Category: procedure

WHAT IS FOREHEAD SKIN LUMP?

• Forehead skin lump is a broad term that refers to any abnormal growth or bump that appears on the forehead area. Forehead skin lumps are fairly common. They can cause substantial social embarrassment and also physical discomfort with certain headgear.
• The nature of these skin lumps can be:
  • Lipoma
  • Osteoma

What is a Lipoma?

• Benign (non-cancerous) abnormal collection of fatty tissue growth within a thin fibrous capsule.
• Can be found in almost any part of the body.
• Complete removal is achieved when the lipoma is removed with the capsule.
• Usually soft, but over the forehead, lipoma tends to be deep and may feel firm.
• Usually does not resolve by itself. Treatment is by surgical removal.

 What is an Osteoma?

• Benign (non-cancerous) bony growth. Usually 1-2 cm in diameter. Feels bony hard.
• Can be found in many parts of the body.
• May be painful in some cases.
• Usually does not resolve by itself. Treatment is by surgical removal.

OPEN (TRADITIONAL) VS SCARLESS (ENDOSCOPIC) FOREHEAD SKIN LUMP REMOVAL

	Open (Traditional)	Scarless (Endoscopic)
Skin cut	Open Technique of forehead lump removal Direct skin cut over the skin lump	Endoscopic (Scarless) Forehead Lump Removal – no visible scar Two skin cuts hidden behind the hairline in the scalp.
Scar visibility	The scar may be pigmented in a dark-skinned individual.	The scar may blend with forehead wrinkles in older patients but is more visible in younger patients. Scar is hidden by the hair.
Technique	Direct cut and removal of the skin lump.	Special equipment is needed. A video endoscopic guides another cutting instrument to remove the skin lump remotely.
Patient Satisfaction	Average	Usually much better.

SUITABLE CANDIDATES FOR LIPOMA REMOVAL SURGERY

• Most patients are suitable for the technique except for those with a receding hairline.

DESCRIPTION OF SKIN LUMP REMOVAL SURGERY PROCEDURE

Endoscopic (Scarless) Forehead Lump Removal

• Tumescent fluid is injected into the forehead around the skin lump to separate the tissue layers. 
• Two small skin cuts (incisions) are made behind the hairline on the scalp. 
• A video scope is inserted to visualise the skin lump. 
• Another instrument is inserted via the second scalp incision to remove the skin lump under visualisation of the video scope. 
• Additional instruments may be needed to chisel or burr down a bony osteoma. 
• The skin lump removal surgery is usually completed within an hour. 
• Secure forehead bandaging is applied.

ANAESTHESIA

• Intravenous sedation or general anaesthesia.

POST SKIN LUMP REMOVAL SURGERY CARE

• Patients may go home the same day or stay overnight in the hospital.
• Forehead bandaging is to be worn for at least 3 days to reduce the risk of bruising over the forehead and around the eyes.
• Swelling and bruising usually resolves within about 2 weeks.
• Avoid exertion and rest at a 30 degree incline for optimal recovery.
• Apply antibiotic ointment to the scalp wound regularly 3-5 times a day.
• Pain is usually minimal and well controlled by oral medications.

RISK AND COMPLICATION OF SKIN LUMP REMOVAL SURGERY

• Bleeding and forehead haematoma (blood clot accumulation) (Risk minimised by adequate forehead bandaging)
• Small area of scalp numbness may take a few months to resolve.

FREQUENTLY ASKED QUESTION

Why do patients still choose scarless (endoscopic) forehead lump removal despite the increased cost?

Most patients would choose to avoid a scar over an otherwise flawless forehead whenever possible. The recovery time is comparable with the open technique, but the patient satisfaction level is much higher for the scarless technique. The patients who choose the open technique do so usually because of cost consideration or because they were not told of the scarless (endoscopic) option.

When is lipoma surgery recommended?

Lipoma surgery may be recommended if the lipoma or skin lumps are causing discomfort and emotional distress, or are located in a position that interferes with daily activities.

Does lipoma go away on its own?

Lipomas rarely go away on their own. Lipomas are Benign (non-cancerous) fat cells that form a lump under the skin. While they are usually harmless, they can sometimes cause discomfort. The most effective way to remove a lipoma is through surgical excision.

After the consultation, Dr Ng will assess if the forehead lump is a lipoma (fat) or an osteoma (bone). He will recommend the best surgical option for forehead lump removal – endoscopic scarless forehead lump removal or direct open method. The best surgical method remains scarless forehead lump removal which would also be recommended by top plastic surgeons in Korea or around the world.

WHAT IS FAT GRAFTING?

• The ageing process is characterised by:
  • Loss of elastic components of the skin e.g. collagen and elastin fibres
  • Loss of volume due to loss of fat and dermis thickness.
  • This result in a saggy and sunken appearance, which is more indicative of ageing than wrinkles alone.

• Anti-ageing treatment aims to:
  • Improve skin elasticity e.g. Laser resurfacing, Profractional laser, infra-red therapy (Sciton SkinTyte) radiofrequency and high powered focused ultrasound.
  • Restore lost volume e.g. hyaluronic acid filler injection and fat grafting or injection.

• Terminology:
  • Fat injections, fat grafting and fat transfer surgery are essentially synonymous.

Fat Grafting Vs Filler Injection

Sites of Fat Grafting Surgery include

• Face
• Breast
• Scar
• Wounds with delayed healing
  • Studies have shown improved wound healing after fat injection to non-healing wounds due to the small amount of adipose (fat) derived stem cells present.

Fat Grafting to Face:

• For anti-ageing purpose: Temporal area, upper and lower eyelid, nasolabial fold and Marionette line
• For contour deficiency and to improve the 3-dimensional profile of the face: e.g. forehead and chin
• Scarring:
  • There are usually a few needle puncture marks which heal without scarring.

Fat Grafting to Breast:

• Purpose:
  • Alternative to breast augmentation using breast implant:
  • Improve the shape of sagging breast
  • Restore contour irregularity after previous breast surgery.
• Important technical points:
  • It is absolutely important to inject the fats only into the subcutaneous layer (skin layer) of the breast and NOT into the actual breast parenchyma (the breast tissue that is capable of milk production).
  • It is also possible to inject the fats just above the pectoralis major muscle (chest muscle). However this is difficult to achieve accurately and may risk puncturing the lungs.
• Mammography after fat grafting to breast:
  • Not all the fat injected will survive. Most non-surviving fats cells are completely absorbed by the body. Some of these may leave behind minute amount of calcium deposits. This pattern of calcium deposition is called “macro-calcification”. This is different from the “micro-calcification” pattern shown on mammogram characteristic of breast cancer.
  • In the past radiologist have difficulty differentiating between the two patterns of calcification. Nowadays, most of them are able to tell them apart.
• Volume retention:
  • The potential volume transferrable depends on how much fat reserve a patient has for harvesting. Therefore it is not possible to transform from “A” to “C” cup if the patient has hardly any fat reserve.
  • In general it is possible to increase half to one cup size in each fat grafting session.
• Scarring:
  • There are usually one to two (less than 5 mm) puncture marks which heal without noticeable scarring.

Fat Grafting to Scar:

• Purpose:
  • Fill up volume deficit for sunken (atrophic) scar
  • Improve the skin texture of scar

SUITABLE CANDIDATES FOR FAT TRANSFER AND FAT GRAFTING SURGERY

• Most people have sufficient fat reserves for the grafting procedure.

DESCRIPTION OF FAT TRANSFER AND FAT GRAFTING PROCEDURE

PROCESS OF FAT GRAFTING (COLEMAN TECHNIQUE)

• Modern day fat grafting procedures are largely modelled after the technique of structural fat grafting pioneered by Dr Sydney Coleman.

Fat harvesting from via a small puncture

Fat Harvesting:

• The donor sites are usually the abdomen, thighs or buttocks.
• Fat is harvested using a 10 ml syringe via a small cut (less than 5 mm). This process is manual and it is very important to be gentle to minimise damage to the fat cells.
• The fat obtained from an actual liposuction procedure is not of the best quality. This is because the liposuction process uses a vibrating mechanical device which induces mechanical trauma to the fat cells.

Centrifugation to separate fats harvested into three layers

Purifying fat by removal of unnecessary component before grafting

Fat Processing:

• The harvested fat is then centrifuged to separate it into 3 layers: (1) top layer of oil from broken fat cells, (2) middle layer of usable fat cells, and (3) bottom layer of blood and water.
• The top and bottom layers are discarded. The middle layer is used for injection.
• The middle layer of fat cells is transferred carefully into 1 ml syringes for injection.
• There are other systems available for fat processing. However, some may risk contamination of the fat.

Fat injection in small parcels in layers to ensure maximal survival

Fat Injections:

• • The fat is injected in small parcels (aliquots) in multiple layers to ensure even distribution and to allow maximal surface area for the fats cells to absorb blood and oxygen from the surrounding tissue to improve survival.
  • It is best to use 1 ml syringes which allow accurate control of this injection process.
  • Therefore, injecting 100 ml would require the use of many of these syringes.

FAT SURVIVAL AFTER FAT GRAFTING

With proper techniques by an experienced fat transfer plastic surgeon in Singapore, at least 60-70% of the injected fat cells would survive. These would yield permanent results.

The following are best practices to improve fat survival:

• Careful aspiration of fat by hand using low suction power.
• Centrifugation to separate the fat cells from the unwanted fluid
• Careful injection in small parcels in multiple layers to ensure maximal fat cell survival.
• Avoid over injection which would increase tissue pressure and reduce blood flow and hence fat cell survival.

PROCEDURES DONE TOGETHER WITH FAT GRAFTING

Fat grafting can be done in association with the following procedures:

• Facelift 
• Upper eyelid surgery 
• Eyebag removal 
• Breast Augmentation 
• Scar revision 
• A patient undergoing liposuction of the abdomen and thighs may transfer the unwanted fat to the breasts
• A Mummy makeover which consists of a tummy tuck and breast augmentation. Fat transfer to the breast can be considered instead of breast implant. 
• Fat transfer to face and breast concurrently.

ANAESTHESIA

• It can be done under local anaesthesia, a combination of local anaesthesia and sedation or general anaesthesia, depending on the volume to be transferred.

POST OPERATIVE CARE

• Day surgery procedure; home on the same day.
• Mild discomfort and ache over fat donor site – relieved by painkiller.
• Swelling and bruising are usually resolved within two weeks of recuperation.
• Avoid exertion and when resting, raised the affected body part upright to 30 degrees for optimal recovery.
• Avoid pressure over the fat grafted area to ensure optimal survival.

RISK AND COMPLICATION OF FAT TRANSFER SURGERY

• Bruising and swelling are within expectation and are usually resolved within two weeks.
• Uneven fat absorption, and asymmetry
• Macrocalcification e.g. in the breast

COST OF FAT GRAFTING

• Fat grafting is usually done for cosmetic reasons and therefore not insurance claimable.
• The exception would be when this is done as part of a reconstructive surgery to restore contour irregularity.

FREQUENTLY ASKED QUESTIONS

Why do I hear more about filler injection than Fat grafting or injection?

The majority of patient requests are for small volume injections. This is achieved by hyaluronic acid filler which can be administered by plastic surgeons, dermatologists and aesthetic physicians.

A minority of patients are aware of the potential of using fat grafting for rejuvenation and improvement of the contour of their whole face. A limited number of plastic surgeons perfrom fat grafting compared to doctors administering fillers.

When should I choose filler injection?

Filler is suitable when you need only a small volume replacement e.g. nasolabial fold (which typically requires 1-2 ml of filler). It is a quick and convenient treatment.

When should I consider fat grafting?

Fat grafting is more cost effective when larger volume replacement is needed e.g. more the 5-6 ml of volume replacement or full face volume replacement. The result is permanent.

Who are the candidates who choose breast augmentation using fat grafting rather than breast implant?

The candidates who opt for fat grafting to the breast would insist on the most natural result, without the risk of implant capsular contracture and implant rupture. They are willing to undergo multiple fat grafting sessions to achieve the desired volume.

Why do some people complain of complete fat loss after fat grafting?

There is almost always some fat retention after fat grafting. However poor fat survival rate can occur if the best practices for fat grafting, as discussed above, are not followed. Also, there is a substantial amount of swelling after fat grafting. When this swelling resolves over weeks to months gradually, some patients have a false impression that all the volume has been lost.

As one of the best fat grafting surgeons in Singapore, Dr. Ng will customise the most suitable strategy for rejuvenation and volume filling for you, during the consultation. This could include fat grafting (transfer), face lift procedures and laser resurfacing and skin tightening. A combination of procedures to achieve a harmonious result is commonly recommended by top plastic surgeons in Singapore and around the world.