, now when they do their tummy tucks, et cetera, they'll actually take some of that fat from the lipo. And as they're doing the tummy tuck, they will repair the tummy muscles to bring them back together, but they'll actually inject a little bit of fat under direct visualization into the actual tummy muscle, rectus muscles themselves. Not to create a big steroid, like huge, bulky muscle, but just to give it a little bit more bulk. And it's really cool actually to see how that plays out postoperatively, because now when we're sculpting trying to form three dimensions, we actually have a back base of muscle that gives a little bit more push and we're getting a little bit more shape. So I think that's a really cool thing that's honestly going on with fat in another application of fat that we're using.

Eva Sheie (06:35):
What's driving all this development in the fat category?

Dr. Nykiel (06:38):
It's really interesting to go back to it, for the longest time, fat was just kind of not paid attention to it. We looked at more,

Eva Sheie (06:44):
It was discarded.

Dr. Epstein (06:45):
It was medical waste.

Dr. Nykiel (06:46):
And in plastic surgery we had the idea, we couldn't even use it. It's blood supply's too delicate. You can't transplant it, you can't do anything with it. And then probably early two thousands, wouldn't you say, is when the idea of stem cells, and I'm blanking on the very famous man's name,

Dr. Epstein (07:00):
Michael. Longaker.

Dr. Nykiel (07:01):
Longaker. And then who was injecting the fat in the people's hands in,

Dr. Epstein (07:04):
Oh,

Dr. Nykiel (07:05):
Sidney Coleman, right?

Dr. Epstein (07:06):
Yes. Coleman.

Eva Sheie (07:07):
Coleman.

Dr. Nykiel (07:07):
Yeah. Coleman. I mean, these people, again, just pioneers willing to try some things

Eva Sheie (07:12):
Who looked at the fat and said, why are we throwing this away?

Dr. Nykiel (07:14):
Right? Who heard a complaint from his patients that they were loving this plastic surgery was doing? They hated when people were taking photos of their rings because it gave away their age because of how age their hands look. And he thought, well, I take some of this fat and start to spin it down and give that back. And would that make the hand look better? I mean, it's just crazy.

Dr. Epstein (07:33):
Yeah. When you get away from the paradigm of just remove, remove, remove, and as Matt said, it's body balancing. It's filling in the peaks and the valleys and creating the contour that you want. You have to have something to do volumization.

Eva Sheie (07:49):
Alright, give me your Instagram, your website, and where to find you.

Dr. Epstein (07:52):
Epsteinplasticsurgery.com. And our Instagram is Dr.Mark. MARK, Epstein. You can find me on Long Island in Hauppauge. It's in Suffolk County.

Dr. Nykiel (08:03):
And I am a SoCal plastic surgeon. Matt Nykiel in Newport Beach.

Eva Sheie (08:07):
Thanks for listening. I'm your host, Eva Sheie. Follow the show and submit questions for our experts at wherebeforemeetsafter.com. Where Before Meets After is a production of The Axis.