Why Most Fat Transfers Fail: The Truth About Preparation vs. Surgery | Dr. Rob's SHARP Method

Welcome to the Circle. It's Tuesday night, and because you are in this room— hey, Leah— not in the public feed, not waiting or watching on YouTube, not reading a blog post, we can have a completely different kind of conversation. You can say howdy, partner, here. Um, I want you to understand what that means. Uh, what I'm going to share tonight is not the version I give at conferences. It's not the version I give on Instagram, which I get censored on a lot. It is the version I give the people that have gained our trust by joining the circle, and they want to use this information intelligently. And that's you, the members of the circle. So welcome everybody once again. Um, I, I really appreciate you coming on tonight. We're opening the fat transfer preparation series, and I have a lot of things to add about fat transfers. And before I get into the science, I need to tell you something about, uh, plastic surgery as an industry that most surgeons will never say out loud because it It makes them uncomfortable. It may make them feel bad or inadequate. Most surgeons, most plastic surgeons, can treat fat transfer like, like a construction project. They think, I have a material in location A and I need to move it to location B. They treat your fat like spackle. They harvest it, they spin it, they inject it, and then they cross their fingers and hope that it works. And when it doesn't work, when the fat dies or calcifies or you lose a large percentage of the volume in the first 3 to 6 months, they blame your body. They say, well, fat transfer is unpredictable. And so I don't think that should be the case. I don't think it is unpredictable. I think there's a lot of steps we can take collectively, patients and providers, to make it more predictable. It is, in my hands, highly predictable if you understand the physiology and if you prepare correctly. I think that's the case. Tonight I'm going to show you exactly why the standard model is broken. I'm going to give you the view inside of how I think about it, how I approach it, and I'm going to explain why the preparation you do before every time we go to the OR is what matters. It matters infinitely more every time I think about it. I think more and more we have to concentrate on the front end and not respond to problems on the back end. So why most surgeons are getting fat transfer candidacy wrong. They're worried about BMI mostly and kind of doing a cursory exam to figure that out. So let's start with candidacy because this is where the entire industry to me gets it wrong. So I'm just going to pause here for a moment and acknowledge I do a lot of low body weight, a lot of low BMI fat transfers, but we work really, really hard to make it a more predictable outcome. If you walk into a standard plastic surgery clinic and say, I'm interested in fat transfer, I, I think most of the time you get the, like I said, cursory evaluation. The surgeon will pinch areas of your thighs and abdomen and, and your love handle area and say, yep, you have enough fat, let's, let's get it done, let's book it. That's it. Uh, It may be like a cursory medical history, maybe a small, if any, labs, and that's it. And then you're scheduled, um, probably no preparation otherwise. And having fat does not make you a candidate for fat transfer. Having healthy, metabolically active, non-inflamed fat makes you a much more attractive candidate. The distinction is everything. And all of my patients who come have problems of varying degrees of inflammation, like we all do, and most Almost no one is like taking that into consideration. And fat is not just a nerd padding we carry around like a big sweater. Fat is an endocrine organ. It stores toxins, it responds to hormones, it is highly vascularized, it communicates with your immune system. If you are dealing with systemic inflammation, you definitely have underlying toxicity, things like mold exposure, autoimmune activity, gut dysbiosis, or chronic oxidative stress, then your fat's gonna be inflamed as well. It is gonna be metabolically compromised. Now think of that and it makes you, I think, understand a little bit by— I wrote the book, "The Sharp Method," and why I'm so interested in the front end, the preparation rather than the back end and responding to a problem. I have this incredible team that we've assimilated Chelsea, Gina, Melinda to help people up front. We have our nurse practitioner Violet. We have all of my staff in the office who are super helpful. The only way you can't get help from us is not try, honestly. So now if you take someone, think, who's medically inflamed— I'm sorry, who is chronically inflamed, metabolically compromised, and you move the fat from one place to another, whether it's your uh, breast, face, butt. What do you think happens? Well, a portion of it will fail because your body's not ready to transfer it. Your body's not ready to accept it. It doesn't really integrate, and that becomes the issue. And you end up with hardness, maybe calcification, maybe cyst formation, all these things. And it's not what you're looking for, which is soft, nice result. So who is a good candidate? And a good candidate is someone whose systemic inflammation is under control, somebody who has good cellular health, um, and someone who understands that we are not moving tissue. We are— we're going to transplant something and we want to heal with its friends in the right space, like the fatty friends. And, um, I think in the history of my practice, I had one patient come who had literally nothing on their TOX test, and she had made the determination about 15 years ago that she was just gonna live a lower toxic, lower toxin lifestyle and have as many things taken out of the home, really pay attention to food, pay attention to products that you utilize on your skin, 'cause that's how we get a lot of exposures. So going back to her, who was already a really good candidate from a metabolic standpoint, if you're not metabolically optimized, you're not gonna be a candidate yet. That word yet is because that's the whole nature of the Sharp Method is to help prepare people 'cause that's exactly what the system is designed to do and designed to help with and rectify. So what fat transfer actually is, and understand why preparation is not really something you wanna negotiate about, you have to understand what we're actually doing at the physiologic level. When we perform a fat transfer, we are executing basically a, a graft that is transplant— that transplant that has to heal. When I remove a fat cell from your flank and I am, um, removing it from its, its native blood supply and taking it to a new blood supply, that cell is now on a clock. You know, it has no oxygen, no nutrients. It's surviving on borrowed time. When we put it back in the correct space, in the correct amount, and this timing we're talking about, that will give it its best opportunity to heal, whether it's in your face, breast, or buttock. It does not simply, um, you know, transfer and then plug into a wall. There's no outlet inside your body that's going to manage that. It has to survive in that environment that we place it, that has less oxygen, that through a process of Initially, imbibition, which means basically like, think of like you're in the goo and you're absorbing the nutrition from the goo basically. And eventually as the process of revascularization happens over the next many, many days and weeks, the cells survive because of the nutrition it can get around it, and then permanently it can take hold through the process of angiogenesis, which is a new growth of blood vessels around it. And this has been studied and known for a long period of time. So obviously, if you have more chronic inflammation, you want to work hard to get it down because that makes it easier for the process that we're talking about, angiogenesis, to take place. If your immune system is chronically overstimulated, it's going to be busy managing that fat and that inflammation and not efficiently build a new blood supply for the new fat that we transfer. So it could pass away, it could calcify. But if your body is— like we mentioned previously about the patient, and for anybody who wants to listen to the show I did with her, her name's Alexi Panos, wonderful patient of ours— but if your body's primed, if your circulation is good, if you're optimized, if your oxidative stress or cellular stress is low, if your energy production at the cellular level is good, if enhancing your lymphatic drainage efficiently, those new blood vessels can grow more rapidly, it can be more efficient. Now, you all know I have all these little cheats I do in the office. I have the Human Regenerator, I have the Flowpresso combined with Nano V, and I did the Flowpresso and Nano V before I got on this podcast, uh, tonight with this live stream. And, you know, the hyperbaric chamber really helps low oxygen environment, so I leverage that always combined with red light like we have in the office. Doing all those things helps. To what degree each modality helps is debatable. I think the, the priority always is sleep hygiene, then proper nutrition, always, and then lowering the cortisol state, quickly resetting the circadian rhythm. And then when I think of things that are adjuncts that I want more and more of is more oxygen at higher oxygen tension. And that's why we use hyperbaric, because it helps with wound healing. It's been known for a long period of time. It's not a hypothesis. This is established vascular biology. We, you know, have a biology degree and a medical degree, so, um, I'm not, you know, quote unquote— I guess I'm a human biologist like some famous people claim to be. We're not doing something exotic. We're basically aligning the internal environment with the, you know, systemic, if you will. So we want all the biologic requirements for successful engraftment, and you cannot do that, uh, the morning of surgery. You can't come up with that idea pre-op, uh, the day before, the morning of, and say, ah, we're going to do this now. So that's why spending more time in the programming helps. It creates a better environment, and it helps, I think, My biggest example of this is I had a teacher from New York who only could have time to travel in the summer when school's out. And so we met her in the fall of one year and she had surgery in the summer of the next, but she ran our program, the Short Method, the entire time, did her testing, did her supplementation, really modified her diet, improved her sleep hygiene, and she did amazing. It was great. So those are the types of of stories you can have. And those are the things I want everybody to experience. So why preparation for me is most important is really the whole reason I sat down and wrote the book, The SHARP Method. The SHARP Method, you know, we'll not go through the long name, but we'll just say SHARP is a system that my team and I have worked really hard over the last several years to continue to refine and work with patients on who are really trying to level up prior to surgery and after surgery. We like to get it started as soon as possible because I know people are anxious to get this done. I know they want the best possible results, whether it's a, a fat transfer for augmentation or explant, whether without a lift for, uh, BII, or just they don't want implants anymore, or they feel a lot of pain or issues. And then I do simultaneous fat transfers, so those require the most workup. So most surgeons tell you to stop taking aspirin 2 weeks before surgery and show up, you know, nothing to eat or drink after midnight the night before. That's pretty standard. That's how obviously we're all quote unquote educated. But I think the advantage, the difference that we have, is we know that there's a better method, and you know, it's the Sharp method. So that is a recipe, uh, if you take the one I mentioned, that's pretty average, right? That's not— that's not doing anything to help, uh, in the long run. So in my clinic, the procedure is, um, really the, the midpoint of the journey, not the beginning. The real work happens in the weeks before you ever arrive to Austin and head into the operating room, which will soon be the new surgery center. And, uh, because once you're asleep on my operating room tables, I can only control, like, surgically what we're doing. I can't, you know, make your cellular health better. I can't optimize mitochondria. I cannot fix your gut microbiome in the middle of a procedure. I cannot reduce your systemic inflammation while you're, uh, prepped and draped. So that work has to be done before you arrive, and it is your work to do. I really want patients to take ownership and be accountable for this because we know it works. You don't have to sit and question me on a call or the team on a call. Like, we've done this thousands of times. Our preoperative protocols are designed to accomplish like these goals, right? We want to lower inflammation. Want to really use what we consider to be targeted supplementation for your genetic pathways and level those up. We want really consistent protocols for this and get your testing done. Um, we want to lower the burden of inflammation. We want to really optimize the environment, especially if we're going to do a fat transfer like I mentioned. Um, we use hyperbaric oxygen like I mentioned, red light therapy like I mentioned. Um, we have very specific protocols, um, for post-op, uh, activities. I encourage everybody just to walk initially. That's a tremendous exercise. Get out, get morning light, reset your circadian rhythm, lower cortisol levels. Super important. If you build that tiny set of habits, that infrastructure will grow, grow, and that will support the graft survival. Um, we also want to support, um, and continue to support detoxification, energy production. Of course, we want to continue to work on the gut. I can't emphasize this enough. The gut is so difficult to get just on track in every single patient. I had a patient recently, she may be on here, Sherilyn had tough, tough, tough gut trouble. She's been on a couple of times back and forth and on the live streams, but she's doing her work and putting in the effort and she's gonna get better. So we're going to continue to support the gut, support the mitochondria. Um, and once again, we're not just getting someone prepared for surgery, but you're really trying to engineer it so that the environment— if I'm placing fat into it, whether without an explant— is the best it can be. That will give you more and more, uh, opportunity to heal. And so yes, I, you know, I performed several thousand explant procedures. I've seen what, you know, toxic or inflamed tissues look like, and we really want people to be as healthy as possible. I just operated on a patient today earlier who had explant and waited to do a fat transfer because they just wanted more time to feel better and heal, and then we did the fat transfer today. She's had a very complicated case in terms of her chest wall, but she already, you know, is going to have a much, much better result. And then I bet you her difference in recovery speed is going to be better. I bet you the graft retention is better, and I bet you her overall results are going to be better. I should have her come on, um, the show. Maybe we'll have her hop on. Um, when you prepare properly you're not hoping for a good result. You're just basically setting the foundation up to have one regardless. So what skipping preparation actually does cost you significantly? And I want to be direct because I think it needs to be plain. If, if you skip prep and just have an operation, then you really— there's not anything that from a surgeon that is, is that controllable. So you kind of in that setting get what you get: the potential fat necrosis, the calcifications, um, any additional problems with the results afterwards. Um, certainly if you're not doing well, you can definitely cause yourself more of a reaction after surgery. And I think it's going to be hard to assess, like, what to expect as an outcome. And I don't want to do this in a way that is, you know, worrying patients. We just want to prepare patients so they have best possible outcomes. So education is key here. Um, As for the other side of it, when you are in alignment with your physiology, I think the surgical goals are much easier. The results become very natural and durable and integrate fully. I've had patients recently, you know, come back a year later, have had fat transfer, and they're super happy with the results. And I think it can lead to a lot, a lot more satisfaction. And so moving fat from one place to another is not the game. The game is preparation. The game is helping people get prepared so that they're feeling as, um, and not everybody's going to feel perfect obviously before surgery, especially with chronic inflammation. We're trying to really improve that. So I think this is the difference between technically just trying to execute an operation and then the way we approach it. We're trying to be very, very strategic. I think many people tactically or technically, uh, obviously can move fat. I think our strategy is different. It's, it's preparation. Lots of preparation leads to a better operation. Now, inside the circle, obviously you have access to us and many of our protocols. We talk about them. If you have questions about detoxification, supplementation, how our frameworks work, any kind of adjunctive therapies, how we use them, Obviously, now's the time to start asking, and that will help you in your decision-making process. Now tonight was just about the foundation. It was about just kind of, you know, put broad strokes around how I think about the process. And so in part 2, we're gonna go obviously deeper, but I wanted you to understand and focus on preparation in this. And the quality of that preparation is what to me really determines the, the outcomes. I, I think that has been shown time and time again, and it makes sense. The, the best situations that I've been part of are ones where we've had really good preparation, patients extremely bought into what we're doing. They're really controlling the fluid quality food quality, air quality. They're being very good with their sleep hygiene. They're doing a good job with supplementation and remaining consistent. And these are what you would call just tiny, tiny changes that add up to a much larger outcome. So in part 2 of the series, we're going to get into the mechanics of the actual procedure and timelines for recovery and post-op protocols that, that we have after the OR. So tomorrow's session, we're going to start it at noon. Now it's going to be public. I'll make a live stream for everybody. We'll do the part 2 talk and then we'll hop into the circle and do a live Q&A just for y'all. So take what you've heard tonight, you know, obviously we can answer some questions now and, and see I want everybody once again, always just to get educated so they make better and better decisions. We want you to not be worried or concerned about a fat transfer if that's your goal of having one. We just wanna help you get there. And yeah, I look forward to seeing everybody at noon tomorrow. All right, so that's my talk for tonight. I'll take some questions. And I see we have Leah, Morgan, Christine, and Danielle. Thank you all for joining. Do we have anybody else? I know there's a delay, so I'll just hang out. Y'all have the floor. Yeah, Morgan, you can do a gentler plan with Cellcore. So, um, it really depends on the patients and where they're starting from. But yes, you can do that. What I, what I would say, and I can't speak for Chelsea, my lead practitioner, but she says it's really, really hard obviously to get aggressive when someone still has implants in place. All right, who's next? Is Lana on this call? Lana recently had surgery. And I want to make sure she's doing okay. So Christine, I would say uneven fat transfers for breasts are not super common. Um, the, the one I did today, the patient had a lot of chest wall asymmetry. And so think of like the chest, if you could have like a perfectly flat surface like my desk, then it would be easy to build upon. But when someone has any kind of indents or differences side to side, it's nice to have fat because fat is more easy to work with the contour. So I always try to remind everybody that for the first, um, 15 years of my career, I mostly did cancer reconstruction. So I would do about 100 to 150 fat transfers per year because I did that many breast reconstructions typically. And I got really effective at contouring problems with breast cancer reconstructions that typically happen after mastectomy. But that gave me a lot of experience in the transition and do more cosmetic fat transfers. So I don't really, in my practice, see problems with asymmetry. It's super rare. Um, if it happens, I worry about like somebody sleeping a particular way or wearing a maybe tight-fitting garment. Um, so we're super careful with that. Always like little loose-fitting camis. If you're going to sleep on your side, be super careful that you're not getting anything squashed or laying flat. Kind of like when they do the, the butt lifts, they, you know, make you sleep on your tummy for 3 months. So you're trying to be super careful and not smash your chest. Um, I hope that answers your question. Good. Um, so we had a question from Christine Morgan. Yeah, I've talked about that, Morgan. I think for resiliency, thinking about longevity, you want to maintain thigh strength. And so I'd always transition out of high-intensity workouts because they don't make a lot of sense for longevity. Also, they make absolutely no sense to maintain a fat transfer. The goal in fat transfer is to have your BMI stay stable. And then I would like people to think about increasing their BMI in healthy ways by building more muscle mass. And healthy fat is fine, but you have to train in a way that makes sense, that doesn't create a calorie deficit. So you want to train— so like resistance training, yoga is fine, Pilates is fine, walking is fine— and then not create a problem with your nutritional status so that you get out of balance. These are good questions, y'all are doing a great job. No, Christine, you just, whether you're a back or a side sleeper, you just have to position yourself so you're not pushing too hard on the breast. I think just like the buttock, like a buttock is weird 'cause on your backside and you gotta lay a certain way, right? You gotta lay on your tummy. Here, you know, we're mostly gonna have you, you know, supine, but then you can be a little bit on your side. And a lot of side sleepers, that helps. That's what I meant. Yeah, I wasn't trying to confuse you. I have people side sleep all the time because I want them to sleep. Y'all know I'm the sleep person. I want you to get great rest. That's super important. Yeah, it's a great question, Christine. So we commonly use the posterior inner thighs, outer thighs, flanks, and abdomen. Leah sent this to me on Instagram, so I'm going to look at this case. Oh, I wanted to ask y'all, would you like to have a case discussion? We can do that. I can put up pictures in a video. I mean, I've got several thousand of them. Um, yeah, I saw that. Um, that's in that group. Yeah. Oh man, I hate— like, so that's the problem with doing an anchor, especially on someone who maybe had a whole old anchor incision. So what Leah is, uh talking about is this post today on Facebook. And, uh, hold on, let me see. Let me put it up on my camera. That's the bottom of the breast. So that happens, um, unfortunately The anchor incision, and I talk about a lot at the triple point, um, think of like the T. Anytime you make 3 points, uh, where the incision is in 3 directions, basically the blood flow is the least at the triple point or the T point. And that's a problem, right? So I'm always super careful about these, and especially in revisions. I think, um, and I didn't comment on this, um, so is that— where is that lady at, Leah? Does she say— so what I would do for is hyperbaric oxygen therapy. That's how I would resolve that. Okay, I, I just responded to the comment you made to her, Leah, and I said I would use hyperbaric oxygen. Um, oh my God, somebody wrote this is completely normal. Oh my God, no, it's not actually. Everybody knows that's a concern and it's not completely normal. That's why, you know, you make decisions pre-op and you talk to patients about those potential problems and how to avoid them. So the reason I don't have that problem is I will rarely take apart a whole breast like that, especially in someone who's larger. That looks like a very, you know, large area. So disappointing. Yeah, I don't wanna post that I have a life, or I would say it this way, I'm reluctant to post in those things because I've had people attack me and I think somebody got wiped off of Facebook for using a fictitious profile to attack me and I reported it because all we try to do at my clinic, all I've ever wanted to do for patients is, give them the best opportunity, you know, to heal and recover. And I certainly have taken, um, a fair amount of grief for it. So yeah, Morgan and Danielle, the problem with what your request is, is you don't know what someone looks like who's got very little breast tissue pre-op with implants. So then it becomes, um, what do I have to do to resolve it? Now, on exam, I can feel very little breast tissue sometimes, so there's options, right? You can just do an explant and try to do a simultaneous fat transfer with the amount of volume that you can obtain. Um, and there are nuances to that. You can do it with or without a skin lift. There's different ones to do— a circle, you can do a vertical, you can do a horizontal and a circle. There's lots of ways to do it. Um, oh, Leah, you can invite her, that's fine. Totally fine. Whatever is fine. So I agree, it'd be nice to have those options to show and tell and help everybody better understand it. I kind of wish my kind of dream scenarios are super small implants because those are easy for me to take care of. Um, my other is if somebody has, uh, saline, then I sterilely deflate them, let everything calm down, then I can see how much, you know, tissue is there because the implant is just pressing everything out. And as soon as it deflates, it'll go down, you'll see everything. So that's helpful. Like, there's lots of tactics, but if you have big, big implants and small, small frame, that's the toughest situation always, for Absolutely. All great questions tonight. You guys are knocking it out of the park tonight. Awesome. Yeah, Christine, don't worry about it being under the muscle. I mean, gosh, if I, I feel like I get a whole like, I've got a 3-part capsulectomy somewhere, a series somewhere. I know I recorded it. And my previous, uh, podcast team was working on editing it, but I may just have to have a video editor, uh, do that. So Morgan, do you have saline or silicone? Silicone. Okay, so in that case, what I try to do is, um, obviously do a fat transfer. And so I'm always trying to, certainly in smaller patients, let them know that more than one fat transfer is absolutely fine. And it's really up to the patient, right? So I can only control so many things at one time. So think of the things I'm trying to do. I'm trying to take out an implant with all of its surrounding scar tissue. All right, so we'll use the prop here I have on my desk. I want to take this out with all the scar tissue. Then I want to get the muscle back to cover the rib cage. As much as possible, I want to cover the rib cage and make it quote-unquote normal again from an anatomy standpoint. And then if we've got a lot of stretched out skin, do we need to control the skin with a circle lift, a vertical lift, or horizontal lift, or some combination? And that depends on the amount of breast tissue. So it's easier to do when you have more breast tissue, obviously. If we're just talking about stretched out skin I've done tailored skin lifts just to help reduce the size, and then if I can add volume back in the fatty layer. That's a good question, Paula. I think it's a fair question. And the, the short answer is it depends, right? So if you've gained and lost weight or you've breastfed the skin stretches and doesn't always recoil. As we get older, it doesn't want to snap back as easily, so that gives me a little opportunity to take care of it. It's easier. I do need to have like a whole fat transfer portfolio. Nobody really wants to give us up a bunch of pictures though. Um, it's just one of those things where I get it, and I, I I don't wanna have anybody worried about their photos, so, in any event. All right, y'all. Well, it's almost 8. I'm gonna shut everything down. Give me your last questions, comments, concerns, complaints. Lots of great comments tonight, thank y'all. All right, I will see y'all tomorrow at noon, and then 7:00 PM, on Thursday, okay? All right, good night, y'all, bye-bye.