Boston Back Bay Plastic Surgery

With the increase in popularity of fat transfer to the buttocks in body contouring surgery, new patient subsets are emerging. The gender confirmation patient has specific characteristics that must be addressed to achieve the best outcomes. The authors performed an observational prospective study including 36 consecutive patients who underwent body feminization as a gender affirming operation using large-volume fat transplantation with or without gluteal implants. Thirty-six consecutive male-to-female transgender patients have undergone large-volume fat transplantation to the buttocks performed by the authors, between July of 2016 and January of 2019. In 12 of these 36 cases, large-volume fat grafting was supplemented by intramuscular placement of silicone implants. The mean waist-to-hip ratio before surgery was 1.11, and this improved to 0.81 after surgery (fat transfer-only group, 0.88; fat transfer plus implants group, 0.75). The transgender patient is a unique patient requiring a specific set of surgeon's skills and intraoperative strategies to achieve good outcomes. Composite solutions with both implants and lipofilling lead to better outcomes in terms of waist-to-hip ratio in these patients. Therapeutic, IV.

What do table-top copiers, Polaroid cameras, and coronary stents have in common? They are all disruptive innovations. In the 1980s, the table-top copier replaced expensive offset devices and put printing in the hands of small business owners and homeowners. The Polaroid camera did the same for photography. In their classic Harvard Business Review article, “Will Disruptive Innovations Cure Health Care?” Christensen and Bohmer1 state that disruptive innovations work in an industry by “enabling a larger population of less-skilled people to do in a more convenient, less expensive setting things that historically could be performed only by expensive specialists.” This sounds familiar in cardiac surgery and in plastic surgery. Consider angioplasty. Busy cardiac surgeons initially “covered” cardiologists in the 1990s in the event a procedural complication occurred during angioplasty. Little did these surgeons know they were putting themselves out of business. Today, many of our cardiac surgeon colleagues are out of a job or have changed specialties because of the dramatic reduction in coronary bypass surgery that began in the mid 1990s. Just as angioplasty and stents changed the playing field for cardiac surgeons, fat grafting may be plastic surgery's “disruptive technology.” The good news about fat grafting is that it is relatively simple to perform. The bad news is exactly the same. Every week we receive e-mails to attend “stem cell” fat grafting courses taught by non–plastic surgeons. The Internet is flooded with increasing numbers of claims made by “creators” of natural breast augmentation2 and other fat grafting techniques3 aided by unproven technology. Because of a lack of procedural standards and no system of transsocietal governance, there is a wide gray area between evidence-based outcomes and questionable medicine. In this wide gray area we find our competition making the first move. The unproven and potentially dangerous promises of fat grafting do not adequately serve the true potential of the procedure, the reputation of plastic surgeons, or most of all, the safety of our patients. Although it is unlikely that fat grafting will replace breast implants for that population of patients seeking significant core tissue projection, it is a technique with which we must reckon in a thoughtful, proactive manner. Our strengths as plastic surgeons, including broad surgical skills and clinical judgment built on a foundation of structured training, can be leveraged to make this disruptive technology an asset to our specialty. We must take a leadership role in defining the best indications for fat grafting and rigorously evaluating safety and efficacy. Importantly, we must educate our patients (and the public at large) that fat grafting is but one surgical tool available to us, and that a qualified plastic surgeon is the best person to determine how this treatment compares with other surgical options for each individual case. As leaders in transplantation and in breast surgery, plastic surgeons must focus their positive energies on research and clinical collaboration to define the role of this emerging technology for our patients and for the viability of our specialty.