Can facial fat grafting make your skin strong again? [Ricardo Rodriguez, MD, Baltimore]

Eva Sheie (00:00):
My guest today is Ricardo Rodriguez, and I understand that you're both a plastic surgeon, a professional wrestler, and a professional soccer player. Is that correct?

Dr. Rodriguez (00:11):
No. No, only a plastic surgeon.

Eva Sheie (00:15):
Alright.

Dr. Rodriguez (00:15):
I did wrestle in high school.

Eva Sheie (00:17):
Oh, you did? Okay. Little known fact about you already.

Dr. Rodriguez (00:22):
Right around 2008, right after I built this surgery center, I stumbled on the fat grafting thing. And so immediately we started focusing on how to get the best fat graft. And again, this is another one of these great suggestions from my wife. She says, it's process engineering because of course she's an engineer. And so I started applying an approach of process engineering to the fat graft. So a lot of people, when they get a fat graft, they'll just get a syringe or a vacuum and they'll just suck it out and then they'll re-inject it. And so we started looking at every step in the fat graft from at what pressure, I took it out, what kind of diameter cannula I took it out of, what size of the hole was it, and then what the steps in refining the fat? Do you filter it? Do you wash it?

Dr. Rodriguez (01:19):
And started looking at each one of those critically. And then finally, how do you inject it? What particle size you inject it? And so each one of those steps has taken me on a little journey, like learning new things, learning. And the final injection phase, which is what I have been focusing on lately, has led me to do things literally orthogonal. If you don't, for orthogonal means, it means perpendicular angle than everybody else, which is I now inject right underneath the dermis. I inject right on the most superficial aspect that I can. And there's a couple of reasons for that. One of them has to do with the way tissues, the soft tissues are organized in the body. And there was this wonderful French surgeon that took an endoscope, went underneath his skin and filmed it, and he discovered that the skin, the muscles and the bones and the blood vessels, they all have this interconnecting mesh of connecting tissue that acts as what they call a tensegrity system.

Dr. Rodriguez (02:41):
Everything is held by tension and fixed elements, which are your bones, and then the movable sliding elements and all that is everything else. And you got to understand really where the things hang from and how tension to apply there so that now when I'm injecting fat or when I'm rejuvenating a face, rather than thinking what am I going to cut and stretch, I now understand that really cutting and stretching are the last things you should do. The first things you have to do is restore all the pillars and restore all the basic structure before you go on to the last superficial edge. And even then, at the superficial edge, what I've sort of been reading about lately is this layer of tissue right underneath the dermis. It's called a dermal white adipose tissue, and it's a different type of fat because it derives from the skin itself and not from the deeper tissue.

Dr. Rodriguez (03:49):
So it comes from a different place and it's much more metabolically active. It's much more has a much higher content of stem cells in it than regular fat. And that layer that's right underneath the skin, as it turns out, is also connected different with those little ligaments. And that was what this guy Guimberteau, the one that made the films underneath the skin. He worked out that layer that had a lot of tighter little ligaments. So the reason the skin sags is not because it got stretched, and it is not because it hangs more, is that it went from being like a thick layer, a thick piece of suede to being a very, very, very thin piece of suede. And I'm talking about suede because lately I've been interested in suede. But it's like comparing horse hide suede, which is very thick and firm and heavy to lamb suede, which is literally like folding paper.

Dr. Rodriguez (05:00):
You could use it like a shirt. And so that's what happens to the skin of the face. So when I'm rebuilding and rejuvenating a face with fat grafting, I focus more on what are the pillars that I want to strengthen and where do I want to make that layer of suede thicker? Because there are, for example, older ladies who will have more fat content in their face, but yet the skin will look very crinkly, which is they need above all to thicken that superficial layer. So it is possible even on a heavier set woman for me to be fat grafting right underneath the skin and yet liposuctioning under in the deeper layers, which is a concept that a lot of people at the national meetings will call me crazy for doing. But it works out in clinical practice that it's that top layer of skin that works well.

Dr. Rodriguez (06:03):
So the fat grafting thing has been one of the things that leads you in a lot of different directions. So for example, I'll be doing fat grafting for reconstruction is great for radiated breasts. It actually heals the tissue. There's nothing in medicine that heals radiated tissue except for fat grafting. But again, that's a byproduct of that, looking at the fat graft in a process engineering way, how does it work? Where does it work? Et cetera, et cetera. So that's my other major thing, the fat grafting. I use it a lot. I think it's great for facial rejuvenation. It's actually probably the first thing a woman needs as she's sliding, oh yeah, I forgot to mention one thing is that it's very estrogen sensitive. That layer the DWIT right underneath the skin. So as a woman starts going into menopause and the estrogen levels start becoming irregular or deteriorating that layer, that's when it begins folding and thinning out.

Dr. Rodriguez (07:19):
So usually when younger women come to me, the first thing that I'll recommend to them is injecting fat under the eyes and into the cheekbones because mostly where they need that. And that's a permanent solution that doesn't work like a filler because a filler can only give you volume and it's a little volume, not that much. Whereas a fat graft gives you all the volume you need, plus it changes the character of your skin. Your skin will actually look more like it did when it was younger, and it'll function more like when it was younger because the sebaceous glands on it will start working again and pouring out more oil into the skin. So it makes the skin a little bit more shinier. That gives it that, the youthful glow really is a reflection of light on the skin, and that's created by the skin oil. So that fat graft underneath the eyes is another great thing that I've stumbled upon. That's a small procedure and it makes a ton of difference.

Eva Sheie (08:22):
If we're listening today, I want to find out more about you. Your website is cosmeticsurg.net. Is there an Instagram? Is there somewhere else you can point us?

Dr. Rodriguez (08:32):
There's an Instagram cosmeticsurg. I'm not that active on it, I used to be. I'm not that active now. It's the website. But the best thing is experiencing the whole office from the office staff to me and all that.

Eva Sheie (08:46):
On this podcast, we bring you directly to the doctors who are where before meets after. Links to our guest's website and contact are in your show notes. Follow us on Instagram @wherebeforemeetsafter. If you're a board certified plastic surgeon and would like to be a guest or a sponsor of the show, go to wherebeforemeetsafter.com for more information. Where Before Meets After is a production of The Axis, the podcast Agency for Aesthetics. theaxis.io.