autologous fat transfer [electronic resource] art, science, and clinical practice

Preface This book is the most up to date text on autologous fat transfer and includes chapters concerning the history of fat transfer and fat transfer survival, principles of fat transfe

Autologous Fat Transfer

Melvin A Shiffman (Ed.)

Autologous Fat Transfer

Art, Science, and Clinical Practice

ISBN: 978-3-642-00472-8 e-ISBN: 978-3-642-00473-5

DOI: 10.1007/978-3-642-00473-5

Springer Heidelberg Dordrecht London New York

Library of Congress Control Number: 2009926019

© Springer-Verlag Berlin Heidelberg 2010

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Tustin Hospital and Medical Center

It is with great pleasure that I submit a foreword for this new book

Many authors have written in detail about fat transplantation; however, experience and education are never enough on any of the cosmetic fi elds The fi rst text on fat transplantation by Charles H Willi dates back to 1926 This means that someone before us understood the importance of autologous resources that we have

The technique has naturally evolved and has developed in these years It is of utmost importance for a cosmetic surgeon to know every detail about the techniques: anatomy, metabolism of fat, pharmacology, and eventually the treatment of complica-tions A simple procedure is not necessarily a procedure that has no complications.All over the world and all over the centuries beauty has been a great spiritual force and has affected the evolution of civilization

Nowadays we are going toward an era in which major cosmetic surgical niques are not so requested anymore Patients want to stay young; they do not want

tech-to become young again!

Fat is a wonderful resource, which can be used for reconstructive purposes or for cosmetic ones

It is important for any surgeon paving the fi rst steps in this fi eld to study and read and learn every time a bit more in order to have the best results with the least problems

I congratulate the author and my friend Mel Shiffman for his precious contributions

in everything he does

With great affection

Foreword

Preface

This book is the most up to date text on autologous fat transfer and includes chapters concerning the history of fat transfer and fat transfer survival, principles of fat transfer, adipose cell anatomy and physiology, guidelines for fat transfer and interpretation of results, subcision and fat transfer, fat transfer to a variety of areas of the body for aes-thetic purposes and plastic reconstruction, fat autograft to muscle, complications of fat transfer, and medical legal aspects of fat transfer Included are chapters on fat transfer for nonaesthetic purposes such as for recontouring postradiation defects, treatment of migraine headaches, treatment of sulcus vocalis, transfer around temporomandibular prosthesis, for skull base repair after craniotomy, and for congenital short palate There are 63 chapters by international experts with the newest techniques explained in detail.Fat transfer is now one of the most common aesthetic procedures performed Use

of fat avoids the complications of other fi llers, including solid and injectable, both temporary and permanent Fat for transfer is available on almost all patients so that there is essentially no cost Local anesthesia and/or tumescent local anesthesia are most commonly used and this increases the safety of the procedure

The effects of fat transfer are marked, resulting in a younger appearance, ing the three-dimensional correction of the face, and elevating depressions and defi -cits Fat transfer may also prevent excessive fi brosis in noncosmetic applications.The techniques have improved allowing better volume retention of fat Many pro-cedures in fat transfer are discussed and described so that the reader will have a better understanding of the procedure and should be able to perform fat transfer avoiding many of the complications

complet-Much of the improvement in fat transfer to the liposuction technique can be uted to the contribution of liposuction by Fischer that was fi rst reported in 1975 [1] and the many surgeons who contributed to the advances improving fat retention and safety The history of fat transfer is replete with attempts to make fat transfer a viable procedure and to improve the techniques to increase the percentage of retention.The improvements of fat transfer have been through the contributions of surgeons

attrib-in many specialties We should recognize these attrib-international specialists who have spent their efforts in making fat transfer a viable procedure in aesthetic surgery

Contents

Part I History, Principles, Fat Cell Physiology and Metabolism

1 History of Autologous Fat Transfer 3Melvin A Shiffman

2 History of Autologous Fat Transplant Survival 5Melvin A Shiffman

3 Principles of Autologous Fat Transplantation 11Melvin A Shiffman

4 The Adipocyte Anatomy, Physiology, and Metabolism/Nutrition 19Mitchell V Kaminski and Rose M Lopez de Vaughan

5 Fat Cell Biochemistry and Physiology 29Melvin A Shiffman

6 White Adipose Tissue as an Endocrine Organ 37Kihwa Kang

Part II Preoperative

7 Preoperative Consultation 43Melvin A Shiffman

Part III Techniques for Aesthetic Procedures

8 Guidelines for Autologous Fat Transfer, Evaluation,

and Interpretation of Results 47Sorin Eremia

9 Face Rejuvenation with Rice Grain-Size Fat Implants 53Giorgio Fischer

10 Fat Transfer in the Asian 59Samuel M Lam

11 Subcison with Fat Transfer 65

14 Use of Platelet-Rich Plasma to Enhance Effectiveness

of Autologous Fat Grafting 87

Robert W Alexander

15 Fat Transfer to the Face 113

Melvin A Shiffman and Mitchell V Kaminski

16 Fat Autograft Retention with Albumin 123

Mitchell V Kaminski and Rose M Lopez de Vaughan

17 Aesthetic Face-lift Using Fat Transfer 135

Anthony Erian and Aqib Hafeez

18 Fat Transfer to the Glabella and Forehead 147

Felix-Rüdiger G Giebler

19 Eyebrow Lift with Fat Transfer 153

Giorgio Fischer

20 Treatment of Sunken Eyelid 155

Dae Hwan Park

21 Fat Graft Postvertical Myectomy for Crow’s

Feet Wrinkle Treatment 165

Fausto Viterbo

22 Optimizing Midfacial Rejuvenation: The Midface Lift

and Autologous Fat Transfer 171

Allison T Pontius and Edwin F Williams III

23 Autologous Fat Transfer to the Cheeks and Chin 179

Steven B Hopping

24 Nasal Augmentation with Autologous Fat Transfer 185

Jongki Lee

25 Lipotransfer to the Nasolabial Folds and Marionette Lines 189

Robert M Dryden and Dustin M Heringer

26 Autologous Fat Transplantation to the Lips 197

Steven B Hopping, Lina I Naga, and Jeremy B White

27 Three Dimensional Facelift 203

Sid J Mirrafati

28 Complementary Fat Grafting of the Face 209

Samuel M Lam, Mark J Glasgold, and Robert A Glasgold

29 Fat Transplants in Male and Female Genitals 217

Enrique Hernández-Pérez, Hassan Abbas Khawaja,José Enrique Hernández-Pérez, and Mauricio Hernández-Pérez

30 History of Breast Augmentation with Autologous Fat 223

Melvin A Shiffman

31 Breast Augmentation with Autologous Fat 229

Tetsuo Shu

32 Fat Transfer and Implant Breast Augmentation 237

Katsuya Takasu and Shizu Takasu

33 Fat Transfer with Platelet-Rich Plasma for Breast Augmentation 243

Robert W Alexander

34 Cell-Assisted Lipotransfer for Breast Augmentation:

Grafting of Progenitor-Enriched Fat Tissue 261

Kotaro Yoshimura, Katsujiro Sato, and Daisuke Matsumoto

35 Fat Transfer to the Hand for Rejuvenation 273

Pierre F Fournier

36 Correction of Deep Gluteal and Trochanteric Depressions Using a Combination of Liposculpturing with Lipo-Augmentation 281

Robert F Jackson and Todd P Mangione

37 Buttocks and Legs Fat Transfer: Beautifi cation, Enlargement, and Correction of Deformities 291

Lina Valero de Pedroza

38 Autologous Fat Transfer for Gluteal Augmentation 297

Adrien E Aiache

39 Autologous Fat for Liposuction Defects 301

Pierre F Fournier

40 Periorbital Fat Transfer with Platelet Growth Factor 303

Julio A Ferreira and Gustavo Ferreira

41 Cryopreserved Fat 305

Bernard I Raskin

Part IV Techniques for Non-Aesthetic Procedures

42 Fat Transfer for Non-Aesthetic Procedures 315

Melvin A Shiffman, Enrique Hernández-Pérez,

Hassan Abbas Khawaja , José Enrique Hernández-Pérez,

and Mauricio Hernández-Pérez

43 Fat Transplantation for Mild Pectus Excavatum 323

Luiz Haroldo Pereira and Aris Sterodimas

44 Correction of Hemifacial Atrophy with Fat Transfer 331

Qing Feng Li, Yun Xie, and Danning Zheng

45 Recontouring Postradiation Thigh Defect

with Autologous Fat Grafting 341

Richard H Tholen, Ian T Jackson, Richard Simman,

and Vincent D DiNick

46 Management of Migraine Headaches

with Botulinum Toxin and Fat Transfer 347

Devra Becker and Bahman Guyuron

47 Retropharyngeal Fat Transfer for Congenital Short Palate 357

P H Dejonckere

48 Autologous Fat Grafts Placed Around

Temporomandibular Joint (TMJ) Total Joint

Prostheses to Prevent Heterotopic Bone 361

Larry M Wolford and Daniel Serra Cassano

49 Autologous Fat Grafts for Skull Base Repair

After Craniotomies 383

Jose E Barrera, Sam P Most, and Griffi th R Harsh IV

Part V Fat Processing and Survival

50 Fat Processing Techniques in Autologous Fat Transfer 391

Nancy Kim and John G Rose Jr

51 Injection Gun Used as a Precision Device for Fat Transfer 397

Joseph Niamtu

52 Tissue Processing Considerations for Autologous Fat Grafting 403

Adam J Katz and Peter B Arnold

53 Fat Grafting Review and Fate of the Subperiostal Fat Graft 407

Defne Önel, Ufuk Emekli, M Orhan Çizmeci,

Funda Aköz, and Bilge Bilgiç

Part VI Complications

54 Complications of Fat Transfer 417

Hassan Abbas Khawaja, Melvin A Shiffman, Enrique Hernandez-Perez, Jose Enrique Hernandez-Perez, and Mauricio Hernandez-Perez

55 Facial Fat Hypertrophy in Patients Who Receive Autologous Fat Tissue Transfer 427

Giovanni Guaraldi, Pier Luigi Bonucci, and Domenico De Fazio

56 Lid Deformity Secondary to Fat Transfer 433

Brian D Cohen and Jason A Spector

Part VII Miscellaneous

57 The Viability of Human Adipocytes After Liposuction Harvest 439

John K Jones

58 Autologous Fat Grafting: A Study of Residual Intracellular Adipocyte Lidocaine 445

Robert W Alexander

59 Autologous Fat Transfer National Consensus Survey:

Trends in Techniques and Results for Harvest, Preparation, and Application 451

Matthew R Kaufman, James P Bradley, Brian Dickinson, Justin B Heller, Kristy Wasson, Catherine O’Hara, Catherine Huang,Joubin Gabbay, Kiu Ghadjar, Timothy A Miller, and Reza Jarrahy

60 Medical Legal Aspects of Autologous Fat Transplantation 459

Melvin A Shiffman

61 Editor’s Commentary 463

Melvin A Shiffman

Index 467

Adrien E Aiache 9884 Little Santa Monica Blvd, Beverly Hills, CA 90212, USA,

aaiachemd@sbcglobal.net

Funda Aköz Department of Plastic and Reconstructive Surgery,

Osmaniye State Hospital, Osmaniye, Turkey, fundaakoz@gmail.com

Robert W Alexander Department of Surgery, University of Texas,

Health Science Center at San Antonio, San Antonio, TX, USA

Department of Surgery, University of Washington, Seattle, WA, USA

3500 188th St S.W Suite 670, Lynnwood, WA 98037, USA

rwamd@cybernet1.com

Peter B Arnold University of Virginia, P.O Box 800376, Charlottesville,

VA 22908-0376, pba9m@virginia.edu

Jose E Barrera Department of Otolaryngology, Division of Facial Plastic and

Reconstructive Surgery, Wilford Hall Medical Center, 59 MDW/SGOSO,

2200 Bergquist Drive, Ste 1, Lackland AFB, TX 78236-9908, USA

jebarrera@yahoo.com

Devra Becker 29017 Cedar Road, Cleveland (Lyndhurst), OH 44124, USA,

devra:becker@uhospitals:org

Bilge Bilgiç Department of Pathology, Istanbul University, Fevzi Pasa cad

Sarachane Parki Yani Fatih, Istanbul, Turkey, bbilgik@istanbul.edu.tr

Pier Luigi Bonucci Strada del Diamante 86, 41100 Modena, Italy

Pierluigi.bonucci@fastwebnet.it

James P Bradley Division of Plastic and Reconstructive Surgery, 200 UCLA

Medical Plaza, Suite 465, Los Angeles, CA 90095, USA, jbradley@mednet.ucla.edu

Daniel Serra Cassano Rua Vicente Satriana, 316 apt 52, Jardim Sao Jorge,

Araraquara, Sao Paulo, Brazil 14807-9878, serracassanoctbmf@yahoo.com.br

Brian D Cohen Combined Divisions of Plastic Surgery, New York-Presbyterian,

The University Hospital of Columbia and Cornell, 525 East 68th Street, P.O Box 115, New York, NY 10065, USA, bc2152@columbia.edu

M Orhan Çizmeci Department of Pathology, Istanbul University, Fevzi Pasa cad

Sarachane Parki Yani Fatih, Istanbul, Turkey, ocizmeci@istanbul.edu.tr

Domenico De Fazio Strada del Diamante 86, 41100 Modena, Italy,

dododefazio@libero.it

Contributors

P H Dejonckere The Institute of Phoniatrics, ENT Department, Division of

Surgery, University Medical Centre, P.O Box 85 500, 3508 Utrecht, The

Ufuk Emekli Department of Pathology, Istanbul University, Fevzi Pasa cad

Sarachane Parki Yani Fatih, Istanbul, Turkey, ufekemekli@ekolay.net@

Sorin Eremia Cosmetic Surgery Unit, Division of Dermatology, UCLA,

Brockton Cosmetic Surgery Center, 4440 Brockton, Suite 200, Riverside,

Giorgio Fischer Via della Camiluccia, 643, 00135 Rome, Italy,

giorgiofi scher@fl ashnet.it

Pierre F Fournier 55 Boulevard de Strasbourg, 75 010 Paris, France,

Felix-Rüdiger G Giebler Vincemus-Klinik, Brückenstrasse 1a,

25840 Friedrichstadt/Eider, Germany, info@vincemus-klink.de

Mark J Glasgold Robert Wood Johnson Medical School,

University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA

31 River Road, Highland Park, NJ 08904, USA, drmark@glasgoldgroup.com

Robert A Glasgold Robert Wood Johnson Medical School,

University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA,

drrobert@glasgoldgroup.com

Giovanni Guaraldi Department of Medicine and Medicine Specialities,

Infectious Diseases Clinic, University of Modena and Reggio Emilia School

of Medicine, Via del Pozzo 71, 41100 Modena, Italy, g.guaraldi@unimo.it

Bahman Guyuron Department of Plastic Surgery, Case Western Reserve University,

Cleveland, OH 44124, USA, bguyuron@aol.com

Griffi th R Harsh IV Department of Neurosurgery, Stanford University,

School of Medicine, Stanford, CA, USA

875 Blake Wilbur Drive CC2222, Stanford, CA 94305, USA, gharsh@stanford.edu

Justin B Heller 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095,

José Enrique Hernández-Pérez Center for Dermatology and Cosmetic Surgery,

Pje Dr Roberto Orellana Valdé #137, Col Médica, San Salvador CP 0-804,

El Salvador, enrimar@vip.telesal.net

Mauricio Hernández-Pérez Center for Dermatology and Cosmetic Surgery,

Pje Dr Roberto Orellana Valdé #137, Col Médica, San Salvador CP 0-804,

El Salvador, enrimar@vip.telesal.net

Steven B Hopping George Washington University, Washington, DC, USA

The Center for Cosmetic Surgery, 2440 M Street, NW, Suite 205, Washington,

DC 20037, USA, hoppingmd@msn.com

Catherine Huang 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095,

USA, bradley3@pol.net

Ian T Jackson Gretchen Hofman, Craniofacial Institute, 16001 West Nine Mile Road,

Third Floor Fisher Center, Southfi eld, MI 48075, USA, ianjackson@juno.com

Robert F Jackson 330 North Wabash Avenue, Suite 450, Marion IN 46952, USA,

rjlipodr@comteck.com

Reza Jarrahy Division of Plastic Surgery, 200 UCLA Medical Plaza, Suite 465,

Los Angeles, CA 90095, USA, rezadotcom@yahoo.com

John K Jones 6818 Austin Center Blvd, Suite 204, Austin, TX 78731-3100, USA,

jkj@austin.rr.com

Mitchell V Kaminski Finch University of Health Sciences, Chicago Medical

School, 230 Center Drive, Vernon Hill, Chicago, IL 60061-1584, USA, mvkaminski@comcast.net

Kihwa Kang Department of Genetics and Complex Diseases,

Harvard School of Public Health, 665 Huntington Avenue, Bldg2,

Rm 129, Boston, MA 02115, USA, kkangj@gmail.com

Adam J Katz Department of Plastic and Maxillofacial Surgery, University of

Virginia, P.O Box 800376, Charlottesville, VA 22908-0376, USA, ajk2f@virginia.edu

Matthew R Kaufman Drexel College of Medicine, Shrewsbury, NJ, USA

Plastic Surgery Center, 535 Sycamore Avenue, Apt 732, Shrewsbury,

NJ 07702-4224, USA, kaufmanmatthew@hotmail.com

Hassan Abbas Khawaja Cosmetic Surgery and Skin Center, 53A, Block B II,

Gulberg III, 53660 Lahore, Pakistan, drhassan@nexlinx.net.pk

Nancy Kim Oculoplastics Service, Department of Ophthalmology,

University of Wisconsin Hospitals and Clinics, 600 Highland Avenue,

F3-332, Madison, WI 53703, USA, nkim@ophth.wisc.edu

Edward B Lack 2350 Ravine Way, Ste 400, Glenview, IL 60025, USA,

elack2000@yahoo.com

Samuel M Lam Willow Bend Wellness Center, Lam Facial Plastic Surgery Center

and Hair Restoration Institute, 6101 Chapel Hill Boulevard, Suite 101, Plano,

TX 75093, USA, drlam@lamfacialplastics.com

Jongki Lee In & In Apt 101-Dong 903-Ho, 834 Jijok-Dong Yooseong-Gu

Daejeon-City, Korea 305-330, tumorlee@hotmail.com

Qing Feng Li Department of Plastic and Reconstructive Surgery,

Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine,

639 Zhizhaoju Road, Shanghai, PR China, 200011, liqfl iqf@yahoo.com.cn

Rose M Lopez de Vaughan Successful Longevity Clinic, 381 W Northwest

Highway, Palatine, IL 60067, USA, rlopez@megsinet.net

Todd P Mangione Pasco Surgical Associates, 37840 Medical Arts Court,

Zephyrhills, FL 33541-4325, USA, tpmangione@hotmail.com

Daisuke Matsumoto Department of Plastic Surgery, University of Tokyo School

of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan,

Sam P Most Departments of Otolaryngology and Surgery (Plastic Surgery),

Division of Facial Plastic and Reconstructive Surgery, Stanford University,

School of Medicine, 801 Welch Rd, Stanford, CA 94305, USA,

smost@ohns.stanford.edu

Lina I Naga The Center for Cosmetic Surgery, 2440 M Street, NW, Suite 205,

Washington, DC 20037, USA, lina@gwu.edu

Joseph Niamtu 11319 Polo Pl., Midlothian, VA 23113-1434, USA,

niamtu@niamtu.com

Catherine O’Hara 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095,

USA, bradley3@pol.net

Defne Önel Plastic and Reconstructive Surgery Department, Medical Park Hospital,

Fevzi Pasa cad Sarachane Parkı Yani Fatih, Istanbul, Turkey,

defneonel@gmail.com

Dae Hwan Park Department of Plastic and Reconstructive Surgery,

College of Medicine, Catholic University of Daegu, 3056-6 Daemyung 4-dong Namgu,

Daegu, 705-718, Korea, dhpark@cu.ac.kr

Luiz Haroldo Pereira Luiz Haroldo Clinic, Rua Xavier da Silveira 45/206,

22061-010, Rio de Janeiro, Brazil, haroldo@unisys.com.br

Allison T Pontius The Williams’ Center for Plastic Surgery,

1072 Troy Schenectady Road, Latham, NY 12110, USA, allisonpontius@yahoo.com

Bernard I Raskin Department of Medicine, Division of Dermatology,

Geffen School of Medicine at UCLA, Los Angeles, CA, USA, bernieraskin@gmail.com

John G Rose Jr Davis Duehr Dean and The Aesthetic Surgery Center,

Dean Health Systems, 1025 Regent Street, Madison, WI 53715, USA, john.rose@deancare.com

Katsujiro Sato Cellport Clinic Yokohama, Yokohama Excellent III Building 2F,

3-35, Minami-nakadori, Naka-ku, Yokohama, Japan, sato@cell.port.jp

Melvin A Shiffman Department of Surgery, Tustin Hospital and Medical Center,

17501 Chatham Drive, Tustin, CA 92780-2302, USA, shiffmanmdjd@yahoo.com

Tetsuo Shu Daikanyama Clinic, 4F, 1-10-2 Ebisu-Minami, Shibuya-ku, Tokyo,

Japan 150-0022

Richard Simman 2130 Leiter Road, Suite 205, Miamisburg, OH 45342, USA,

richardsimman@hotmail.com

Jason A Spector Division of Plastic Surgery, Weill Medical College of Cornell

University, 525 East 68th Street, Payson 709, New York, NY 10065, USA, jas2037@med.cornell.edu

Aris Sterodimas Department of Plastic Surgery, Ivo Pitanguy Institute,

Pontifi cal Catholic University of Rio de Janeiro, Rua Dona Mariana 65, 22280-020, Rio de Janeiro, Brazil, aris@sterodimas.com

Katsuya Takasu Takasu Clinic, 2-14-27 Akasaka, Kokusai-Shin-Akasaka Building,

Higashi-kan 2F, Minato-ku, Tokyo 107-0052, Japan, katsuya@co.jp

Richard H Tholen Minneapolis Plastic Surgery, Ltd., 4825 Olsen Memorial

Highway, Suite 200, Minneapolis, MN 55422, USA, dtmps@comcast.net

Lina Valero de Pedroza Carrera 16 No 82-95-Cons: 301, Bogotá DC, Colombia,

Jeremy B White Division of Otolaryngology Head and Neck Surgery,

George Washington University Washington, DC, USA

2440 Virginia Avenue, Apt D710, Washington, DC 20037, USA, jwhite@gwu.edu

Edwin F Williams III Division of Otolaryngology-Head and Neck Surgery,

Department of Surgery, Albany Medical Center, Albany, NY 12208, USAThe Williams’ Center for Plastic Surgery, 1072 Troy Schenectady Road, Latham,

NY 12110, USA, edwilliams@nelasersurg.com

Larry M Wolford 3409 Worth Street, Suite 400, Dallas, TX 75246, USA,

Lwolford@swbell.net

Yun Xie Department of Plastic and Reconstructive Surgery,

Shanghai Ninth People’s Hospital, 639 Zhizhaoju Road, Shanghai,

PR China, 200011, amiyayun@gmail.com

Kotaro Yoshimura Department of Plastic Surgery, University of Tokyo School of

Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan,

yoshimura-pla@h.u-tokyo.ac.jp

Danning Zheng Department of Plastic and Reconstructive Surgery,

Shanghai Ninth People’s Hospital, 639 Zhizhaoju Road, Shanghai,

PR China, 200011, adizdn@@gmail.com

Part

History, Principles, Fat Cell Physiology

and Metabolism

I

M A Shiffman (Ed.), Autologous Fat Transfer 3

DOI: 10.1007/978-3-642-00473-5_1, © Springer-Verlag Berlin Heidelberg 2010

1.1 Introduction

The history of autologous fat augmentation gives an

insight into the development of fat transfer for both

cos-metic and non-coscos-metic problems Transplantation of

pieces of fat and occasionally diced pieces of fat advanced

to the removal of small segments of fat by liposuction

after the development of the technique by Fischer and

Fischer, reported in 1975

1.2 History

Neuber (1) reported the use of small pieces of fat from

the upper arm to reconstruct a depressed area of the

face resulting from tuberculosis osteitis He concluded

that small pieces of fat, of bean or almond size, appeared

to have a good chance of survival Czerny (2) used a

large lipoma to fill a defect in the breast following

resection of a benign mass The transplanted breast,

however, appeared darker in color and smaller in

vol-ume than the opposite breast Verderame (4) observed

that fat transplants solved the problem of shrinkage at

the transplant site Lexer (3) reported personal

experi-ence with fat transplants and found that larger pieces

of fat gave better results Bruning (5) used fat grafts

to fill a post-rhinoplasty deformity by placing fat in

a syringe and injecting the tissue through a needle

Tuffier (6) inserted fat into the extrapleural space to treat pulmonary conditions Biopsy of the fat 4 months post transplant showed that most of the fat was resorbed and replaced by fibrous tissue

Straatsma and Peer (7) used free fat grafts to repair postauricular fistulas and depressions or fistulas result-ing from frontal sinus operations Cotton (8) used a technique of broad undercutting and insertion of finely cut fat that was molded to fill defects

Peer (9) noted that grafts the size of a walnut appear

to lose less bulk after transplanting than do smaller multiple grafts He also found that free fat grafts lose about 45% of their weight and volume 1 year or more following the transplantation because of the failure of some fat cells to survive the trauma of grafting as well as the new environment Fat grafts are affected by trauma, exposure, infection, and excessive pressure from dress-ings (10) Peer (11) stated that microscopically, grafts appear like normal adipose tissue 8 months after trans-plantation

Liposuction was conceived by Fischer and Fischer

in 1974 (12) and put into practice in 1975 (13).Fischer (14) first reported removal of fat by means of

5 mm incisions using a “rotating, alternating instrument electrically and air powered.” This allowed aspiration of fat through a cannula Through a separate incision, saline solution was injected to dilute the fat In 1977 (15), they reviewed 245 cases of liposuction with the “planotome”

for treatment of cellulite in the lateral trochanteric areas

There was a 4.9% incidence of seromas despite wound suction catheters and compression dressings Pseudocyst formation, which required removal of the capsule through

a wider incision and the use of the planotome, occurred

in 2% of cases

The advent of liposuction spurred a move toward using the liposuctioned fat for reinjecting areas of the body for filling defects or augmentation Bircoll (16)

History of Autologous Fat Transfer

Melvin A Shiffman

1

M A Shiffman

Department of Surgery, Tustin Hospital and Medical Center,

17501 Chatham Drive, Tustin, CA, 92780-2302, USA

e-mail: shiffmanmdjd@yahoo.com

1 Reprinted with permission of Lippincott Williams & Wilkins.

first reported the use of autologous fat from

liposuc-tion for contouring and filling defects Illouz (17)

claimed that in 1983, he began to inject aspirated fat

Johnson (18) stated that in 1983, he began to use

auto-logous fat injection for contouring defects of the

but-tocks, anterior tibial area, lateral thighs, coccyx area,

breasts, and face Bircoll (19) presented the method of

injecting fat that had been removed by liposuction

Krulig (20) asserted that he began to use fat grafts by

means of a needle and syringe He called the procedure

“lipoinjection.” He began to use a disposable fat trap

to facilitate the collection process and to ensure the

fat’s sterility Newman (21) stated that he began

rein-jecting fat in 1985 The idea of utilizing the aspirated

fat, which was otherwise wasted, was an attractive idea

and other surgeons began to make use of the aspirate to

augment defects and other abnormalities

The American Society of Plastic and Reconstructive

Surgery (ASPRS) Ad-Hoc Committee on New

Proce-dures produced a report on 30 September 1987,

regard-ing autologous fat transplantation (22) The conclusions

were:

1 Autologous fat injection has a historical and

scien-tific basis

2 It is still an experimental procedure

3 Fat injection has achieved varied results, and

long-term, controlled clinical studies are needed before

firm conclusions can be made regarding its validity

4 Fat transplant for breast augmentation can inhibit

early detection of breast carcinoma and is

hazard-ous to public health

Coleman and Saboeiro (23) reported success in fat

transfer to the breast and concluded that it should be

considered as an alternative to breast augmentation and

reconstruction procedures Two of 17 patients had breast

cancer diagnosed by mammography, one 12 months and

the other 92 months after fat transfer to the breast

Now fat transfer to the breast area is being used

out-side the breast itself, into the pectoralis major muscle

and behind and in front of the muscle The fat is also

being used to augment tissues around the breast

fol-lowing treatment for breast cancer

Although most of the fat transfer procedures are for

augmentation of tissues, there has been a surge of the

use of fat for non-cosmetic procedures

5 Bruning P Cited by Broeckaert, TJ, Steinhaus, J Contribution

e l’etude des greffes adipueses Bull Acad Roy Med Belgique 1914;28:440.

6 Tuffier T Abces gangreneux du pouman ouvert dans les bronches: Hemoptysies repetee operation par decollement pleuro-parietal; guerison Bull et Mem Soc de Chir de Paris 1911;37:134.

7 Straatsma CR, Peer LA Repair of postauricular fistula by means of a free fat graft Arch Otolaryngol 1932;15:620–621.

8 Cotton FJ Contribution to technique of fat grafts N Engl JMed 1934;211:1051–1053.

9 Peer LA The neglected free fat graft Plast Reconstr Surg 1956;18(4):233–250.

10 Peer LA Loss of weight and volume in human fat grafts Plast Reconstr Surg 1950;5:217–230.

11 Peer LA Transplantation of Tissues, Transplantation of Fat Baltimore, Williams & Wilkins, 1959.

12 Fischer G The evolution of liposculpture Am J Cosm Surg 1997;14(3):231–239.

13 Fischer G Surgical treatment of cellulitis Third Congress of the International Academy of Cosmetic Surgery, Rome, 31 May 1975.

14 Fischer G First surgical treatment for modeling body’s lulite with three 5 mm incisions Bull Int Acad Cosm Surg 1976;2:35–37.

cel-15 Fischer A, Fischer G Revised technique for cellulitis fat reduction in riding breeches deformity Bull Int Acad Cosm Surg 1977;2(4):40–43.

16 Bircoll M Autologous fat transplantation The Asian Congress of Plastic Surgery, February 1982.

17 Illouz YG The fat cell “graft”: A new technique to fill depressions PlastReconstrSurg 1986;78(1):122–123.

18 Johnson GW Body contouring by macroinjection of gous fat Am J Cosm Surg 1987;4(2):103–109.

autolo-19 Bircoll MJ New frontiers in suction lipectomy Second Asian Congress of Plastic Surgery, Pattiyua, Thailand, February 1984.

20 Krulig E Lipo-injection Am J Cosm Surg 1987;4(2):123–129.

21 Newman J, Levin J Facial lipo-transplant surgery Am J Cosm Surg 1987;4(2):131–140.

22 American Society of Plastic and Reconstructive Surgery Committee on New Procedures Report in autologous fat transplantation September 30,1987 Plast Surg Nurs 1987; Winter:140–141.

23 Coleman SR, Saboeiro AP Fat grafting to the breast ited: Safety and efficacy Plast Reconstr Surg 2007;119(3): 775–785.

revis-M A Shiffman (Ed.), Autologous Fat Transfer 5

DOI: 10.1007/978-3-642-00473-5_2, © Springer-Verlag Berlin Heidelberg 2010

2.1 Introduction

The survival of free fat used as an autograft is operator

dependent and requires delicate handling of the graft

tissue, careful washing of the fat to minimize

extrane-ous blood cells, and installation into a site with

ade-quate vascularity

There is evidence that fat cells will survive and that

filling of defects is not from the residual collagen

fol-lowing cell destruction There is some loss of fat after

transplant, and most surgeons tend to overfill the

recip-ient site

2.2 Historical Review

Verderame (1) reported that autogenous fat grafts in

ocu-lar surgery became reduced in size and advised the use

of a larger transplant than that seemed necessary to fill

the defect Lexer (2) claimed that manipulation and

tear-ing of the graft at the time of transfer would cause a great

degree of graft shrinkage Kanavel (3) felt that graft

sur-vival was improved by not using suture to secure the

graft, careful hemostasis, and aseptic technique He

transplanted sheets of fat varying from 0.25 to 1 in in

thickness to prevent adhesions and contractures and

lessen deformity of tendons, nerves, blood vessels, and

joints He felt that fat can be transplanted into any

ordinary field with the assurance that it will not act as a foreign body Clinically it appears to live, become a part

of the structure in which it is placed, and persists for many months and probably years Davis (4) concluded that omentum, transplanted freely beneath the skin in a mass, 1 in in diameter, maintains the greater part of its bulk Lexer (5) reported excellent clinical results with very large fat grafts but stated that up to 66% of the fat autografts were absorbed and significant overcorrection should be used He stated that multiple small grafts would turn to scar, while larger grafts would remain fatty tissue Mann (6) performed free transplant of omentum fat and stated that it remained seemingly viable for as long as 1 year and retained a small percentage of its fat

Neuhof (7) examined available experimental and clinical evidence and concluded that:

1 Transplanted autologous fat undergoes practically some changes as transplanted bone

2 The transplant dies and is replaced either by fibrous tissue or by newly formed fat

3 Newly formed fat occurs through the activity of a large wandering histocyte-like cell, which takes on fat and becomes a fat cell

Guerney (8) noted that autogenous fat grafts should be transplanted in larger bulk than required since only 25–50% of the graft survives 1 year after transplanta-tion He studied transplanted, 1.7 mm3 (average size), fat grafts over a period of 12 months in rats and con-cluded that:

1 Liberation of fat by contiguous cells probably gives rise to fatty cysts

2 Phagocytosis of liberated fat was assisted by morphonuclear leucocytes

poly-3 The percentage of normal fat in any surviving graft gradually increased throughout the year

History of Autologous Fat Transplant

Melvin A Shiffman

2

M A Shiffman

Department of Surgery, Tustin Hospital and Medical Center,

17501 Chatham Drive, Tustin, CA 92780-2302, USA

e-mail: shiffmanmdjd@yahoo.com

1 Reprinted with permission of Lippincott Williams & Wilkins.

4 A certain portion of the transplanted tissue gained

an adequate blood supply early and continued to

survive, while the remainder of the graft

degener-ated and was gradually elimindegener-ated from the site of

the implant without evidence of gross scar

5 Crushed grafts eventually disappeared attesting to the

devastating effect of trauma on the vitality of a graft

6 Single pieces of fat remain viable for at least 1 year,

while grafts of a similar size cut into smaller pieces

may last as long as 6 months, but the majority

dis-appear by the third month

7 Absolute hemostasis is essential since even a slight

hemorrhage jeopardizes the viability of the graft

8 Although slight infection results in only a small

loss of tissue, gross infection leads to a loss of the

whole graft

9 Phagocyte cells do not use their fat to form new fat

cells during the first year after transplantation

Hilse (9) showed histologically that free fat transplants

regenerate fatty tissue without any exception He

referred to the histocyte filled with fat as a “lipoblast.”

Green (10) used fat and fat-fascia autografts in the

treatment of osseous defects secondary to

osteomyeli-tis He presumed that transplanted fat would become

connective tissue and then bone, closing the defect

Wertheimer and Shapiro (11) studied fat physiology

and determined that fat develops from primitive

adi-pose cells the structure of which is like that of the

fibroblasts of connective tissue

Peer (12) implanted autogenous fat (single piece

compared to a piece cut into 20 segments) into the

rec-tus muscle Grafts were removed at intervals from 3 to

14 months Grossly all grafts were surrounded by a

connective-tissue capsule and, upon sectioning, the

bulk of the graft contained fatty tissue Single grafts

(the size of a walnut) lost 45% of their weight while

multigrafts lost 79% of their weight He concluded that

the fat grafts appeared like normal fat tissue 1 year or

more after transplantation

Bames (13) noted that circulation in grafts is

estab-lished in about 4 days after transplantation by

anastomo-sis between the host and graft blood vessels Traumatized

fat grafts lose much more weight and volume than

gen-tly handled transplants (50% loss after 1 year) Normal

appearing adipose cells were present in all the

trans-plants Dermal-fat grafts provide a readily available

transplantation material for establishing normal contour

in small breasts instead of foreign implants

Hansberger (14) proposed that histocytes tose the lipid and do not replace graft fat After the graft of mature autotransplanted fat goes through ini-tial ischemia, fat cells either necrose or dedifferentiate into immature cells Under suitable conditions, the immature fat cells revert to mature adipocytes.Schorcher (15) reported using autogenous free fat transplantation to treat hypomastia He noted that the connective elements remained intact with fat shrink-age to 25% of the original size by 6–9 months He believed that if the graft was in several pieces, it would receive better nourishment from the recipient site.Van and Roncari (16, 17) demonstrated conversion

phagocy-of adipocyte precursors into adult adipocytes, both in vitro and in vivo, in rats Saunders et al (18) studied fat autograft survival and observed initial adipose tis-sue breakdown followed by revascularization There is early breakdown of fat cells with formation of cyst like lipid deposits and infiltration by host histocytes.Illouz (19) opined that the human body is an excel-lent culture medium and that the fat cells apparently sur-vive by intercellular lipolysis and osmosis until they are revascularized The area to be augmented should be over corrected by 30% because approximately 30% necrosis

of fat cells results when using the wet technique.Illouz (20) reported that fat transplantation in one patient biopsied 9 and 16 months later, showed normal fat cells

Asken (21) found that 90% of fat extracted by tion appears viable, assuming it is not traumatized either

liposuc-by handling or liposuc-by high suction pressure Damage incurred

by the adipocytes is inversely related to the diameter of the instrument used for harvesting and injection.Campbell et al (22) noted, both morphologically and biochemically, that adipocyte integrity and metabolism remain intact when subjected to liposuction Johnson

(23) examined liposuctioned fat and noted that 90% or more of the fat cells remained viable He found that there was 75–85% of original fat present 3 months after trans-plantation Agris (24) claimed that trauma and desicca-tion injured transplanted fat cells Bircoll (25) stated that the ASPRS report (26) of 30% survival and Peer’s report

(27) of 50% survival of autologous fat transplantation were based on the older technique of bulk fat transfer Biopsies show 80% survival of fat after 1 year and an additional bulk of 10–20% of fibrous tissue Fat trans-plants must be placed into the fatty subcutaneous tissue.Billings and May (28) analyzed the histology of free fat grafts and noted the following:

Markman (29) has suggested that the number of fat

cells may increase, through differentiation of existing

preadipocytes, when fat cells reach a “critical size.”

Illouz (30) reported that fibroblast-like precursor

cells are able to multiply and give rise to fibroblasts or

cells that resemble fibroblasts When these cells are

stimulated to absorb fat vacuoles with insulin or

dex-amethasone, they do not because adipocytes He noted

that adipocytes are very fragile and have a short life

span outside the body The cells live longer if mixed

with normal saline and kept at a moderate temperature

They do not tolerate excessive manipulation,

refrigera-tion, or major trauma such as grinding

Hudson et al (31) demonstrated a greater cell size

and lipogenic activity (using measurement of activity

of lipogenic enzyme adipose tissue lipoprotein lipase

[ATLPL]) in the gluteal – femoral area compared to

the abdomen Facial fat was found to have small cells

with almost no ATLPL activity This may have

impli-cations for donor site suitability

Nguyen et al (32) compared suctioned fat,

aspi-rated fat, and excised fat 9 months after implantation

Suctioned fat was obtained by using 1 atm negative

pressure and on microscopy, only 10% of the fat cells

were found with intact cell membrane In all the grafts,

fat was replaced with fibrosis, and only a small number

of surviving adipocytes were still present

Kononas et al (33) compared the loss of fat

fol-lowing transplant between surgically excised fat cut

into small pieces and suctioned fat which was

centri-fuged Weight loss was 59% for excised fat and 67%

for suctioned fat Ersek (34) used a wire whisk to

agi-tate harvested fat and then strained it He reported

disappointing results even with repeated injection

and concluded that little, if any, autologous fat vives in its new site

sur-Courtiss et al (35) reported marginal success in fat grafting of two patients with postliposuction depres-sions Asaadi (36) reported 5-year successful retention

of fat transplanted to a right trochanteric post-traumatic depressed scar

Samdal et al (37) measured blood flow and the amount of surviving fat following needle abrasion of the recipient site in rats Abrasion was performed by a criss-cross pattern with 20 strokes using an 18 gauge needle in the subcutaneous tissue prior to transplant and compared this to controls without abrasion They found that the mean weight of the fat transplant had shrunk to 44.6% of the original weight in the abraded group and 33.5% in the control group The mean blood flow in fat was 0.165 mL/min/g in normal fat, 0.120 mL/min/g in the controls, and 0.187 mL/min/g in the abraded group Microscopic examination of the transplanted fat varied from oil cysts, connective tissue, and inflammatory cells

in some specimens and completely normal fatty tissue

in others Fat survival varied from 0–90% They cluded that fat transplant survival was unpredictable.Eppley et al (38) reported that the addition of basic fibroblast growth factor delivered by dextran beads to fat grafts results in a larger weight maintenance of fat

con-at 1 year than controls

Time (days) Histology

First 4 days Cellular infiltrate: polymorphonuclear cells, plasma cells, lymphocytes, eosinophils

With vessels of graft: red blood cells were clumped together, white blood cells were in the process of diapedesis (passage of blood cells through intact vessel walls)

No degeneration of graft endothelial cells and fibroblasts of the stroma Fourth day Engorgement and dilatation of smaller stromal vessels with abundant red blood cells and diapedetic white

blood cells (anastomoses between smaller graft vessels and host red blood supply) Increased number of eosinophils in cellular infiltrate Foreign-body type giant cells often seen

10 days Areas of necrotic adipose tissue Regenerative proliferation of original fat cells mostly at periphery of lobules

– includes proliferating adipose cells of the graft and host round “histocyte-like” cells that took up lipid and enlarged 14–21 days.

Further adipose cell breakdown.

Increasing number of large host histocytes that appear to be picking up lipid with formation of droplets within their cytoplasm

30–60 days Increasing numbers of large histocytes which peak at 2 months Coalescing of fat globules in the cytoplasm.

Group A Fat aloneGroup B Fat with dextran beads Group C Fat with dextran beads soaked with

cytochrome C (nonmitogenic control solution)

Group D Fat with dextran beads soaked with basic

fibroblast growth factor

Histologically, he noted extensive interlacing collagen

formation between the adiposites that provide support

for the known effects of basic fibroblast growth factor on

mesenchymal cell lines There was an increased

unifor-mity in adipocyte size seen in 1 year grafts compared to

1 month grafts which may indicate a possible

matura-tion of these more “immature” cells Whether this

repre-sents repair of damaged adipocytes, preadipocyte

differentiation, conversion of infiltrating macrophages

or fibroblasts, or entrapped lipid material is speculative

Carpaneda and Ribeiro (39) examined fat 2 months

after transplantation and noted viable tissue only in the

peripheral zone of 3.5 mm diameter cylindrical grafts

There was 60% loss of grafted tissue which occurred

closer to the center They reported, in 1994 (40), that

graft viability depends on the thickness and geometric

shape and is inversely proportional to the graft

diame-ter if the diamediame-ter is greadiame-ter than 3 mm The maximum

percentage of viability is 40% when the graft is no

greater than 3.0 mm thick

Niechajev and Sevchuk (41) reported 50% fat

sur-vival over 3.5 years after single fat transplantation with

50% overcorrection They found that fat obtained under

maximum negative pressure (−0.95 atm) results in

par-tial breakage and vaporization of the fatty tissue About

two-thirds of the fat withstood the trauma of aspiration

Low pressure (−0.5 atm) resulted in smaller cell size

(29% smaller than with aspiration at −0.95 atm) and

they assumed that high pressure causes mechanical

dis-tention of the adipocytes which increases the risk of and

sometimes causes cell breakage

Courtiss (42) stated that fat grafting remains

contro-versial and poorly understood and that “some surgeons

have some impressive results, but most of us have many

disappointing results.” Fagrell et al (43) examined fat

6 months after implantation in the ears of rabbits The

fat implanted was obtained by:

1 Fat cylinder retrieved with 4.5 mm internal diameter

syringe pushed into the fat and pulling the piston back

2 Excised fat, 1 mg in weight

3 Aspirated fat using 2 mm (14 gauge) cannula and

syringe

The tissue was examined by light microscopy and computer-assisted image analysis There was no dif-ference between the weight of the 6 month excised specimen (no weight loss) between the fat cylinder and excised fat, but there was a 59% loss of weight of the aspirated fat The conclusion was that fat aspiration is traumatic and breaks up the cells However, there was histologic evidence of viable fat cells in all transplants

Jones and Lyles (44) harvested fat with a 60 mL syringe, 3.0 mm pyramid cannula, and locked the plunger

at 35 mL The harvested fat was washed three times with normal saline and gently agitated Cell cultures were pre-pared and maintained for 1 day to 2 months Microscopy disclosed maintenance of mature adipose cells without dedifferentiation into a precursor phenotype There was very little evidence of cellular damage or debris

Using photographs over a 6 year period of time, Coleman (45) demonstrated long-term survival of lipo-suctioned fat transplanted into the nasolabial fold He stated that fat can migrate as the pressure of excess tis-sue forces the transplanted fat to shift and that fat can die from inadequate nutrition and oxygen from compe-tition with other transplanted parcels of fatty tissue Placement of fat into multiple tunnels allows closer location to nutrition He concluded that fat survival is technique dependent and the primary reason for failure

of long-term correction of the nasolabial fold is initial inadequate correction

Sattler and Sommer (46) found that autologous fat, dried over sterile swabs and frozen at −20°C (lower temperatures down to −70°C are preferable) up to 2 years and then thawed at room temperature, contains only fat cells and no fibrous debris

Ullmann et al (47) added Cariel, a modified serum-free cell culture medium (MCDB 153), to aspirated human fat prior to reinjection into mice Cariel contains essential and nonessential amino acids, vitamins, inorganic salts, trace elements, buf-fers, thyroxin, growth hormone, insulin, and sodium selenite There was 46% of the weight of the fat remaining after 15 weeks in the group with Cariel compared to 29% in the control without Cariel They concluded that the addition of nutrients enriched with anabolic hormones enabled the survival and take of more adipose cell in the graft United States Patent (Lindenbaum) Composition and methods for enhanc-ing wound healing Patent No 5461030 Date of patient: 24 October 1995

Group Weight retention after

1 Verderame P Ueber fettransplantation bei adharenten

kno-chennarben am orbitalran Klin Montsbl f Augenh 1909;

4 Davis CB Free transplantation of the omentum,

subcutane-ously and within the abdomen J Am Med Assoc 1917;68:

705–706.

5 Lexer E Fatty tissue transplantation In: Die Transplantation,

Part I Stuttgart, Ferdinand Enke, 1919, pp 265–302.

6 Mann FC The transplantation of fat in the peritoneal cavity

9 Hilse A Histologische ergebuisse der experimentellen freien

fettgewebstronsplantation Beitr 2 Path Anal U Z Allg Path

12 Peer LA Loss of weight and volume in human fat grafts: With

postulation of a “cell survival theory.” Plast Reconstr Surg

1950;5:217–230.

13 Bames HO Augmentation mammoplasty by lipotransplant

Plast Reconstr Surg 1953;11(5):404–412.

14 Hansberger FX Quantitative studies on the development of

autotransplants of immature adipose tissue of rats Anat Rec

1995;122:507.

15 Schorcher F Fettgewebsver pflanzung bei zu kneiner brust

Munchen Med Wochenschr 1957;99(14):489.

16 Van RL, Roncari DA Complete differentiation of adipocyte

precursors: A culture system for studying the cellular nature

of adipose tissue Cell Tiss Res 1978;195(2):317–329.

17 Van RL, Roncari DA Complete differentiation in vivo of

implanted cultured adipocyte precursors from adult rats

Cell Tiss Res 1982;225(3):557–566.

18 Saunders MC, Keller JT, Dunsker SB, Mayfield FH Survival

of autologous fat grafts in humans and mice Connect Tiss

Res 1981;8(2):85–95.

19 Illouz YG: New applications of liposuction In Illouz YG

(ed), Liposuction: The Franco-American Experience Beverly

Hills, CA, Medical Aesthetics, 1985, pp 365–414.

20 Illouz YG The fat cell “graft”: A new technique to fill

depres-sions Plast Reconstr Surg 1986;78(1):122–123.

21 Asken S Autologous fat transplantation: Micro and macro

techniques Am J Cosm Surg 1987;4:111–121.

22 Campbell GL, Laudenslager N, Newman J The effect of

mechanical stress on adipocyte morphology and metabolism

Am J Cosm Surg 1987;4:89–94.

23 Johnson GW Body contouring by macroinjection of

autog-enous fat Am J Cosm Surg 1987;4(2):103–109.

24 Agris J Autologous fat transplantation: A 3-year study Am

J Cosm Surg 1987;4(2):95–102.

25 Bircoll M Autologous fat transplantation: An evaluation of microcalcification and fat cell survivability following (AFT) cosmetic breast augmentation Am J Cosm Surg 1988;5(4) 283–288.

26 ASPRS Ad-Hoc Committee on new Procedures: Report on Autologous fat transplantation Plast Surg Nurs 1987 Winter; 7(4):140–141.

27 Peer LA The neglected free fat graft Plast Reconstr Surg 1956;18(4):233–250.

28 Billings E Jr, May JW Historical review and present status

of free fat graft autotransplantation in plastic and tive surgery Plast Reconstr Surg 1989;83(2):368–381.

reconstruc-29 Markman B Anatomy and physiology of adipose tissue Clin Plast Surg 1989;16(2):235–244.

30 Illouz YG Fat injection: A four year clinical trial In Hetter

GP (ed), Lipoplasty: The Theory and Practice of Blunt Suction Lipectomy, Second Edition, Boston, Little Brown, 1990,

pp 239–246.

31 Hudson DA, Lambert EV, Block CE Site selection for fat autotransplantation: Some observations Aesthetic Plast Surg 1990;14(3):195–197.

32 Nguyen A, Pasyk KA, Bouvier TN, Hassett CA, Argernt LC Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques Plast Reconstr Surg 1990;85(3):378–386.

33 Kononas TC, Bucky LP, Hurley C, May JW Jr The fate of suctioned and surgically removed fat after reimplantation for soft-tissue augmentation A volume and histologic study in the rabbit Plast Reconstr Surg 1993;91(5):763–768.

34 Ersek RA Transplantation of purified autologous fat:

A 3-year follow-up is disappointing Plast Reconstr Surg 1991;87(2):219–227.

35 Courtiss EH, Choucair RJ, Donelan MB Large-volume tion lipectomy: An analysis of 108 patients Plast Reconstr Surg 1992;89(6):1068–1079.

suc-36 Asaadi M, Haramis HT Successful autologous fat injection

at 5-year follow-up Plast Reconstr Surg 1993;91(4): 755–756.

37 Samdal F, Skolleborg KC, Berthelsen N The effect of operative needle abrasion of the recipient on survival of autologous free fat grafts in rats Scand J Reconstr hand Surg 1992;26(1):33–36.

pre-38 Eppley BL, Sidner RA, Plastis JM, Sadove AM Bioactivation

of free-fat transfers: A potential new approach to improving graft survival Plast Reconstr Surg 1992;90(6):1022–1030.

39 Carpaneda CA, Ribeiro MT Study of the histologic tions and viability of the adipose graft in humans Aesthetic Plast Surg 1993;17(1):43–47.

altera-40 Carpaneda CA, Ribeiro MT Percentage of graft viability versus injected volume in adipose autotransplants Aesthetic Plast Surg 1994;18(1):17–19.

41 Niechajev I, Sevchuk O Long-term results of fat tation: Clinical and histologic studies Plast Reconstr Surg 1994;94(3):496–506.

transplan-42 Courtiss EH Surgical correction of postliposuction contour irregularities Plast Reconstr Surg 1994;94:137–138; discus- sion 137–138.

43 Fagrell D, Eneström S, Berggren A, Kniola B Fat cylinder transplantation: An experimental comparative study of three different kinds of fat transplants Plast Reconstr Surg 1996; 98(1):90–96.

44 Jones JK, Lyles ME The viability of human adipocytes after

closed-syringe liposuction harvest Am J Cosm Surg 1997;

14:275–279.

45 Coleman SR Long-term survival of fat transplants:

Con-trolled demonstrations Aesthetic Plast Surg 1995;19(5):

M A Shiffman (Ed.), Autologous Fat Transfer 11

DOI: 10.1007/978-3-642-00473-5_3, © Springer-Verlag Berlin Heidelberg 2010

3.1 Introduction

The introduction of liposuction for fat reduction and

body contouring has developed into transplantation of

the extracted fat for augmentation of defects or for

cos-metic purposes There has been a controversy

concern-ing the manner of collectconcern-ing, injectconcern-ing, and cleansconcern-ing

the fat and the effectiveness of the fat transfer Some

physicians have been disappointed with the long-term

results of fat transplantation

The process of fat transplantation has not yet been

standardized, and there is a need to analyze some of

the methods and results

3.2 Fat Transplant Survival

Vitamin E is a necessary factor in the maintenance of fat

tissue (1) while insulin increases the metabolic activity

of fat cells (2) and retards lipolysis (3–7) Hiragun et al

(8) theorized that insulin may induce fibroblasts to pick

up lipid lost from lipolysis and become adipocytes

Skouge (3) felt that fat cells from an area of relatively

poor vascularity will be more hardy, have decreased

metabolic needs, and increase survival Asken (9),

how-ever, stated that the more fibrous areas, such as upper

abdomen, are not ideal for donor sites

Fat characteristics may be helpful in determining

which area of fat is more likely to be retained The

adi-pocytes with alpha 2 receptors are antilipolytic with poor

response to diet and appear more likely to survive with

little change from weight loss or weight gain in son with adipocytes with beta 1 receptors (Table 3.1)

compari-Survival of adipocytes depends on the tion used for harvesting and injecting the fat Damage is inversely related to the diameter of the instrument to extract and inject fat (10) The pressure generated in injecting fat increases as a function of decreasing needle diameter (from 16 to 22 gauge) (11) There is some decrease in the metabolic activity of fragments that are passed through 20-gauge needles or smaller (Table 3.2)

instrumentaHowever, the size of the extracted particles is not de scribed If the extraction of fat is with a cannula that is 20 gauge, it is doubtful that the 20-gauge needle would cause damage to the adipocytes

-The presence of blood in the fat injected stimulates macrophage activity to remove the cells Washing the cells in a physiologic solution prior to injection will solve the problem (12–14) Skouge (3) raised the ques-tion of whether washing decreases the viability of frag-ile adipocytes

Campbell et al (11) concluded that adipocyte rity and metabolism of fat fragments subjected to mechanical manipulation by liposuction using wall suc-tion remain intact Illouz (12) biopsied the areas of fat injection and found normal fat cells

integ-McCurdy (15) analyzed fat cell survival and cluded that the technical factors to accomplish the goal

con-of 40–50% transplanted adipocyte survival include:

1 Low vascularity of donor site

2 High vascularity for recipient site

3 Low pressure technique of aspiration of fat

4 Filtering and washing harvested adipocytes

5 Use of ³2 mm cannula for injection to minimize adipocyte injury

6 Multilayered deposition of fat

7 Overcorrection of the recipient site

Principles of Autologous Fat Transplantation

Melvin A Shiffman

3

M A Shiffman

Department of Surgery, Tustin Hospital and Medical Center,

17501 Chatham Drive, Tustin, CA 92780-2302, USA

e-mail: shiffmanmdjd@yahoo.com

Because of the problem of resorption of fat with fat

transplantation, 30–50% overinjection is ordinarily used

(16–21) Asadi and Haramis (16) determined that

sub-dermal injection is important for long-term results

3.3 Indications for Fat Transplantation

There have been two papers that relate to the

indica-tions for autologous fat transplantation

Skouge (22): Indications for fat transplantation

2 Soft-tissue defects of the body

In analyzing these lists, a simpler and more useful classification can be devised:

Indications (Shiffman)

1 Fill defects (a) Congenital (b) Traumatic (c) Disease (acne) (d) Iatrogenic

2 Cosmetic (a) Furrows (wrinkles) (b) Refill Lost Supportive Tissue (aging) (c) Enhancement

3 Non cosmetic (a) Migraine headaches, clival chordoma surgery, congenital short palate, vocal cord paralysis, lum-bar laminectomy, sulcus vocalis, vocal cord scar, hemifacial atrophy, myringoplasty, eye socket recon struction, frontal sinus fracture, temporo-mandibular joint reconstruction)

Some of these procedures need fat transfer to prevent scarring

Alpha 2 receptors Beta 1 receptors Lipolysis Antilypolytic Lipolytic

Response to diet Poor Good

Region of fat Abdominal, trochanteric

(genetic fat)

Facial, arms, upper torso

Table 3.1 Fat characteristics (8)

Table 3.2 Needle size and cell survival (11)

+ = 75% or more without cell damage

o = 25–75% cell damage

− = > 75% cell damage

3.4 Complications of Fat

Transplantation

Injection of small globules will prevent cyst

forma-tion Johnson (24) showed that one, three, and five cc

injections resulted in small cysts, but 10 cc injection

had macroscopic cyst formation Oil cysts develop

through the confluence of necrotic fat cells having a

lining of macrophages, and resorption may take years,

thus giving a false impression of a successful

trans-plantation (25)

Sterility of fat retrieval and injection must be

maintained

Infection has not been reported (22)

Bruising, temporary swelling, and tenderness may

result from fat transplantation (22)

Teimourian (26) reported that a patient upon

injec-tion of fat into the glabellar frown lines complained of

pain and loss of vision in one eye There was central

retinal artery thrombosis, probably secondary to fat

particle embolism

Calcifications have only been reported in fat

trans-plantation to the breast for augmentation This does

not appear to be a significant risk since the timing of

the appearance, the position, and the character of the

calcifications will indicate the etiology

The most important problem encountered is fat

resorption Trauma to the cells, desiccation during

transfer, and the presence of blood are contributing

factors At least an 18-gauge needle should be used to

reinject fat Ersek (27) reported that very little

autolo-gous fat survives but his use of a whisk in the cleansing

process probably destroyed most of the fat cells

3.5 Technique of Autologous Fat

Transplantation

The lack of standardization of fat collection and

trans-plantation allows a wide range of methods with varied

results

Following are methods utilized by certain cosmetic

surgeons, which the author obtained by personal

commu-nication:

Billie (28)

“I do have patients whose cases go back to over 10

years, at this point I have had good fortune over all

with non-smokers and actually a moderate amount of success among smokers I have found that the younger the patients are, the better they seem to do We placed

it at multiple sites, including defects in legs from matic events such as automobile accidents or recluse spider bites, the nasal labial furrows in aging patients.Over the years, I have washed the fat, sometimes not washed the fat, added insulin, sometimes not added insulin, tried everything and currently even utilizing a 4-mm cannula to remove the fat, catching it in the ster-ile in-line trap, not washing it and reapplying it utiliz-ing a 16-gauge fat grafting needle with a 10-mL syringe apparatus.”

trau-Fragen (29)

“I have found that autologous fat transplantation is

a very effective part of my facial rejuvenation surgery, provided I give the patients a detailed explanation of the limited nature of the procedure and the fact that it

is always somewhat temporary Depending on the patient and the location to where the fat is transferred, the fat survives for a variable period I have found that transferring fat under skin grafts, scars, and on top of semirigid or rigid surfaces improves the viability of the fat transfer For example, if one transfers fat under the skin post mastectomy, it seems to stay there and offers some padding Putting it under burn scars will help increase the padding of the burn scar and make the skin grafts over it more pliable and flexible If fat is transferred to a lip, it seems to survive there the least, because of the active nature of the lip

My method of transfer is very simple I like to call

it a closed system Essentially what is done is the area for fat harvesting is prepped and draped and infiltrated with a Klein solution The fat is then harvested with

a 14-gauge blunt cannula on a 10-cc syringe If there appears to be excess saline, the excess saline is decanted

If there is excess bloody tissue, then the specimen is washed in saline and again decanted If, as is usual, essentially pure fat is removed from the donor site, then it is maintained within the syringe with the blunt 14-gauge cannula

A small stab incision is made near the site for fat transfer, and the blunt cannula is then placed into the donor area Several tunnels are made with the blunt cannula so that the fat is not squeezed into the area, but rather easily injected into the donor site Then, the fat

is transferred to the donor site Both sites are prepared sterilely If the patient is under general anesthesia then usually no anesthesia is used for the recipient site If

this is done under local anesthesia, a small amount of

1% Xylocaine with adrenaline is infiltrated into either

the lips or the glabella or whatever site we are

transfer-ring the fat to

I usually over-fill the graft site by approximately

50%, and I tell patients that the swelling will last 3–5

days I routinely do fat transferring on face lift patients

I do somewhere around ten or more face lifts per month,

and I would guess that 80% of those have a fat transfer

associated with it

Untoward effects include bruising, short-term

swell-ing, occasional lumpiness, and stimulation of fever

blis-ters The lumping has never been a problem, in that the

fat can easily be compressed, even months later Once a

patient had a small fat cyst that was easily removed

It is my feeling that fat injected into the lower

por-tion of the nasolabial fold, the lips, and the droll lines

has a relatively short life span, with the ideal results

being reached in approximately 2 weeks and slow

dis-appearance over 2–4 months In the glabella, I believe

the fat will last six to more months and, in many cases,

over a year I think the area nearer the nose in the

nasolabial fold will retain fat a little better In that area

also the fat will last 6–8 months Fat injected under

graft sites, scars, and over other hard prominences I

think lasts for many months and I have several cases

where the fat has lasted several years The primary

advantage of fat transfer is that it can very effectively

camouflage cosmetic defects (such as thin upper lips

with wrinkling, glabellar frown lines, drool line, etc)

which are difficult to correct without other extensive

procedures In Palm Springs, we find many people

who do not want to restrict their outdoor activities,

such as tennis and golf These patients accept the safe,

though temporary, correction by fat transfer Their

biggest complaint is that the wonderful result they get

is short-lived, but, until we find a safe, nonresorbable

filler which the FDA will approve, we do not have a

better alternative.”

Tobin (30)

“About 10 years ago, when liposuction surgery was

first introduced, we began hearing recommendations

for re-injection of fat My initial experience with this

procedure was to attempt to refine breast reconstruction

cases by injecting small amounts of fat adjacent to

implants or in patients on whom other surgeons had

carried out flap reconstructions We initially harvested

the fat with a syringe and reinjected it using an old,

mechanical injector that was designed initially to inject

Teflon into the vocal cords In essence, we were ing it through an 18-gauge needle with a very precise ratchet mechanism The results were discouraging with rapid re-absorption We felt that perhaps this was related

inject-to the fact that we were injecting ininject-to a scarred area

At about the same time, we began injecting fat into the face My first experience with this procedure was

to attempt to correct grooving in the cheeks that was caused by facial liposuction We did not understand the risks that were involved when liposuction was car-ried out in this area Many of us ended up with patients who had irregularities or waviness Again, we used the same technique – namely aspiration with a syringe and re-injection through the Teflon gun Again, the results were discouraging

Because of these failures, we essentially abandoned the technique Sometime later, we heard about suc-cesses with injection of fat into the back of the hand and we attempted a few cases By this time, we had stopped using the Teflon gun and were simply aspirat-ing the fat with the syringe and transferring it to smaller syringes through a small transfer tube after which the fat was injected into the back of the hand Our tech-nique included aspiration of fat with a syringe, rinsing and straining with saline and then re-injection Again, both we and our patients were disappointed with the results

About 3 years ago, after hearing of successes with the injection of separated fat, we were tempted to try again Several surgeons had various techniques of morselizing the fat and injecting the fibrous portion Often, this mate-rial was called autologous collagen, although I am not aware of any confirmation that the material was in any way similar to the bovine collagen that had become so popular under the trade name Zyderm

We utilized the technique recommended by Hilton Becker of Palm Beach Kits were available which included syringes for transferring the material through

a progressively smaller orifice This resulted in the morse lization of the material Following this, the mate-rial was centrifuged and the collagenous component was obtained to be used for re-injection The material was supposedly capable of being preserved by freezing and we attempted this as well We probably treated about 25 patients with this process, carrying out multi-ple injections over a period of several months As far as

I can remember, we did not have even a single patient who was really pleased with the results and we have since then abandoned it

At present, our use of injectable fat is uncommon

When patients request for it, we explain the fact that

the previous experiences have not been very positive,

but we do offer it as an option

Occasionally, patients request it but once again, I

have not seen any convincing evidence that there is any

permanent augmentation

Obviously, I am perplexed by the reports and the

literature by reputable surgeons who claim they see

permanent results Until I see a series of consecutive

cases presented over a relatively long period of time, I

will remain unconvinced but will attempt to be open

minded.”

3.6 Insulin

Some physicians have added insulin to the fat in

prepa-ration for transplantation (12, 31, 32) The theory is

that insulin inhibits lipolysis

Sidman (33) found that insulin decreases lipolysis

Hiragun et al (34) stated that theoretically insulin may

induce fibroblasts to pick up the lipid lost and become

adipocytes

Chajchir et al (35) found that the use of insulin did

not show any positive effect on adipocyte survival

dur-ing transplantation compared to fat not prepared with

insulin

3.7 Centrifugation

Some physicians centrifuge the adipose tissue to remove

blood products and free lipids to improve the quality of

the fat to be injected (31, 36, 37)

Asken (9) stated that his “method of reducing the

material to be injected to practically pure fat is to place

the fat-filled syringe with a rubber cap (the plunger

having been previously removed and kept in a sterile

environment) into a centrifuge The syringe is then

spun for a few seconds at the desired rpm and the

serum, blood, and liquefied fat collects in the

depen-dent part of the syringe…”

Toledo (36) reported that “for facial injection we

spin the full syringes for 1 min… in a manual

centri-fuge (about 2,000 rpm), eject the unwanted solution,

and transfer the fat…”

Uebel (38) centrifuged autologous fat at 10,000 rpm for 10 min in order to obtain a “fat-collagen graft.” The centrifuged material on histologic examination showed cell residues, collagen fibers, and 5% intact fat cells The material is absorbed at a slow rate and main-tains the contour and volume for 18–24 months A new graft procedure is always performed to achieve a more permanent result

Chajchir et al (35) centrifuged 1 cc of bladder fat pad from mince (both at 1,000 rpm for 5 min and 5,000 rpm for 5 min) and injected it into the malar area sub-dermis Microscopically, after 1–2 months there were macrophages filled with lipid droplets, giant cells, focal necrosis of adipocytes, and cyst like cavities of irregu-lar size and shapes After 112 months following injec-tion no recognized adipocytes could be found Total cellular damage was present in both groups

Brandow and Newman (39) found that tion of harvested fat did not alter the microscopic structured integrity of cells Spun and unspun samples were examined and were similar

centrifuga-Fulton et al (40) found that centrifuged fat, 3 min at 3,400 rpm, works well for small volume transfers, but not for large volume transfers into breasts, biceps, or buttocks

3.8 Ratchet Gun for Injection

Neuman and Levin (41) designed a lipo-injector with gear driven plunger to inject fat tissue evenly into desired sites Fat injected with excessive pressure in the barrel

of a syringe can cause sudden injections of undesired quantities of fat which will pour into recipient sites.Agris (42) stated that a ratchet-type gun allows con-trolled accurate deposition of autologous fat Each time the trigger is pulled, 0.1 cc is deposited

Neichajev (43) used a ratchet gun for free plantation of fat harvested at −0.5 atm pressure EH noted only partial resorption of the fat but with signifi-cant improvement of the contour

trans-Asadi and Haramis (44) described the use of a gun with disposable 10 mL syringe for fat injection.Niechajev and Sevc´uk (45) utilized a special pistol and a blunt typed cannula, with 2.3 mm internal diam-eter, to inject the fat

Berdeguer (23) used a lipotransplant gun to inject fat into areas to be enhanced

Fulton et al (40) stated that it is beneficial for a

beginning surgeon i.e., a fresher to use a ratcheted

pis-tol for injection as this gives a more uniform injection

volume

3.9 Severing Tethering Bands

Several surgeons have suggested severing of tethering

bands, usually with a needle, paddle shaped, or V shaped

(“pickle-fork”) typed instrument, to allow the skin to lift

more easily with injection of fat (36, 46–48) Recurrence

of depressions was thought to be less likely

3.10 Machine Liposuction

“Liposuction harvesting of fat is traumatic and results in

a graft composed of intact cells combined with cellular

debris and free lipid” (49) Liposuction removal of

autol-ogous fat by −1 atm suction was reported by Nguyen

et al (50) as showing microscopically 90% elongated,

irregularly shaped, and ruptured adipocytes and only

10% unchanged, normal-appearing adipocytes With the

use of a 10-ml syringe for aspiration of fat, they found

95% unchanged adipocytes May (51), in commenting

of Nguyen’s study stated that “…one would have thought

that aspiration could produce nearly the same degree of

suction (1 atm.) as formal suctioning If the degrees of

negative pressure produced by these two techniques are

similar, and if the cannulas are similar then the degree of

cell damage should have been similar.”

Niechajev (43) obtained fat for grafting using a

vacuum pump with –0.5 atm pressure Using a ratchet

gun for injection into the cheek, he noted only partial

resorption of the fat over 1½–4 years (mean 3 years)

Niechajev and Sevc´uk (45) reported 50% fat survival

over 3.5 years after single fat transplantation with 50%

overcorrection They found that fat obtained under

maximum negative pressure (–0.95 atm.) results in

partial breakage and vaporization of the fatty tissue

About two-thirds of the fat withstood the trauma of

aspiration Low pressure (–0.5 atm.) results in smaller

cell size (29% smaller than with aspiration at –0.95%

atm.) and assumed that high pressure causes

mechani-cal distention of the adipocytes which increases the

risk of and sometimes causes cell breakage

Elam et al (52) noted more effective fat removal by lowering the negative suction pressure during liposuction Negative pressures varied from 15 in of mercury (–375

mm mercury) to 30 in (–750 mm) (–760 mm = 1 atm.) Above 25 in of mercury (–625 mm) an obvious amount

of blood appears in the aspiration along with air bles At maximum vacuum (–750 mm) the aspirate is a blood-tinged mixture of fatty globules with significant amounts of dark venous blood The ideal liposuction vacuum pressure at sea level was felt to be a negative

Injection should be on withdrawing the needle to prevent accidental injection into vessels and over injec-tion into an area that is fibrous causing resistance to the cannula insertion

Sharp needles should not be used to inject fat into the recipient site Recently, small cannulas have been devised with relatively blunt tips that can be used for reinjection without the problem of bleeding in the recipient area Blood in the donor fat should be removed

by decanting with physiologic solution Blood, as is infection, is the enemy of fat and will result in a major loss of the transferred fat

4 Sidman RL The direct effect of insulin on organ cultures of brown fat Anal Rec 1956;124(4):723–739.

5 Smith U Human adipose tissue in culture studies on the abolic effect of insulin Diabetologia 1976;12(2):137–143.

6 Solomon SS Comparative studies of the antilipolytic effect

of insulin and adenosine in the perfused fat cell Horm Metab Res 1980;12(11):601–604.

7 Solomon SS, Duckworth WC Effect of antecedent hormone

administration on lipolysis in the perfused isolated fat cell

J Lab Clin Med 1976;88(6):984–994.

8 Hiragun A, Sato M, Mitsui H Establishment of a clonal cell

line that differentiates into adipose cells in vitro In Vitro

1980;16(8):685–693.

9 Asken S Autologous fat transplantation: Micro and macro

techniques Am J Cosmet Surg 1987;4(2):111–121.

10 Dolsky RL Adipocyte survival Presented at the Third

Annual Scientific Meeting of the American Academy of

Cosmetic Surgery and The American Society of

Lipo-Suction Surgery, Los Angeles, February 1987.

11 Campbell GL, Laudenslager N, Newman J The effect of

mechanical stress on adipocyte morphology and

metabo-lism Am J Cosmet Surg 1987; 4(2):89–94.

12 Illouz YG The fat cell “graft”: A new technique to fill

depressions Plast Reconstr Surg 1986;78(1):122–123.

13 Krulig E Lipo-injection Am J Cosmet Surg 1987;4(2):

123–129.

14 Lewis CM Correction of deep gluteal depression by

autolo-gous fat grafting Aesthetic Plast Surg 1992;16(3):247–250.

15 McCurdy JA, Jr Five years of experience using fat for leg

con-touring (Commentary) Am J Cosmet Surg 1995;12(3):228.

16 Asadi M, Haramis HT Successful autologous fat

injec-tion at 5-year follow-up Plast Reconstr Surg 1993;91(4):

755–756.

17 Chajchir A, Benzaquen I Liposuction fat grafts in face

wrin-kles and hemifacial atrophy Aesthetic Plast Surg 1986;10(2):

115–117.

18 Chajchir A, Benzaquen I Fat-grafting injection for soft tissue

augmentation Plast Reconstr Surg 1989;84(6):921–934

19 Chiu DT, Edgerton BW Repair and grafting of dermis, fat,

and fascia In: McCarthy, J (ed), Plastic Surgery Philadelphia,

W.B Saunders, 1990, p 515.

20 Illouz YG De l’utilization de la graisse aspiree pour combler les

defects cutanes Rev Chir Esthet Langue Fr 1985;

10(40):13.

21 Matsudo PK, Toledo LS Experience of injected fat grafting

Aesthetic Plast Surg 1988;12(1):35–38.

22 Skouge J The effectiveness and long term survival of

trans-planted fat Presented at American Academy of Cosmetic

Surgery, Philadelphia, 7–9 Aug 1992.

23 Berdeguer P Five years of experience using fat for leg

con-touring Am J Cosmet Surg 1995;12(3):221–229.

24 Johnson GW Body contouring by macroinjection of

autog-enous fat Am J Cosmet Surg 1987;4(2):103–109.

25 Smahel J Fat cylinder transplantation: An experimental

study of three different kinds of fat transplants Plast Reconstr

Surg 1996;98(1):97–98.

26 Teimourian B Blindness following fat injections Plast

Reconstr Surg 1988;82(2):361.

27 Ersek RA Transplantation of purified autologous fat: A

3-year follow-up is disappointing Plast Reconstr Surg 1991;

30 Tobin H Fat transfer Personal communication 3//5/96.

31 Ellenbogen R Free autogenous pearl fat grafts in the face –

A preliminary report of a rediscovered technique Ann Plast Surg 1986;16(3):179–194.

32 Newman J Preliminary report on “fat recycling” – Liposuction fat transfer for facial defects Am J Cosmet Surg 1986;3: 67–69.

33 Sidman RL The direct effect of insulin on organ cultures of brown fat Anat Rec 1956;124(4):723–739.

34 Hiragun A, Sato M, Mitsui H Establishment of a clonal line that differentiated into adipose cells in vitro In Vitro 1980;16(8):685–693.

35 Chajchir A, Benzaquen I, Moretti E Comparative mental study of autologous adipose tissue processed by dif- ferent techniques Aesthetic Plast Surg 1993;17(2):113–115.

experi-36 Toledo LS Syringe liposculpture: A two-year experience Aesthetic Plast Surg 1991;15(4):321–326.

37 Zocchi M Produccion y utilizacion de Colegeno Autologo para el remodelaje facial II Congreso Chileno de Cirugia Plastica, 1991.

38 Uebel CO Facial sculpture with centrifuged fat-collagen In: Hinderer VT (ed), Plastic Surgery, Vol II Amsterdam, Excerpta Medica, 1992, pp 749–752.

39 Brandow K, Newman J Facial multilayered micro lipo- augmentation Int J Aesth Restor Surg 1996;4(2):95–110.

40 Fulton JE, Suarez M, Silverton K, Barnes T Small volume fat transfer Dermatol Surg 1998;24(8):857–865.

41 Newman J, Levin J Facial lipo-transplant surgery Am

44 Asaadi M, Haramis HT Successful autologous fat injection at 5-year follow-up Plast Reconstr Surg 1993;91(4):755–756.

45 Niechajev I, Sevc´uk O Long term results of fat tion: Clinical and histologic studies Plast Reconstr Surg 1994;94(3):496–506.

transplanta-46 Fournier PF Liposculpture: The Syringe Technique Paris, Arnette, 1991.

47 Gasparotti M Superficial liposuction: a new application of the technique for aged and flaccid skin Aesthetic Plast Surg 1992;16(2):141–153.

48 Grazer FM Cellulite lysing Aesth Surg 1991;11:11.

49 Eppley BL, Sidner RA, Platis JM, Sadove AM Bioactivation

of free-fat transfers: A potential new approach to improving graft survival Plast Reconstr Surg 1992;90(6):1022–1030.

50 Nguyen A, Pasyk KA, Bouvier TN, Hassett CA, Argenta LC Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques Plast Reconstr Surg 1990;85(3):378–386.

51 May JW Jr Comparative study of survival of autologous pose tissue taken and transplanted by different techniques (Discussion) Plast Reconstr Surg 1990;85(3):387–389.

adi-52 Elam MV, Packer D, Schwab J Reduced negative pressure liposuction (RNPL): Could less be more? Int J Aesth Restor Surg 1997;5:101–104.

M A Shiffman (Ed.), Autologous Fat Transfer 19

DOI: 10.1007/978-3-642-00473-5_4, © Springer-Verlag Berlin Heidelberg 2010

4.1 Introduction

With an understanding of the subcutaneous fat anatomy,

physiology, and metabolism/nutrition, the surgeon can

gain familiarity with the interrelationship between these

three aspects of subcutaneous fat as they relate to

adi-pocyte mass, appearance, and liposculpture With this

knowledge, the surgeon should gain a deeper

under-standing of the impact of the surgical procedure that

may lead to improved results following fat transfer

An appreciation of the importance of interstitial

soluble protein is crucial because Klein’s solution

dra-matically dilutes its content and predictably, causes a

temporarily pseudo-leaky membrane in that region

Using excess Klein’s solution can produce symptoms

of acute congestive heart failure When administered

properly, Klein’s solution is safe in which the total

body’s soluble protein reserve will re-equilibrate over

a relatively short period of time

Until recently, the study of the lowly lipocyte was

considered boring and therefore limited Fat was

viewed as an adynamic tissue that stored energy,

improved insulation, and functioned as a shock

absorber The differences in fat distribution between

the sexes are well recognized and have been the subject

of discussion as well as artful renderings Removal of

fat by liposuction was thought the end of the line,

pro-ducing a localized permanent reduction in number;

however, nothing could be further from the truth Adult

stem cells are abundant within the fat mass, and in the

face of excess calorie consumption, these stem cells

are recruited to form new lipocytes as necessary It is clear that fat is also an endocrine and exocrine organ It reacts to and is the source of pro-inflammatory cytok-ines and has a role in immunity, as well as a dynamic role in metabolic activity and response to injury As will be detailed at the end of this chapter, fat represents one of the most exciting tissues of the body

4.2 Histology

Fibroblast appearing preadipocytes are noted in the embryo as well as in adult subcutaneous fat tissue The ultimate shape of a fat-laden mature adipocyte is that

of a cygnet ring as the central lipid accumulation pushes the nucleolus to the periphery (Fig 4.1)

The fibroblast appearing preadipocyte is tential During calorie deprivation fat cells can also dedifferentiate back into the fibroblast appearance

pluripo-The adult stem cell within the fat tissue has been ulated to form muscle and bone

stim-The Adipocyte Anatomy, Physiology, and Metabolism/Nutrition

Mitchell V Kaminski and Rose M Lopez de Vaughan

4

M V Kaminski ()

Finch University of Health Sciences, Chicago Medical School,

230 Center Drive, Vernon Hill, Chicago, IL 60061-1584, USA

Every lipocyte is surrounded by or touching a

capil-lary (Fig 4.1) These capillaries are highly sensitive to

epinephrine that causes vasoconstriction This is a

phe-nomenon associated with Klein’s tumescent anesthesia

that has made office-based liposuction a relatively

non-bloody procedure, and safe outside of the hospital

set-ting No other additive in Klein’s formula is as important

This surgeon uses 2 mg of epinephrine per 1,000 mL of

crystalloid rather than the recommended 1 mg Total

amount of tumescent solution with 2 mg of epinephrine

per liter should be limited to 3 L or less per procedure

4.3 The Interstitium

The connective tissue of the interstitium is host to myriad

cell types, including fibroblasts, adipocytes, macrophages

(histiocytes), neutrophils, eosinophils, lymphocytes,

plasma cells, mast cells, monocytes, and undifferentiated

mesenchymal cells These cells, either fixed or transient,

interact with each other and the extracellular matrix

com-ponents (i.e., collagen, elastic fibers, adhesion

glycopro-teins) and as mentioned a substantial amounts of soluble

protein (1, 2) Within this integrated gel-sol assemblage

are the vital components of the vasculature, initial

lym-phatics, and nervous system (lightly myelinated fibers to

free nerve endings, myelinated fibers to encapsulated

neural structures) The importance of the vasculature and

lymphatics in maintaining homeostasis of protein and

fluid concentration of the blood and interstitium is well

documented and cannot be overstated The neural

com-ponents at a single anatomic site, although perhaps not

vital, provide for the general sense of well-being The

presence of the above constituents within the interstitium,

however, cannot be overlooked and may represent the

seed medium for the growth of normal adipose tissue

Considering the cell biology of the anatomic site,

liposuction procedures are traumatic, albeit transient,

events Even with the most careful technique, the

archi-tecture and physiology are altered dramatically, which

sets in motion a cascade of systemic and

cytokine-mediated cellular responses

Providing a unified concept on the restructuring of this

anatomic site after traumatic events is a challenge that

needs to be met The inventory of the components of the

interstitium and how they interact is far from complete

Current techniques yield a heterogeneous material

composed of liberated fat, locules of adipose cells,

col-lagen fibers and septa, vessels and nerves, clots, ruptured

cells, hemoglobin, inflammatory proteins, proteases, genic enzymes, and electrolytes including calcium (3).Weber et al (4) developed a concept of extracellular homeostasis This concept is one of self-regulation of cellular composition and structure based on fibroblast-derived angiotensin that regulates the elaboration of trans forming growth factor-1 This is a fibrogenic cyto-kine responsible for connective tissue formation at nor-mal and pathologic sites Biologic responses are found

lipo-in various connective tissues, lipo-includlipo-ing adipose tissue Given that the three-dimensional architecture is altered profoundly, it is astonishing that it can be reconstituted

to normalcy in a relatively short period of time.Lipocytes are not islands unto themselves They are surrounded by a sea of supportive cells, proteins, growth factors and electrolytes

4.4 Physiology

For the most part, the adipocytes are not rounded, bloated spheres They have one or more flattened sides and are better described as polygonal and appear packed between the vasculature This is because they are com-pressed by colloid osmotic pressure, which is gener-ated by soluble protein in the interstitial space Under these conditions, the cells are like peanuts sealed by vacuum in a bag The interstitial proteins that surround cells create −7 mmHg pressure (5) Interstitial protein

is reported as total protein (TP) when measured by a laboratory Its three components are albumin, globulin, and fibrinogen Albumin is the principle soluble pro-tein and makes up at least 60% of TP (6) Because albumin is the smallest molecule that cannot pass eas-ily through the semi permeable membrane of the capil-lary, it contributes most of the oncotic force, squeezing cells together The number of particles in solution on one side of a semi permeable membrane, not their size, creates an oncotic force To be specific, albumin is 69,000 Daltons (Da), whereas globulin is 150,000 Da, and fibrinogen is 400,000 Da Thus, one gram of albu-min has twice as many molecules as 1gram of globulin, and eight times that of 1 g of fibrinogen

To understand that this is oncotic pressure and not osmotic pressure, one should recall that if the particle in solution can pass back and forth across the semi perme-able membrane, it cannot create an oncotic force For example, if a glass funnel is covered with a semi perme-able membrane whose pore size allows water, sodium,

and chloride to pass but not sucrose, and if that funnel

is then partially filled with a sugar and salt water

solu-tion and placed upside down in a beaker of fresh water,

after a period of time the sugar molecules on the funnel

side of the membrane are responsible for drawing fluid

into it Because sodium and chloride easily traverse the

membrane, they cannot create an oncotic force and will

distribute equally on both sides of the membrane

In vivo, soluble proteins that surround adipocytes

are dynamic Even if it be slow, albumin molecules

make a circuit from the heart across the capillary

mem-brane through the interstitial space and return to the

heart by way of lymphatic flow within 24–48 h

4.5 Gross Anatomy

There are three layer of subcutaneous fat: the apical,

the mantle, and deep layers

4.5.1 Apical Layer

This layer, just beneath the reticular dermis (Fig 4.2)

is also called thecal or periadnexal layer in that it

sur-rounds sweat glands and hair follicles

Slightly deeper, the apical layer also surrounds cular and lymphatic channels Depending on the quan-tity and depth of color of fruits and veggies in the diet this layer is rich in carotenoids and tends to be yellow

vas-in appearance Because of the neural, vascular and phatic potential for damage this layer should be avoided during liposuction Extensive disruption of these ana-tomical elements can lead to seroma, erythema, hyper-pigmentation and even full thickness dermal necrosis This was more of a problem in the past when larger diameter 8 and 10 mm cannulas were directed at the deep fat layer, but these complications have become rare in this era of 2 and 3 mm cannulas

lym-4.5.2 Mantle Layer

Just beneath the adipocytes’ investing dermal tures is another anatomically organized layer of fat cells that is part of the superficial fat layer It is called the mantle layer and is composed of more columnar shaped lipocytes It is separated from the deep layer

struc-of fat by a fascia-like layer struc-of fibrous tissue The tle is absent from the eyelids, nail beds, bridge of the nose and penis

man-This layer significantly contributes to the skin’s ity to resist trauma It causes external pressure to be distributed across a larger field; much like a box spring mattress absorbs sitting pressure

abil-4.5.3 Deep Layer

This layer extends from the undersurface of the tle layer to the muscle fascia below Its shape and thickness depends on the sex, genes, and diet of the individual This is the layer best suited for liposculp-ture Here fat cells are arranged in pearls and pearls gathered into globules These globules are then pack-aged like eggs in an egg crate between fibrous septa and then arranged between tangential and oblique fibrous planes

man-Histologically tangential planes are thicker and run parallel to the underlying muscle fascia, but they are of little consequence when performing liposuction.Oblique planes are thinner and interconnect the tan-gential fibrous layers They hold fat globules in their

Fig 4.2 The general lipocyte distribution from the dermis to the

muscular fascia The apical and mantle layers represent the “no

man’s zone” of liposuction Damage to these layers may

com-promise the blood supply to the skin and predispose to

postop-erative complication such as seroma or dermal necrosis

relative positions Though thinner, they are of a

cos-metic consequence because the vertical arrangement

of subcutaneous fat from skin to muscle fascia is the

cause of cellulite

4.6 Deep Fat of the Neck

A wattle is produce by accumulation of excess of fat

between platysma and the superficial layer of the deep

cervical fascia and is superficial to the anterior bellies of

the digastric muscles (Fig 4.3) The fat immediately

beneath the platysma is amenable to liposuction

How-ever, the fat between the digastric muscles and beneath

the superficial layer of the deep, or the investing fascia of

the neck should not be removed Doing so may result

in a permanent depression

The buccal fat pad accounts for the chipmunk fascial

features noted in some families It extends anterior to

the mandibular ramus into the cheek, deep into the

sub-cutaneous musculoaponeurotic system (SMAS)

bucci-nators The buccal branch of C7 courses over and just

lateral to the buccal fat pad

4.7 Upper Arm Fat

Liposuction without brachioplasty is suitable for younger

patients with minimal to moderate fat excess, who

exhibit taut skin It is generally limited to the posterior

flap This flap in layman’s terms produces a “kimono

arm” deformity (Fig 4.4)

For the patient who is middle aged and has loose

skin, liposuction may have to be accompanied by a

brachioplasty Loose skin of the posterior arm shrinks poorly The patient who chooses liposuction without resection should understand that an excision may be required later

A middle aged to older individual who complains of loose skin following weight loss or due to senile laxity, will always require an excision of the redundant tissue Preoperative notes should make clear the fact that these considerations were discussed in detail with the patient

4.8 Abdomen

The subcutaneous fat of the abdominal wall is divided

by two easily identifiable fascial layers: The superficial Campers fascia and the deeper Scarpas fascia These layers are most easily observed in the lower abdomen The deep fascia overlays the musculoaponeurosis and is continuous with the fascia lata of the thigh It also cov-ers the small arteries and veins along the surface of the anterior rectus sheath Liposuction using small cannulas

of 2–3.7 mm in diameter can be artfully performed

Fig 4.3 Submantle fat is amenable to standard liposuction

tech-nique using very small canuulas Removal of the buccal fat

requires an intra-oral incision just lateral to the second molar

tooth Removal of the intra-digastric fat also requires an incision but is usually not advised unless excessive However, a partial removal may be indicated (after Pitman (7))

Fig 4.4 The majority of upper arm liposuction (alone) dures are performed in younger patients with good skin contrac- tility For older patient or patients with excess skin due to recent weight loss, a brachioplasty is usually indicated as a combined one or two stage procedure (after Pitman (7))

proce-between these fascial layers in the abdomen with

impu-nity However, care must be taken not to injure the

vas-cular and lymphatic complexes within the mantle layer

of fat just beneath the skin (Fig 4.5)

4.9 Hips and Flanks

In the area of the hips and flanks the subcutaneous fat is

divided into two well-defined layers: the superficial and

the deep The superficial fascial system (SFS) encases

the superficial fat This fat is light yellow and dense,

whereas the deeper fat is usually darker and less well

structured Zones of adherence are formed where the

SFS connects to the underlying muscle fascia The zones

of adherence differ between men and women (Fig 4.6)

In men, the attachment runs along the iliac crest, it

confines the deep fat to the mid abdomen The zone of

adherence in women is more inferior, thus localizing the deep fat over the iliac crest This difference is largely responsible for the android vs gynoid appearance of the hip region Popular Western culture appreciates the visible iliac bones in the female Following liposuction women like to feel and see these anatomic features

4.10 Thighs and Buttocks

The muscle mass of the hamstrings largely determines the contour of the upper posterior thigh Laterally the zones of adherence represent an area that should not be violated with a liposuction cannula The gluteal crease represents another zone of adherence (Fig 4.7) Note that anteriorly, the quad underlies the bulk of the upper anterior thigh

4.11 Lower Leg

A subtle tapering from the thighs to the ankle is sidered attractive Thus, although a degree of fullness

con-at the knee is normal it is usually identified as an area

to be reduced during liposuction of the legs The eral knee should never be liposuctioned It is also an area of insertion of thigh musculature (Fig 4.8) No major arteries or nerves run within the subcutaneous fat Rather, they run along or beneath the investing fascia

lat-of the superficial fat lat-of the legs

Fig 4.5 The relationship of Camper’s fascia to Scarpa’s fascia

Scarpa’s fascia in the membranous layer of the subcutaneous

tissue of the abdomen

Fig 4.6 The hip and flank region are distinctly male or female,

specifically, the zones of adherence differ Care should be taken to

preserve these attachments during liposuction (after Pitman (7))

Fig 4.7 The fat anatomy in the hip and buttock region is to be ceptualized as a three dimensional wrap around regarding the gluteal zone of adherence Note the distribution of the superficial and deep fat above and below the zone of adherence (after Pitman (7))

con-4.12 Nutrition and Metabolism

More often than not a patient will present with unwanted

fatty deposits that are secondary to the over

consump-tion of food Stored fat is mobilized during calorie

restriction through the activation of triglyceride lipase

Triglyceride lipase is a cyclic AMP dependant

mobiliz-ing enzyme The hormonal signal to activate triglyceride

lipase is glucagon and to some extent epinephrine When

the insulin glucagon ratio is in favor of insulin, fat

can-not be mobilized Insulin is secreted in response to

cir-culating glucose levels Thus, a meal that raises glucose

will cause insulin secretion, the magnitude of which

depends on the carbohydrate load and the refined vs

complex composition of the food consumed (Fig 4.9)

Eating either fat or protein will not raise insulin All

fruits and veggies are predominantly carbohydrates

Fruits and veggies are complex carbohydrates which

require more time to digest and absorb Compared to

flour and sugar products which are refined carbohydrates

Regarding complex carbohydrates, the tighter the

carbo-hydrates are configured the slower the digestion,

absorp-tion and the lower the maximum post parandial glucose

will be On the other hand, all refined carbohydrates such

as sugar and flour products will dramatically elevate

blood glucose and insulin It is therefore conceivable that someone who eats what he/she believes is a calorie restricted diet will never catabolize stored fat over a 24-h period Such a diet might be a bagel and coffee for break-fast, a sweet roll at 10 a.m on coffee break, a can of pop,

a cheese sandwich for lunch, a pasta dinner, a soda pop with cake for dessert and fat free cookies while watching television Even if small portions are chosen, the refined carbohydrate consumed will guarantee an elevated insu-lin throughout the day The average soft drink contains more than nine packs of table sugar per can

Patients on this diet are perplexed by their inability

to lose weight When a physician tries to get refined carbohydates out of their diet it is not unusual for the patient to vigorously object because they claim that they suffer from hypoglycemia They report that unless they are frequently treating themselves with refined carbohydrates they become severely symp-tomatic They will complain of brain fog, tremor,

Fig 4.8 The deep fat does not extend into the lower leg Note

the zone of adherence located at the lateral knee which has

essential not fat (after Pitman (7))

Fig 4.9 Stored calories are in two forms: (1) Dextrose forms a large starch molecule called glycogen (2) As triglycerides Triglycerides are composed of even numbered carbon atom fatty acids attached to a glycerol base Both respond to insulin and glucagon Insulin promotes uptake of dextrose and fatty acids while glucagon stimulates mobilization Both moieties enter the Kreb’s cycle to generate ATP

and severe hunger pains which are quickly

amelio-rated by consumption of another form of a refined

carbohydrate Thus they are convinced that they are

hypoglycemic or refined carbs would not treat their

symptoms

The fact is that their blood sugar rapidly rises and

then within 90–120 min begins to decline secondary to

the insulin response It is the downward slope of the

serum glucose that triggers what they call a

hypoglyce-mic episode In fact their blood sugar remained above

normal at all times (Fig 4.10) (8)

The potential for any given complex carbohydrate

or refined carbohydrate to raise blood glucose in

comparison to a 50-g dextrose meal is called the

gly-cemic index (GI) All vegetables and fruits are

com-plex carbohydrates but some have a higher GI then

others Keeping the GI below 55 for any given meal

is recommended The GI of anything made from flour

or sugar is near 90 thus all baked goods and pasta

should be avoided

Geletinization is a process that occurs during

boil-ing where a complex carbohydrate vegetable with a

low GI can be converted to a high GI food During

boiling gaps appear in the tight molecular structure

that is quickly filled by a water molecule This new

configuration reduces the time of digestion increasing

the rate of absorption and therefore increasing the GI

Over heating, especially over boiling is another

con-sideration to be avoided in food preparation

Glycosolation refers to the combination of glucose

and protein This occurs naturally by simple contact

Neither heat nor an enzyme is necessary to create this

new molecule Glycosolation irreparably damages the protein just as oxygen changes iron into rust When the damaged glycosolated protein is replaced during a healing process as it floats free it is called a advanced glycosolation end (AGE) product An AGE is recog-nized by the immune system as a foreign micro The AGE binds to a receptor on white blood cells called receptors for advanced glycosolation end (RAGE) product which unregulated the immune response This

up regulation increases free radical production Free radicals then promote all AGE-related disease pro-cesses Inflammation is now known to be a major fac-tion in Alzheimer, osteo and rheumation arthritis, coronary artery and renal disease, etc Understanding this deepens the reason for advising obese patients who consume refined carbohydrate-carboholism, who present themselves for liposuction to get refined carbs out of their diet Details of these nutritional concepts and other lifestyle guidance have recently been sum-marized by the author/surgeon (8)

For almost two decades leptin was pursued as the holy grail in the control of obesity It was considered the adipostat mediator A specific adipostat may never

be found because there are many factors that ute to energy homeostasis Since the introduction of fat free and low fat food the average American’s weight for any given age has increased 10 pounds

contrib-Adipocyte number is not as stagnant as previously thought Decrease occurs via a process called apopto-sis of both preadipocytes and adipocytes Adipocytes may also dedifferentiate into preadipocytes Adipocyte differentiation is the in vitro process by which differ-entiated fat cells revert morphologically and function-ally to less differentiated cells (9, 10) The process has been observed in vitro These adipocytes lost their cytoplasmic liquid and acquired a fibroblast morphol-ogy (11, 12) These dedifferentiated cells also display the gene expression patterns of preadipocytes (13).This is intriguing behavior in that preadipocytes exhibit stem cell-like qualities Zuk (14) reported isola-tion of a population of stem cells from human adipocyte tissue The cells were obtained from liposuction aspi-rate, and were determined to be mesodermal and mes-enchymal in origin In vitro these cells could differentiate into adipogenic, chondrogenic, osteogenic, and myo-genic cells in the presence of proper induction factors (Table 4.1)

Researchers from Duke University Medical Center have enthusiastically reported that adipocytes can

Fig 4.10 The yo-yo hyperglycemia experienced by refined carb

carboholics It is the downward slope of the hyperglycemia curve

that initiated the symptoms described as hypoglycemia by the

patient Note the blood sugar is never normal