Fat. Poor fat, it has been terribly vilified over the years.
Who can forget that moment when Oprah dragged a wagon filled with fat to represent the 67 pounds she lost? The early 1990s, aided and abetted by an FDA that trumpeted the benefits of reducing dietary fat intake, became a tribute to the merits of a low-fat or even more virtuous, a no-fat lifestyle. Remember the introduction of baked potato chips and the legendary Snackwells devil’s food cookie? Eat all you want, it’s also guilt-free. Then came Olestra, the fat substitute approved by the FDA, but came with some rather nasty side effects.
The situation got a little more confusing with the Atkins diet fad. All of a sudden, you could eat all the fat you wanted (although now it was carbs that were verboten), and they promised you would see the pounds melt away - so in the end, fat was still the bad guy.
But that wasn’t always the case. Throughout most of human history - before agriculture and technology made it easier to grow and store food calories - it was a boon for our hunter and gatherer ancestors to be able to easily bank those calories as fat and spend them sparingly.
Artists of the Middle Ages and Renaissance celebrated women with curves, and even into the early 20th century, fuller figures represented wealth and power. By mid-century, however, attitudes began to change, embracing more streamlined shapes.(1)
Today “fat” remains a bit of a dirty word. The “health and wellness” business is poised to become the next trillion dollar industry worldwide. Oprah is now the spokesperson for Weight Watchers (and a key investor), the latest diet trends are variations on “eating clean” and fasting, and #fitspo is a thing.
What if we took a step back to look at fat as, well, just fat?
Traditionally we have understood human fat to be simply a way to store extra calories, worth 9 kcal per gram. But more recently science has found fat to be much more complex - not just a plain storage depot, but perhaps the human body’s largest endocrine organ(2)? And in a plastic surgeon’s eyes, daresay, something a little like magic?
I remember coming across this astounding article in Harper’s Magazine as a medical student, about to embark on my journey to become a plastic surgeon. It captured a bit of the mystique of plastic surgery in its singular portrait of Dr. Joseph Rosen, visionary and professor of surgery at the Dartmouth School of Medicine. A phrase from that piece that has stuck with me pops up as he discusses a challenging series of reconstructive surgeries for a cancer patient and proceeds to riff into the broader future of plastic surgery:
"Where there's fat," Rosen says, "there are possibilities."
Although the media at the time hysterically latched onto some of Rosen’s more fantastical ideas - wings and fins and tails for human beauty/function - some of the concepts he proposed (e.g. using buttocks for breast implants) have become reality.
So it has become apparent that where there is fat, there is tremendous possibility. Surgeons have experimented with the idea of fat transfer - taking fat from one area of the body and “transplanting” it to another area of the same body - as early as 1893, when a German surgeon reported success in improving the appearance of scars with fat. Plastic surgeons continued to explore the possibilities of fat transfer over the next several decades, especially as the advent of liposuction in the 1980s allowed for a simpler way to harvest fat. However, frustration with reproducibility of results subsequently limited widespread acceptance of the fat grafting as a procedure. In the 1990s, Dr. Sydney Coleman became our contemporary guru of fat transfer (3) - removing fat from places of excess through liposuction, gently processing the extra fat, and carefully placing it into areas it was needed. In the last few years there has been an explosion of interest in and application of fat transfer as refinements to technique have improved surgeons’ ability to have consistent, predictable outcomes (4).
Much of the renewed interest is also predicated upon the realization that human fat cells are a vast resource of adult stem cells - cells that not only have a mystical ability to repair themselves but can also morph into other types of cells - in the lab. This function of “just fat” may help explain why scientists and surgeons are observing incredible transformations of skin and other tissues with the injection of fat (and their accompanying adipose-derived stem/stromal cells). Fat grafting can improve the appearance of skin that has been irradiated(5), soften severe scars from burns or trauma (6), and even achieve that holy grail of medicine and science: anti-aging (7).
Stay tuned to learn more about the transformative possibilities that fat can create (a truly natural breast enhancement, a more shapely booty), in the next installment of this short series: Fat is magic.
1. Eknoyan G. A history of obesity, or how what was good became ugly and then bad. Advances in Chronic Kidney Disease. October 2006 13(4): 421–427.
2. Frayn KN et al. Integrative physiology of human adipose tissue. International Journal of Obesity. (2003) 27, 875–888.
3. Coleman S. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 118 (Suppl.): 108S, 2006.
4. Zielins ER et al. Autologous fat grafting: the science behind the surgery. Aesthetic Surg J. 2016 Apr; 36(4): 488–496.
5. Garza RM et al. Studies in fat grafting: part III. Fat grafting irradiated tissue: improved skin quality and decreased fat graft retention. Plast Reconstr Surg. 2014 Aug; 134(2): 249–257.
6. Jaspers MEH et al. Effectiveness of autologous fat grafting in adherent scars: results obtained by a comprehensive scar evaluation protocol. Plast Reconstr Surg. 2017 Jan; 139(1): 212–219.
7. Charles-de-Sá L et al. Antiaging treatment of the facial skin by fat graft and adipose-derived stem cells. Plast Reconstr Surg. 2015 Apr; 135(4): 999–1009.
By Dr. Angeline Lim of Duet Plastic Surgery - Expert Plastic Surgeons
Angeline Lim, M.D. and Jennifer Weintraub, M.D. are the board-certified plastic surgeons of Duet Plastic Surgery, a boutique-style practice in Palo Alto, California. When not guiding her patients through their health and beauty journeys in the operating room, Dr. Lim enjoys embarking on her own journeys through travel and running, and lately, finding creative ways to combine these two obsessions.