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Dr. Mark Berman on Stem Cells in Cosmetic Surgery

Dr Mark BermanThis episode of Inside Cosmetic Surgery covers a topic drowning in red tape, controversy, and mixed reviews: Stem Cells. What are stem cells? How are they being used in cosmetic surgery? Why are these tiny objects so highly prized?

Dr. Mark Berman, former president of the American Academy of Cosmetic Surgery (AACS), answers all these questions and lots more. He tells us why the stem cell facelift involves a lot more than just stem cells and what his organization, The California Stem Cell Treatment Center, is doing with their work on the topic.

Listen to this incredibly eye opening interview, or read through the transcript!

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Sharon Odom (SO): Hi everybody, this is Sharon Odom from and welcome to another episode of our continuing series Inside Cosmetic Surgery. Our special guest today is Dr. Mark Berman, a board certified cosmetic surgeon from Beverly Hills, California. Hi Dr. Berman, how are you?

Dr. Mark Berman (DMB): I’m good, Sharon. How are you?

SO: I’m great. Thank you. Well, thank you for joining us today to discuss the use of stem cell therapy in cosmetic surgery, which I had never heard of. First of all, what are stem cells? Because we usually think of them as related to babies and embryonic stem cells, that sort of thing, so what are they about?

DMB: Well, yeah, stem cells are the popular name for medicine advancement today. When you hear anything with stem cells and you go, “Oh, I’ve got to get that, I got to find out what it is.” And you are right. Everybody thinks stem cells in terms of embryos.

But actually, stem cells are any cells that can replicate or differentiate, in other words change into another body part, and so most people don’t realize it, but within our body, we have stem cells. When we were very young, we have them for all our organs and they tend to deplete with time.

But for example, your bone marrow produces stem cells and these cells can be used to help repair different parts of your body, particularly the structural parts like the bone and the muscle and the cartilage and the parts that hold us up, and it turns out your fat is loaded with stem cells as well.

Well, do you know what? It’s something that happens to be as our dumb luck. We’ve been doing liposuction for years and trying to figure out how to use that to reconstruct different parts of the body and improve facial aging, use it for breast augmentation and so on.

One of the problems is some people don’t have enough fat, so we investigated how can you grow fat. And indeed you can grow a lot of fat. You can take it outside of the body and then the laboratory grows a whole jar of it, but if you try to transplant it, it won’t work because it’s missing an important part, and that’s the stem cell.

So your fat is made up of two prominent cells, the adipocyte and the preadipocyte. The preadipocyte is actually a stem cell, so in fat, when fat cells die, the preadipocytes grow and replace the fat cells that are dying or injured. But if you take those preadipocytes outside of fat, then they are almost the same, and essentially the same as a bone marrow stem cell.

It’s what we call the mesenchymal stem cell. So these cells can actually turn into bone cartilage, muscle, nerve, blood vessels, fat and connective tissue, and if you really want to get fancy, there are ways of taking these cells and reverting back towards an embryonic stage.

When they can turn into all these mesenchymal stem cell or mesodermal products, we call them multipotent. The embryonic stem cell, which can turn into any part of the body is what we call pluripotent or totally potent. In other words, it can become any cell. But the fat stem cells can become all these kind of supportive tissues.

SO: I see, so the embryonic cells are the ones that turn into whole body parts and the adult stem cells, you actually find them and cultivate them somehow?

DMB: Well, there are different things you can do and different things you cannot do depending upon your position with the FDA. The fat stem cells or the stem cells derived from fat could actually be cultured and grown into multiple numbers. There is some limitation to that right now because the FDA has pretty strict guidelines on what you can do with somebody’s own cells.

For example, if you take somebody’s own cells, give it back to him during the same surgical setting with minimal manipulation and you are not promoting the therapy, then that is not regulated by the FDA and technically allowed.

The FDA has set up regulations, however, so that if you are manipulating the cells, growing them in culture or doing something to change the cells, then might require or does require FDA approval. So there are issues that are highly politically charged right now as to what the FDA’s boundaries are. Is that an FDA issue or is that the practice of medicine? And there is kind of a politically charged debate that’s actually going on right now with the FDA and a couple of companies around the country.

SO: How have stem cells been used in therapy so far?

DMB: Well, for a number of years, there have been a number of organizations around the country, different medical groups, have been harvesting bone marrow and then taking the cells from bone marrow and culturing them, if you will, to increase the numbers. Typically, a bone marrow can provide about 60,000 cells in a very good harvest and then over a period of several days you can grow that to maybe two or three million cells and this is considered a reasonable amount for a therapeutic effect.

So these groups of doctors rather, have been injecting joints, arthritic joints, and certain problem areas to effect some positive changes. In fact, there are data around the world where these cells have been used for all kinds of conditions beyond just orthopedic ones, respiratory, for asthma, COPD. Actually, there has been testing done for different heart conditions and so on.

It turns out that your fat has somewhere in the neighborhood of 500,000 stem cells per cubic centimeter of fat. So from 25 cubic centimeters of fat, we can get anywhere from 10 to 30 million cells or more in a single isolation process. So instead of having to harvest the cells and culture them out for several days, within an hour and a half, we can give somebody back 20 to 30 million cells from one 25 cubic centimeter sample of their own fat.

Outside of the US, there are a number of countries where this is commonly used. These fat-derived stem cells are huge in abundance and then it can be used for all these different therapeutic uses. I think some of our athletes recently have been going to Germany and getting some of these treatments as a matter of fact.

SO: Interesting. How are they used in cosmetic surgery?

DMB: Well, in cosmetic surgery, one of the things that you have to understand is because of liposuction and discovering that we couldn’t put fat back into the body unless it had the stem cells, it got us started looking into the stem cells.

So in plastic surgery, what’s happened is these cells have been isolated from fat and technically the cells aren’t isolated as stem cells or isolated. It’s what we call stromal vascular fraction. What that means is this is when you take the fat and then you separate out the fat from the other cells, what you are left is a soup that we call stromal vascular fraction. That’s loaded with stem cells, white blood cells, some growth factors and endothelial cells.

Those cells then are that soup or stromal vascular fraction, and those cells can be added back to harvested fat to sort of fortify the fat cells and then when you take those and put them back in the body, you get better retention rates of the grafted fat.

There is a lot of evidence to suggest that the fat cells themselves don’t even survive that well because of the lack of oxygen. When you graft it back into the body, the fat cells, they largely die. But cell entry to the fat actually is a signal that turns on the stem cells that it causes the stem cells to then replace the fat cells as well as create neovascularization, if you will, but grow new blood supply.

So it’s a pretty remarkable process. It’s very dynamic.

SO: I’ve heard of doctors claiming to do stem cell facelift, so what’s really going on? Are they actually using some fills, or things just aren’t…

DMB: I think it’s kind of a marketing hype. There are a lot of criticisms, especially out of [AACS]. You will remember I’m the past president of the American Academy of Cosmetic Surgery, and a lot of our members are kind of concerned that we shouldn’t be calling something stem cell facelift because it implies that you are just putting stem cells in the face and somehow that’s making the face look younger.

And the truth is while the stem cell is very important, you couldn’t do a stem cell facelift without fat, so it’s technically, in the old days, we just call it fat grafting. Now, we made all these names for the procedure and I think fat grafting is like the name that most of us old guys keep saying because we’ve been doing it for so long.

But the reality is it is a stem cell fat graft, and you need the fat so that the stem cells can signal and turn on and do what they are going to do. If you actually just inject these stem cells or even stromal vascular fraction in the face, basically, the most that would happen is the cells would recognize a low degeneration in the skin.

It might improve the quality of the skin, but they are not going to grow new fat cells because there is significant damage going on. So they need to see that cell injury in order to get turned on. That’s just the nature of the stem cells. Stem cell is a progenitor cell. It reacts to the cell injury, inflammation or degeneration. So those are the things that would going to turn on the cell and get it to activate.

SO: If someone just injected stem cell into the face and that’s not really going to help them much. So the whole stem cell facelift is really just sort of a buzzword, some hype going on there?

DMB: Yeah, exactly. I think it’s a good marketing thing because everybody wants to have a stem cell facelift. That sounds really good.

But it’s really a fat graft procedure, and the fat is loaded with stem cells, and if it wasn’t loaded with stem cells, it wouldn’t work.

SO: How did you get involved in stem cell therapy?

DMB: Well, what happened to me is, first of all, I’ve been doing fat grafting since the late 80’s. So I’ve always recognized that our face is three dimensional. We needed to correct the face by adding volume back and the volume that we are missing is fat. Our fat dies over time and we look older because of it.

But in 2010 in the early part of the year, one of my colleagues, William Chen, tried to talk me into going to Japan and visiting Dr. Kamakura and Dr. Yoshimura who are both doing stem cell enhanced fat grafting. Dr. Kamakura was using the Cytori equipment which is one of the leading companies in automated production of stromal vascular fraction or stem cells.

Dr. Yoshimura was using a piece of equipment that was pretty much the same as what I have, the Lipo Kit machine, or the Adivive that Palomar makes. So I almost was reluctant about it, but I did go and it was a very interesting experience, and I watched both these guys do breast augmentation with stem cell enriched fat. The procedure took about five hours to do.

While I was watching these guys do all this work, I just kept thinking, “God, this is such a waste of stem cells. I can make and do a breast augmentation in 35 minutes.” But I [also] thought, “These are great cells for therapeutic uses.” And as far as I knew there really weren’t too many people using those cells in that regard.

So when I came back home, I did more research and I thought that there was a lot of uses outside of the US for therapeutic stem cells, and I got involved with one of my local orthopedic surgeons. Because I’m a cosmetic surgeon, I could harvest and produce the stromal vascular fraction, but it didn’t seem ethical for me to be the one just injecting people and doing it on my own and I kind of wanted to put a team together.

So I started out real small, real simple, and my local orthopedic surgeon, Dr. Tom Grogan, reviewed the literature that I sent him and he agreed to see a couple of my patients. So initially, I sent in my nurse and esthetician who had a bad knee from a skiing accident and later on I started with my wife. She is a runner and she did several marathons and six miles a day, but it was starting to get painful in the hip. That would have been sore now for three years, and so I sent her to him, and then my father has a knee injury, so I was digging up all these people who are close to me.

And he kind of went along with it. He said, “Okay, let’s try this,” and so I harvest the [stem cells] and we injected them. He actually did the injection. In my wife’s case, we did it with a radiologist, so we could tap into the hip and see that we are in the right spot and we injected the cells and everybody got better, but not just better like amazingly better. My wife has been pain free for over a year. My dad’s knees are much better. My nurse and esthetician is skiing again, and she can’t believe it.

So we kept kind of plowing away and before long he was sending me patients, and then my associate worked with an urologist, Dr. Elliott Lander, who got the brilliant idea that we needed to put a whole group together, and so we formed the California Stem Cell Treatment Center as a kind of privately funded investigational organization, so we would look at the therapeutic uses for this adipose-derived cells.

Along came Jackie See, who is a world-renowned interventional cardiologist, and he found me through some of the press and things that were written about me. He and I met, and he had been sending patients to Germany for $80,000. They were getting stem cell treatments in Germany and he felt what we were doing is even better. So he got in on it and he became part of our group.

Then we’ve got involved with some interventional radiologist and we’ve been setting up protocols for different treatments along that line. I mean, the whole thing has just grown as a multi-disciplinary approach to looking at the use of adipose-derived cells for therapeutic uses, and so we are taking on patients, investigating different conditions. Right now, we’ve treated over a hundred patients and most of them are quiet successful. There are certain areas that we haven’t been terribly successful with, but other areas, especially with orthopedic ones are just phenomenal.

SO: So in the cosmetic surgery realm, how has it been successful in that area?

DMB: Well, I continue to do a lot of facial rejuvenation, and so there is no doubt, the best way to rejuvenate somebody’s face is by treating them three dimensionally. My claim to fame was not being the first guy to fat grafting, but I got up one day and said, “Hey, we misdiagnosed aging. Aging is not just gravity pull in the face down. It’s a loss of volume.” So, as you lose that volume and that volume loss is predominately due to fat that metabolizes or dies over time, the skin looks like it’s sagging, so you need to put that volume back.

So for me the stem cell fat transfer, if you will, is the primary tool for rejuvenating face and doing a facelift or excision blepharoplasty are complementary to that.

With breast augmentation, it’s still a real viable use. You know it’s a lot of work, but if you have a right person who requires substantial amount of liposuction, then you can harvest the fat to produce extra stem cells fortified with fat and use it to create some breast at least a cup size or so, and there are some pretty good results and they are fairly stable. So you can do it.

Certainly, it would be good for different reconstructive uses with somebody who’s had an injury and has lost a fair amount of fat volume would benefit from this as well.

SO: You said it’s used in breast augmentation, correct? Would that be instead of an implant?

DMB: You could use it instead of an implant and you can use it in conjunction with an implant.

SO: I see. This has been really informative. Do you have any other information you would like to tell our listeners about your practice?

DMB: Well, we did put up a website, and it’s called, and it’s basically informative. We’ve tried to put a small library together that has a lot of articles that talks about some of the work that’s being done.

So there is a lot of neat research going on, but I’m telling you, it’s so politically charged that Andy Grove, the former chairman from Intel who now has Parkinson’s, spoke about how the regulatory system is so heavy handed that it’s taking forever to get some of these therapies out to market.

So it’s kind of interesting because we have this unique opportunity to use ourselves now because we don’t violate any rules or regulations. I’m sure the FDA, after hearing this interview, could find some argument with what I’m saying, but truly we are taking the person’s cells and give it back to him within an hour and a half, and the most we are doing to their cells is spinning them down to centrifuge, and that’s considered minimal manipulation.

We are not adding any medication to the cells or anything, and the separation process is done with a medical-grade collagenase produced by Roche Laboratories, and the collagenase really just affects the collagen tissue and we wash that out and that doesn’t affect the cells. We have a cell counter and the ability to actually photograph our cells. We can show the patients what everything looks like and they can see what they are getting back.

So it’s a very interesting time. I think the key for us as cosmetic surgeons is to form these multi-disciplinary groups, so nobody can say, “Oh, you are cosmetic surgeon. You are trying to do orthopedic and neurologic and urologic and all these other things.” I think the key is working together.

SO: As things progress, maybe we will do a follow-up interview in the years to come and see how things have evolved over time.

DMB: Yeah, we will see. We put a protocol together for institutional review board protocol to look at the safety factors. We don’t want anybody to say, “You know, this is unsafe.” People are concerned about safety the most, and we really believe that there is no significant risk, but if we study it with an institutional review board protocol, then we can validate that and we can just kind of keep moving on from there.

SO: Well, thank you, Dr. Berman. This has been fascinating, and I really appreciate the time.

DMB: It’s my pleasure, Sharon. I’ll talk to you some more later.

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