Autologous Fat Transfer Melvin A

Autologous Fat Transfer Melvin A. Shiffman (Ed.)

Autologous Fat Transfer

Art, Science, and Clinical Practice Dr. Melvin A. Shiffman Tustin Hospital and Medical Center Department of Surgery 14662 Newport Avenue Tustin, CA 92680 USA [email protected]

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

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

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Springer is part of Springer Science+Business Media (www.springer.com) Foreword

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 complications. 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 techniques are not so requested anymore. Patients want to stay young; they do not want 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 Rome, Italy Giorgio Fischer

v 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 aesthetic 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, complet- 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 procedures 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. Much of the improvement in fat transfer to the liposuction technique can be attrib- 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 in many specialties. We should recognize these international specialists who have spent their efforts in making fat transfer a viable procedure in aesthetic surgery.

References

1. Fischer G. Surgical treatment of cellulitis. IIIrd Congress International Acad Cosm Surg, Rome, May 31, 1975

California, USA Melvin A. Shiffman

vii Contents

Part I History, Principles, Fat Cell Physiology and Metabolism

1 History of Autologous Fat Transfer ...... 3 Melvin A. Shiffman

2 History of Autologous Fat Transplant Survival ...... 5 Melvin A. Shiffman

3 Principles of Autologous Fat Transplantation...... 11 Melvin A. Shiffman

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

5 Fat Cell Biochemistry and Physiology ...... 29 Melvin A. Shiffman

6 White Adipose Tissue as an Endocrine Organ ...... 37 Kihwa Kang

Part II Preoperative

7 Preoperative Consultation...... 43 Melvin A. Shiffman

Part III Techniques for Aesthetic Procedures

8 Guidelines for Autologous Fat Transfer, Evaluation, and Interpretation of Results ...... 47 Sorin Eremia

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

10 Fat Transfer in the Asian...... 59 Samuel M. Lam

ix x Contents

11 Subcison with Fat Transfer ...... 65 Melvin A. Shiffman

12 Autologous Fat Transplantation for Acne Scars ...... 69 Bernard I. Raskin

13 The Art of Facial Lipoaugmentation ...... 79 Edward B. Lack

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 Contents xi

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 xii Contents

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 Contents xiii

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 Contributors

Adrien E. Aiache 9884 Little Santa Monica Blvd, Beverly Hills, CA 90212, USA, [email protected] Funda Aköz Department of Plastic and Reconstructive Surgery, Osmaniye State Hospital, Osmaniye, Turkey, [email protected] 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 [email protected] Peter B. Arnold University of Virginia, P.O. Box 800376, Charlottesville, VA 22908-0376, [email protected] 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 [email protected] 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, [email protected] Pier Luigi Bonucci Strada del Diamante 86, 41100 Modena, Italy [email protected] James P. Bradley Division of Plastic and Reconstructive Surgery, 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095, USA, [email protected] Daniel Serra Cassano Rua Vicente Satriana, 316 apt 52, Jardim Sao Jorge, Araraquara, Sao Paulo, Brazil 14807-9878, [email protected] 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, [email protected] M. Orhan Çizmeci Department of Pathology, Istanbul University, Fevzi Pasa cad. Sarachane Parki Yani Fatih, Istanbul, Turkey, [email protected] Domenico De Fazio Strada del Diamante 86, 41100 Modena, Italy, [email protected] xv xvi Contributors

P. H. Dejonckere The Institute of Phoniatrics, ENT Department, Division of Surgery, University Medical Centre, P.O. Box 85 500, 3508 Utrecht, The Netherlands, [email protected] Brian Dickinson 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095, USA, [email protected] Vincent D. DiNick 135 S.Prospect, Ypsilante, MI 48198, USA, [email protected] Robert M. Dryden Arizona Centre of Plastic Surgery, Tucson, AZ 85712, USA, rmdryden@fl ash.net Ufuk Emekli Department of Pathology, Istanbul University, Fevzi Pasa cad. Sarachane Parki Yani Fatih, Istanbul, Turkey, [email protected]@ Sorin Eremia Cosmetic Surgery Unit, Division of Dermatology, UCLA, Brockton Cosmetic Surgery Center, 4440 Brockton, Suite 200, Riverside, CA 92501, USA, [email protected] Anthony Erian Orwell Grange, 43 Cambridge Road, Wimpole, Cambridge, UK, [email protected] Gustavo Ferreira Velez Sorsfi eld 220, 1640 Martinez, Buenos Aires, Argentina, drferreira@fi bertel.com.ar Julio A. Ferreira Santiago Del Estero 102 (1640), Buenos Aires, Argentina, drferreira@fi bertel.com.ar 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, [email protected] Joubin Gabbay 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095, USA, [email protected] Kiu Ghadjar 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095, USA, [email protected] Felix-Rüdiger G. Giebler Vincemus-Klinik, Brückenstrasse 1a, 25840 Friedrichstadt/Eider, Germany, [email protected] 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, [email protected] Robert A. Glasgold Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA, [email protected] 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, [email protected] Bahman Guyuron Department of Plastic Surgery, Case Western Reserve University, Cleveland, OH 44124, USA, [email protected] Contributors xvii

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, [email protected] Justin B. Heller 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095, USA, [email protected] Dustin M. Heringer Arizona Centre of Plastic Surgery, Tucson, AZ 85712, USA, [email protected] Enrique Hernandez-Pérez 7801 NW 37th St., Club VIP, Suite 369, Miami, FL 33166-6503, USA, [email protected] 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, [email protected] Mauricio Hernández-Pérez Center for Dermatology and Cosmetic Surgery, Pje. Dr. Roberto Orellana Valdé #137, Col. Médica, San Salvador CP 0-804, El Salvador, [email protected] Steven B. Hopping George Washington University, Washington, DC, USA The Center for Cosmetic Surgery, 2440 M Street, NW, Suite 205, Washington, DC 20037, USA, [email protected] Catherine Huang 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095, USA, [email protected] Ian T. Jackson Gretchen Hofman, Craniofacial Institute, 16001 West Nine Mile Road, Third Floor Fisher Center, Southﬁ eld, MI 48075, USA, [email protected] Robert F. Jackson 330 North Wabash Avenue, Suite 450, Marion IN 46952, USA, [email protected] Reza Jarrahy Division of Plastic Surgery, 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095, USA, [email protected] John K. Jones 6818 Austin Center Blvd, Suite 204, Austin, TX 78731-3100, USA, [email protected] Mitchell V. Kaminski Finch University of Health Sciences, Chicago Medical School, 230 Center Drive, Vernon Hill, Chicago, IL 60061-1584, USA, [email protected] Kihwa Kang Department of Genetics and Complex Diseases, Harvard School of Public Health, 665 Huntington Avenue, Bldg2, Rm 129, Boston, MA 02115, USA, [email protected] Adam J. Katz Department of Plastic and Maxillofacial Surgery, University of Virginia, P.O. Box 800376, Charlottesville, VA 22908-0376, USA, [email protected] Matthew R. Kaufman Drexel College of Medicine, Shrewsbury, NJ, USA Plastic Surgery Center, 535 Sycamore Avenue, Apt. 732, Shrewsbury, NJ 07702-4224, USA, [email protected] Hassan Abbas Khawaja Cosmetic Surgery and Skin Center, 53A, Block B II, Gulberg III, 53660 Lahore, Pakistan, [email protected] xviii Contributors

Nancy Kim Oculoplastics Service, Department of Ophthalmology, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, F3-332, Madison, WI 53703, USA, [email protected] Edward B. Lack 2350 Ravine Way, Ste 400, Glenview, IL 60025, USA, [email protected] 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, [email protected] Jongki Lee In & In Apt. 101-Dong 903-Ho, 834 Jijok-Dong Yooseong-Gu Daejeon-City, Korea 305-330, [email protected] 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 [email protected] Rose M. Lopez de Vaughan Successful Longevity Clinic, 381 W. Northwest Highway, Palatine, IL 60067, USA, [email protected] Todd P. Mangione Pasco Surgical Associates, 37840 Medical Arts Court, Zephyrhills, FL 33541-4325, USA, [email protected] Daisuke Matsumoto Department of Plastic Surgery, University of Tokyo School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan, [email protected] Timothy A. Miller 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095, USA, [email protected] Sid J. Mirrafati 3140 Redhill Avenue, Costa Mesa, CA 92626, USA, [email protected] 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, [email protected] Lina I. Naga The Center for Cosmetic Surgery, 2440 M Street, NW, Suite 205, Washington, DC 20037, USA, [email protected] Joseph Niamtu 11319 Polo Pl., Midlothian, VA 23113-1434, USA, [email protected] Catherine O’Hara 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095, USA, [email protected] Defne Önel Plastic and Reconstructive Surgery Department, Medical Park Hospital, Fevzi Pasa cad. Sarachane Parkõ Yani Fatih, Istanbul, Turkey, [email protected] 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, [email protected] Luiz Haroldo Pereira Luiz Haroldo Clinic, Rua Xavier da Silveira 45/206, 22061-010, Rio de Janeiro, Brazil, [email protected] Contributors xix

Allison T. Pontius The Williams’ Center for Plastic Surgery, 1072 Troy Schenectady Road, Latham, NY 12110, USA, [email protected] Bernard I. Raskin Department of Medicine, Division of Dermatology, Geffen School of Medicine at UCLA, Los Angeles, CA, USA, [email protected] John G. Rose Jr. Davis Duehr Dean and The Aesthetic Surgery Center, Dean Health Systems, 1025 Regent Street, Madison, WI 53715, USA, [email protected] Katsujiro Sato Cellport Clinic Yokohama, Yokohama Excellent III Building 2F, 3-35, Minami-nakadori, Naka-ku, Yokohama, Japan, [email protected] Melvin A. Shiffman Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302, USA, [email protected] 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, [email protected] Jason A. Spector Division of Plastic Surgery, Weill Medical College of Cornell University, 525 East 68th Street, Payson 709, New York, NY 10065, USA, [email protected] 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, [email protected] Katsuya Takasu Takasu Clinic, 2-14-27 Akasaka, Kokusai-Shin-Akasaka Building, Higashi-kan 2F, Minato-ku, Tokyo 107-0052, Japan, [email protected] Richard H. Tholen Minneapolis Plastic Surgery, Ltd., 4825 Olsen Memorial Highway, Suite 200, Minneapolis, MN 55422, USA, [email protected] Lina Valero de Pedroza Carrera 16 No 82-95-Cons: 301, Bogotá DC, Colombia, [email protected] Fausto Viterbo Rua Domingos Minicucci Filho, 587, Botucatu Ð SP 18607-255, Brazil, [email protected] Kristy Wasson 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA 90095, USA, [email protected] 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, [email protected] Edwin F. Williams III Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Albany Medical Center, Albany, NY 12208, USA The Williams’ Center for Plastic Surgery, 1072 Troy Schenectady Road, Latham, NY 12110, USA, [email protected] Larry M. Wolford 3409 Worth Street, Suite 400, Dallas, TX 75246, USA, [email protected] xx Contributors

Yun Xie Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, 639 Zhizhaoju Road, Shanghai, PR China, 200011, [email protected] Kotaro Yoshimura Department of Plastic Surgery, University of Tokyo School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan, [email protected] Danning Zheng Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, 639 Zhizhaoju Road, Shanghai, PR China, 200011, adizdn@@gmail.com Part I History, Principles, Fat Cell Physiology and Metabolism History of Autologous Fat Transfer1 1 Melvin A. Shiffman

1.1 Introduction 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 The history of autologous fat augmentation gives an and replaced by fibrous tissue. insight into the development of fat transfer for both cos- Straatsma and Peer (7) used free fat grafts to repair metic and non-cosmetic problems. Transplantation of postauricular fistulas and depressions or fistulas result- pieces of fat and occasionally diced pieces of fat advanced ing from frontal sinus operations. Cotton (8) used a to the removal of small segments of fat by liposuction technique of broad undercutting and insertion of finely after the development of the technique by Fischer and cut fat that was molded to fill defects. Fischer, reported in 1975. 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 1.2 History about 45% of their weight and volume 1 year or more following the transplantation because of the failure of Neuber (1) reported the use of small pieces of fat from some fat cells to survive the trauma of grafting as well as the upper arm to reconstruct a depressed area of the the new environment. Fat grafts are affected by trauma, face resulting from tuberculosis osteitis. He concluded exposure, infection, and excessive pressure from dress- that small pieces of fat, of bean or almond size, appeared ings (10). Peer (11) stated that microscopically, grafts to have a good chance of survival. Czerny (2) used a appear like normal adipose tissue 8 months after trans large lipoma to fill a defect in the breast following plantation. resection of a benign mass. The transplanted breast, Liposuction was conceived by Fischer and Fischer however, appeared darker in color and smaller in vol- in 1974 (12) and put into practice in 1975 (13). ume than the opposite breast. Verderame (4) observed Fischer (14) first reported removal of fat by means of that fat transplants solved the problem of shrinkage at 5 mm incisions using a “rotating, alternating instrument the transplant site. Lexer (3) reported personal experi- electrically and air powered.” This allowed aspiration of ence with fat transplants and found that larger pieces fat through a cannula. Through a separate incision, saline of fat gave better results. Bruning (5) used fat grafts solution was injected to dilute the fat. In 1977 (15), they to fill a post-rhinoplasty deformity by placing fat in reviewed 245 cases of liposuction with the “planotome” a syringe and injecting the tissue through a needle. 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 1Reprinted with permission of Lippincott Williams & Wilkins. formation, which required removal of the capsule through a wider incision and the use of the planotome, occurred in 2% of cases. M. A. Shiffman The advent of liposuction spurred a move toward Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA, 92780-2302, USA using the liposuctioned fat for reinjecting areas of the e-mail: [email protected] body for filling defects or augmentation. Bircoll (16)

M. A. Shiffman (Ed.), Autologous Fat Transfer 3 DOI: 10.1007/978-3-642-00473-5_1, © Springer-Verlag Berlin Heidelberg 2010 4 M. A. Shiffman first reported the use of autologous fat from liposuc- References tion for contouring and filling defects. Illouz (17) claimed that in 1983, he began to inject aspirated fat. 1. Neuber F. Fettransplantation. Chir Kongr Verhandl Deutsche Johnson (18) stated that in 1983, he began to use auto Gesellsch Chir 1893;22:66. logous fat injection for contouring defects of the but- 2. Czerny V. Plastischer ersatz der brustdruse durch ein lipoma. tocks, anterior tibial area, lateral thighs, coccyx area, Chi Kong Verhandl 1895;2:126. 3. Lexer E. Freie fettransplantation. Deutsch Med Wochenschr breasts, and face. Bircoll (19) presented the method of 1910;36:640. injecting fat that had been removed by liposuction. 4. Verderame P. Ueber fettransplantation bei adharenten kno- Krulig (20) asserted that he began to use fat grafts by chennarben am orbitalrand. Klin Monatsbl fur Augenh 1909; means of a needle and syringe. He called the procedure 47:433–442. 5. Bruning P. Cited by Broeckaert, TJ, Steinhaus, J. Contribution “lipoinjection.” He began to use a disposable fat trap e l’etude des greffes adipueses. Bull Acad Roy Med Belgique to facilitate the collection process and to ensure the 1914;28:440. fat’s sterility. Newman (21) stated that he began rein- 6. Tuffier T. Abces gangreneux du pouman ouvert dans les jecting fat in 1985. The idea of utilizing the aspirated bronches: Hemoptysies repetee operation par decollement pleuro-parietal; guerison. Bull et Mem Soc de Chir de Paris fat, which was otherwise wasted, was an attractive idea 1911;37:134. and other surgeons began to make use of the aspirate to 7. Straatsma CR, Peer LA. Repair of postauricular fistula by augment defects and other abnormalities. means of a free fat graft. Arch Otolaryngol 1932;15:620–621. The American Society of Plastic and Reconstructive 8. Cotton FJ. Contribution to technique of fat grafts. N Engl JMed 1934;211:1051–1053. Surgery (ASPRS) Ad-Hoc Committee on New Proce 9. Peer LA. The neglected free fat graft. Plast Reconstr Surg dures produced a report on 30 September 1987, regard- 1956;18(4):233–250. ing autologous fat transplantation (22). The conclusions 10. Peer LA. Loss of weight and volume in human fat grafts. were: Plast Reconstr Surg 1950;5:217–230. 11. Peer LA. Transplantation of Tissues, Transplantation of Fat. Baltimore, Williams & Wilkins, 1959. 1. Autologous fat injection has a historical and scien- 12. Fischer G. The evolution of liposculpture. Am J Cosm Surg tific basis. 1997;14(3):231–239. 2. It is still an experimental procedure. 13. Fischer G. Surgical treatment of cellulitis. Third Congress of 3. Fat injection has achieved varied results, and long- the International Academy of Cosmetic Surgery, Rome, 31 May 1975. term, controlled clinical studies are needed before 14. Fischer G. First surgical treatment for modeling body’s cel- firm conclusions can be made regarding its validity. lulite with three 5 mm incisions. Bull Int Acad Cosm Surg 4. Fat transplant for breast augmentation can inhibit 1976;2:35–37. early detection of breast carcinoma and is hazard- 15. Fischer A, Fischer G. Revised technique for cellulitis fat reduction in riding breeches deformity. Bull Int Acad Cosm ous to public health. Surg 1977;2(4):40–43. 16. Bircoll M. Autologous fat transplantation. The Asian Coleman and Saboeiro (23) reported success in fat Congress of Plastic Surgery, February 1982. transfer to the breast and concluded that it should be 17. Illouz YG. The fat cell “graft”: A new technique to fill considered as an alternative to breast augmentation and depressions. PlastReconstrSurg 1986;78(1):122–123. reconstruction procedures. Two of 17 patients had breast 18. Johnson GW. Body contouring by macroinjection of autologous fat. Am J Cosm Surg 1987;4(2):103–109. cancer diagnosed by mammography, one 12 months and 19. Bircoll MJ. New frontiers in suction lipectomy. Second Asian the other 92 months after fat transfer to the breast. Congress of Plastic Surgery, Pattiyua, Thailand, February 1984. Now fat transfer to the breast area is being used out- 20. Krulig E. Lipo-injection. Am J Cosm Surg 1987;4(2):123–129. side the breast itself, into the pectoralis major muscle 21. Newman J, Levin J. Facial lipo-transplant surgery. Am J Cosm Surg 1987;4(2):131–140. and behind and in front of the muscle. The fat is also 22. American Society of Plastic and Reconstructive Surgery being used to augment tissues around the breast fol- Committee on New Procedures. Report in autologous fat lowing treatment for breast cancer. transplantation September 30,1987. Plast Surg Nurs 1987; Although most of the fat transfer procedures are for Winter:140–141. 23. Coleman SR, Saboeiro AP. Fat grafting to the breast revis- augmentation of tissues, there has been a surge of the ited: Safety and efficacy. Plast Reconstr Surg 2007;119(3): use of fat for non-cosmetic procedures. 775–785. History of Autologous Fat Transplant Survival1 2

Melvin A. Shiffman

2.1 Introduction 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 The survival of free fat used as an autograft is operator many months and probably years. Davis (4) concluded dependent and requires delicate handling of the graft that omentum, transplanted freely beneath the skin in a tissue, careful washing of the fat to minimize extrane- mass, 1 in. in diameter, maintains the greater part of its ous blood cells, and installation into a site with ade- bulk. Lexer (5) reported excellent clinical results with quate vascularity. very large fat grafts but stated that up to 66% of the fat There is evidence that fat cells will survive and that autografts were absorbed and significant overcorrection filling of defects is not from the residual collagen fol- should be used. He stated that multiple small grafts lowing cell destruction. There is some loss of fat after would turn to scar, while larger grafts would remain fatty transplant, and most surgeons tend to overfill the recip- tissue. Mann (6) performed free transplant of omentum ient site. 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 2.2 Historical Review clinical evidence and concluded that:

Verderame (1) reported that autogenous fat grafts in ocu- 1. Transplanted autologous fat undergoes practically lar surgery became reduced in size and advised the use some changes as transplanted bone. of a larger transplant than that seemed necessary to fill 2. The transplant dies and is replaced either by fibrous the defect. Lexer (2) claimed that manipulation and tear- tissue or by newly formed fat. ing of the graft at the time of transfer would cause a great 3. Newly formed fat occurs through the activity of a degree of graft shrinkage. Kanavel (3) felt that graft sur- large wandering histocyte-like cell, which takes on vival was improved by not using suture to secure the fat and becomes a fat cell. graft, careful hemostasis, and aseptic technique. He Guerney (8) noted that autogenous fat grafts should be transplanted sheets of fat varying from 0.25 to 1 in. in transplanted in larger bulk than required since only thickness to prevent adhesions and contractures and 25–50% of the graft survives 1 year after transplanta- lessen deformity of tendons, nerves, blood vessels, and tion. He studied transplanted, 1.7 mm3 (average size), joints. He felt that fat can be transplanted into any fat grafts over a period of 12 months in rats and concluded that:

1 Reprinted with permission of Lippincott Williams & Wilkins. 1. Liberation of fat by contiguous cells probably gives rise to fatty cysts. 2. Phagocytosis of liberated fat was assisted by poly- M. A. Shiffman morphonuclear leucocytes. Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302, USA 3. The percentage of normal fat in any surviving graft e-mail: [email protected] gradually increased throughout the year.

M. A. Shiffman (Ed.), Autologous Fat Transfer 5 DOI: 10.1007/978-3-642-00473-5_2, © Springer-Verlag Berlin Heidelberg 2010 6 M. A. Shiffman

4. A certain portion of the transplanted tissue gained Hansberger (14) proposed that histocytes phagocy- an adequate blood supply early and continued to tose the lipid and do not replace graft fat. After the survive, while the remainder of the graft degener- graft of mature autotransplanted fat goes through ini- ated and was gradually eliminated from the site of tial ischemia, fat cells either necrose or dedifferentiate the implant without evidence of gross scar. into immature cells. Under suitable conditions, the 5. Crushed grafts eventually disappeared attesting to the immature fat cells revert to mature adipocytes. devastating effect of trauma on the vitality of a graft. Schorcher (15) reported using autogenous free fat 6. Single pieces of fat remain viable for at least 1 year, transplantation to treat hypomastia. He noted that the while grafts of a similar size cut into smaller pieces connective elements remained intact with fat shrink- may last as long as 6 months, but the majority dis- age to 25% of the original size by 6–9 months. He appear by the third month. believed that if the graft was in several pieces, it would 7. Absolute hemostasis is essential since even a slight receive better nourishment from the recipient site. hemorrhage jeopardizes the viability of the graft. Van and Roncari (16, 17) demonstrated conversion 8. Although slight infection results in only a small of adipocyte precursors into adult adipocytes, both in loss of tissue, gross infection leads to a loss of the vitro and in vivo, in rats. Saunders et al. (18) studied whole graft. fat autograft survival and observed initial adipose tis- 9. Phagocyte cells do not use their fat to form new fat sue breakdown followed by revascularization. There is cells during the first year after transplantation. early breakdown of fat cells with formation of cyst like lipid deposits and infiltration by host histocytes. Hilse (9) showed histologically that free fat transplants Illouz (19) opined that the human body is an excel- regenerate fatty tissue without any exception. He lent culture medium and that the fat cells apparently sur- referred to the histocyte filled with fat as a “lipoblast.” vive by intercellular lipolysis and osmosis until they are Green (10) used fat and fat-fascia autografts in the revascularized. The area to be augmented should be over treatment of osseous defects secondary to osteomyeli- corrected by 30% because approximately 30% necrosis tis. He presumed that transplanted fat would become of fat cells results when using the wet technique. connective tissue and then bone, closing the defect. Illouz (20) reported that fat transplantation in one Wertheimer and Shapiro (11) studied fat physiology patient biopsied 9 and 16 months later, showed normal and determined that fat develops from primitive adi- fat cells. pose cells the structure of which is like that of the Asken (21) found that 90% of fat extracted by liposuc- fibroblasts of connective tissue. tion appears viable, assuming it is not traumatized either Peer (12) implanted autogenous fat (single piece by handling or by high suction pressure. Damage incurred compared to a piece cut into 20 segments) into the rec- by the adipocytes is inversely related to the diameter of tus muscle. Grafts were removed at intervals from 3 to the instrument used for harvesting and injection. 14 months. Grossly all grafts were surrounded by a Campbell et al. (22) noted, both morphologically and connective-tissue capsule and, upon sectioning, the biochemically, that adipocyte integrity and metabolism bulk of the graft contained fatty tissue. Single grafts remain intact when subjected to liposuction. Johnson (the size of a walnut) lost 45% of their weight while (23) examined liposuctioned fat and noted that 90% or multigrafts lost 79% of their weight. He concluded that more of the fat cells remained viable. He found that there the fat grafts appeared like normal fat tissue 1 year or was 75–85% of original fat present 3 months after trans- more after transplantation. plantation. Agris (24) claimed that trauma and desicca- Bames (13) noted that circulation in grafts is estab- tion injured transplanted fat cells. Bircoll (25) stated that lished in about 4 days after transplantation by anastomo- the ASPRS report (26) of 30% survival and Peer’s report sis between the host and graft blood vessels. Traumatized (27) of 50% survival of autologous fat transplantation fat grafts lose much more weight and volume than gen- were based on the older technique of bulk fat transfer. tly handled transplants (50% loss after 1 year). Normal Biopsies show 80% survival of fat after 1 year and an appearing adipose cells were present in all the trans- additional bulk of 10–20% of fibrous tissue. Fat transplants. Dermal-fat grafts provide a readily available plants must be placed into the fatty subcutaneous tissue. transplantation material for establishing normal contour Billings and May (28) analyzed the histology of in small breasts instead of foreign implants. free fat grafts and noted the following: 2 History of Autologous Fat Transplant Survival 7

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.

Markman (29) has suggested that the number of fat and concluded that little, if any, autologous fat sur- cells may increase, through differentiation of existing vives in its new site. preadipocytes, when fat cells reach a “critical size.” Courtiss et al. (35) reported marginal success in fat Illouz (30) reported that fibroblast-like precursor grafting of two patients with postliposuction depres- cells are able to multiply and give rise to fibroblasts or sions. Asaadi (36) reported 5-year successful retention cells that resemble fibroblasts. When these cells are of fat transplanted to a right trochanteric post-traumatic stimulated to absorb fat vacuoles with insulin or dex- depressed scar. amethasone, they do not because adipocytes. He noted Samdal et al. (37) measured blood flow and the that adipocytes are very fragile and have a short life amount of surviving fat following needle abrasion of span outside the body. The cells live longer if mixed the recipient site in rats. Abrasion was performed by a with normal saline and kept at a moderate temperature. criss-cross pattern with 20 strokes using an 18 gauge They do not tolerate excessive manipulation, refrigera- needle in the subcutaneous tissue prior to transplant and tion, or major trauma such as grinding. compared this to controls without abrasion. They found Hudson et al. (31) demonstrated a greater cell size that the mean weight of the fat transplant had shrunk to and lipogenic activity (using measurement of activity 44.6% of the original weight in the abraded group and of lipogenic enzyme adipose tissue lipoprotein lipase 33.5% in the control group. The mean blood flow in fat [ATLPL]) in the gluteal – femoral area compared to was 0.165 mL/min/g in normal fat, 0.120 mL/min/g in the abdomen. Facial fat was found to have small cells the controls, and 0.187 mL/min/g in the abraded group. with almost no ATLPL activity. This may have impli- Microscopic examination of the transplanted fat varied cations for donor site suitability. from oil cysts, connective tissue, and inflammatory cells Nguyen et al. (32) compared suctioned fat, aspi- in some specimens and completely normal fatty tissue rated fat, and excised fat 9 months after implantation. in others. Fat survival varied from 0–90%. They con- Suctioned fat was obtained by using 1 atm negative cluded that fat transplant survival was unpredictable. pressure and on microscopy, only 10% of the fat cells Eppley et al. (38) reported that the addition of basic were found with intact cell membrane. In all the grafts, fibroblast growth factor delivered by dextran beads to fat was replaced with fibrosis, and only a small number fat grafts results in a larger weight maintenance of fat of surviving adipocytes were still present. at 1 year than controls. Kononas et al. (33) compared the loss of fat fol- Group A lowing transplant between surgically excised fat cut Fat alone Group B Fat with dextran beads into small pieces and suctioned fat which was centri- Group C Fat with dextran beads soaked with fuged. Weight loss was 59% for excised fat and 67% cytochrome C (nonmitogenic control for suctioned fat. Ersek (34) used a wire whisk to agi- solution) tate harvested fat and then strained it. He reported Group D Fat with dextran beads soaked with basic disappointing results even with repeated injection fibroblast growth factor 8 M. A. Shiffman

Group Weight retention after The tissue was examined by light microscopy and 12 months (%) computer-assisted image analysis. There was no dif- A 48.8 ference between the weight of the 6 month excised B 79.6 specimen (no weight loss) between the fat cylinder and C 75.2 excised fat, but there was a 59% loss of weight of the D 93.8 aspirated fat. The conclusion was that fat aspiration is traumatic and breaks up the cells. However, there was Histologically, he noted extensive interlacing collagen histologic evidence of viable fat cells in all formation between the adiposites that provide support transplants. for the known effects of basic fibroblast growth factor on Jones and Lyles (44) harvested fat with a 60 mL mesenchymal cell lines. There was an increased unifor- syringe, 3.0 mm pyramid cannula, and locked the plunger mity in adipocyte size seen in 1 year grafts compared to at 35 mL. The harvested fat was washed three times with 1 month grafts which may indicate a possible matura- normal saline and gently agitated. Cell cultures were pre- tion of these more “immature” cells. Whether this repre- pared and maintained for 1 day to 2 months. Microscopy sents repair of damaged adipocytes, preadipocyte disclosed maintenance of mature adipose cells without differentiation, conversion of infiltrating macrophages dedifferentiation into a precursor phenotype. There was or fibroblasts, or entrapped lipid material is speculative. very little evidence of cellular damage or debris. Carpaneda and Ribeiro (39) examined fat 2 months Using photographs over a 6 year period of time, after transplantation and noted viable tissue only in the Coleman (45) demonstrated long-term survival of lipo- peripheral zone of 3.5 mm diameter cylindrical grafts. suctioned fat transplanted into the nasolabial fold. He There was 60% loss of grafted tissue which occurred stated that fat can migrate as the pressure of excess tis- closer to the center. They reported, in 1994 (40), that sue forces the transplanted fat to shift and that fat can graft viability depends on the thickness and geometric die from inadequate nutrition and oxygen from compe- shape and is inversely proportional to the graft diame- tition with other transplanted parcels of fatty tissue. ter if the diameter is greater than 3 mm. The maximum Placement of fat into multiple tunnels allows closer percentage of viability is 40% when the graft is no location to nutrition. He concluded that fat survival is greater than 3.0 mm thick. technique dependent and the primary reason for failure Niechajev and Sevchuk (41) reported 50% fat sur- of long-term correction of the nasolabial fold is initial vival over 3.5 years after single fat transplantation with inadequate correction. 50% overcorrection. They found that fat obtained under Sattler and Sommer (46) found that autologous fat, maximum negative pressure (−0.95 atm) results in par- dried over sterile swabs and frozen at −20°C (lower tial breakage and vaporization of the fatty tissue. About temperatures down to −70°C are preferable) up to 2 two-thirds of the fat withstood the trauma of aspiration. years and then thawed at room temperature, contains Low pressure (−0.5 atm) resulted in smaller cell size only fat cells and no fibrous debris. (29% smaller than with aspiration at −0.95 atm) and Ullmann et al. (47) added Cariel, a modified they assumed that high pressure causes mechanical dis- serum-free cell culture medium (MCDB 153), to tention of the adipocytes which increases the risk of and aspirated human fat prior to reinjection into mice. sometimes causes cell breakage. Cariel contains essential and nonessential amino Courtiss (42) stated that fat grafting remains contro- acids, vitamins, inorganic salts, trace elements, buf- versial and poorly understood and that “some surgeons fers, thyroxin, growth hormone, insulin, and sodium have some impressive results, but most of us have many selenite. There was 46% of the weight of the fat disappointing results.” Fagrell et al. (43) examined fat remaining after 15 weeks in the group with Cariel 6 months after implantation in the ears of rabbits. The compared to 29% in the control without Cariel. They fat implanted was obtained by: concluded that the addition of nutrients enriched with 1. Fat cylinder retrieved with 4.5 mm internal diameter anabolic hormones enabled the survival and take of syringe pushed into the fat and pulling the piston back. more adipose cell in the graft. United States Patent 2. Excised fat, 1 mg in weight. (Lindenbaum) Composition and methods for enhanc- 3. Aspirated fat using 2 mm (14 gauge) cannula and ing wound healing. Patent No. 5461030. Date of syringe. patient: 24 October 1995. 2 History of Autologous Fat Transplant Survival 9

References 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) 1. Verderame P. Ueber fettransplantation bei adharenten kno- 283–288. chennarben am orbitalran. Klin Montsbl f Augenh 1909; 26. ASPRS Ad-Hoc Committee on new Procedures: Report on 7:433. Autologous fat transplantation. Plast Surg Nurs 1987 Winter; 2. Lexer E. Ueber freie fettransplantation. Klin Therap Wehnschr 7(4):140–141. 1911;18:53. 27. Peer LA. The neglected free fat graft. Plast Reconstr Surg 3. Kanavel AR. The transplantation of free flaps of fat. Surg 1956;18(4):233–250. Gynecol Obstet 1916;23:163–176. 28. Billings E Jr, May JW. Historical review and present status 4. Davis CB. Free transplantation of the omentum, subcutane- of free fat graft autotransplantation in plastic and reconstruc- ously and within the abdomen. J Am Med Assoc 1917;68: tive surgery. Plast Reconstr Surg 1989;83(2):368–381. 705–706. 29. Markman B. Anatomy and physiology of adipose tissue. 5. Lexer E. Fatty tissue transplantation. In: Die Transplantation, Clin Plast Surg 1989;16(2):235–244. Part I. Stuttgart, Ferdinand Enke, 1919, pp. 265–302. 30. Illouz YG. Fat injection: A four year clinical trial. In Hetter 6. Mann FC. The transplantation of fat in the peritoneal cavity. GP (ed), Lipoplasty: The Theory and Practice of Blunt Suction Surg Clin N Am 1921;1:1465–1471. Lipectomy, Second Edition, Boston, Little Brown, 1990, 7. Neuhof H. The Transplantation of Tissues. New York, pp. 239–246. D. Appleton, 1923, p. 74. 31. Hudson DA, Lambert EV, Block CE. Site selection for fat 8. Guerney CE. Experimental study of the behavior of free fat autotransplantation: Some observations. Aesthetic Plast Surg transplants. Surgery 1938;3:679–692. 1990;14(3):195–197. 9. Hilse A. Histologische ergebuisse der experimentellen freien 32. Nguyen A, Pasyk KA, Bouvier TN, Hassett CA, Argernt LC. fettgewebstronsplantation. Beitr 2 Path Anal U Z Allg Path Comparative study of survival of autologous adipose tissue 1928;79:592–624. taken and transplanted by different techniques. Plast Reconstr 10. Green JR. Repairing bone defects in cranium and tibia. Surg 1990;85(3):378–386. South Med J 1947;40:289. 33. Kononas TC, Bucky LP, Hurley C, May JW Jr. The fate of 11. Wertheimer E, Shapiro B. The physiology of adipose tissue. suctioned and surgically removed fat after reimplantation for Physiol Rev 1948;28:451. soft-tissue augmentation. A volume and histologic study in 12. Peer LA. Loss of weight and volume in human fat grafts: With the rabbit. Plast Reconstr Surg 1993;91(5):763–768. postulation of a “cell survival theory.” Plast Reconstr Surg 34. Ersek RA. Transplantation of purified autologous fat: 1950;5:217–230. A 3-year follow-up is disappointing. Plast Reconstr Surg 13. Bames HO. Augmentation mammoplasty by lipotransplant. 1991;87(2):219–227. Plast Reconstr Surg 1953;11(5):404–412. 35. Courtiss EH, Choucair RJ, Donelan MB. Large-volume suc- 14. Hansberger FX. Quantitative studies on the development of tion lipectomy: An analysis of 108 patients. Plast Reconstr autotransplants of immature adipose tissue of rats. Anat Rec Surg 1992;89(6):1068–1079. 1995;122:507. 36. Asaadi M, Haramis HT. Successful autologous fat injection 15. Schorcher F. Fettgewebsver pflanzung bei zu kneiner brust. at 5-year follow-up. Plast Reconstr Surg 1993;91(4): Munchen Med Wochenschr. 1957;99(14):489. 755–756. 16. Van RL, Roncari DA. Complete differentiation of adipocyte 37. Samdal F, Skolleborg KC, Berthelsen N. The effect of pre- precursors: A culture system for studying the cellular nature operative needle abrasion of the recipient on survival of of adipose tissue. Cell Tiss Res 1978;195(2):317–329. autologous free fat grafts in rats. Scand J Reconstr hand Surg 17. Van RL, Roncari DA. Complete differentiation in vivo of 1992;26(1):33–36. implanted cultured adipocyte precursors from adult rats. 38. Eppley BL, Sidner RA, Plastis JM, Sadove AM. Bioactivation Cell Tiss Res 1982;225(3):557–566. of free-fat transfers: A potential new approach to improving 18. Saunders MC, Keller JT, Dunsker SB, Mayfield FH. Survival graft survival. Plast Reconstr Surg 1992;90(6):1022–1030. of autologous fat grafts in humans and mice. Connect Tiss 39. Carpaneda CA, Ribeiro MT. Study of the histologic altera- Res 1981;8(2):85–95. tions and viability of the adipose graft in humans. Aesthetic 19. Illouz YG: New applications of liposuction. In Illouz YG Plast Surg 1993;17(1):43–47. (ed), Liposuction: The Franco-American Experience. Beverly 40. Carpaneda CA, Ribeiro MT. Percentage of graft viability Hills, CA, Medical Aesthetics, 1985, pp. 365–414. versus injected volume in adipose autotransplants. Aesthetic 20. Illouz YG. The fat cell “graft”: A new technique to fill depres- Plast Surg 1994;18(1):17–19. sions. Plast Reconstr Surg 1986;78(1):122–123. 41. Niechajev I, Sevchuk O. Long-term results of fat transplan- 21. Asken S. Autologous fat transplantation: Micro and macro tation: Clinical and histologic studies. Plast Reconstr Surg techniques. Am J Cosm Surg 1987;4:111–121. 1994;94(3):496–506. 22. Campbell GL, Laudenslager N, Newman J. The effect of 42. Courtiss EH. Surgical correction of postliposuction contour mechanical stress on adipocyte morphology and metabolism. irregularities. Plast Reconstr Surg 1994;94:137–138; discus- Am J Cosm Surg 1987;4:89–94. sion 137–138. 23. Johnson GW. Body contouring by macroinjection of autog- 43. Fagrell D, Eneström S, Berggren A, Kniola B. Fat cylinder enous fat. Am J Cosm Surg 1987;4(2):103–109. transplantation: An experimental comparative study of three 24. Agris J. Autologous fat transplantation: A 3-year study. Am different kinds of fat transplants. Plast Reconstr Surg 1996; J Cosm Surg 1987;4(2):95–102. 98(1):90–96. 10 M. A. Shiffman

44. Jones JK, Lyles ME. The viability of human adipocytes after 46. Sattler G, Sommer B. Liporecycling: Immediate and delayed. closed-syringe liposuction harvest. Am J Cosm Surg 1997; Am J Cosm Surg 1997;14:311–316. 14:275–279. 47. Ullmann Y, Hyams M, Ramon Y, Beach D, Peled IJ, 45. Coleman SR. Long-term survival of fat transplants: Con Linderbaum ES. Enhancing the survival of aspirated human trolled demonstrations. Aesthetic Plast Surg 1995;19(5): fat injected into mice. Plast Reconstr Surg 1998; 101(7): 421–425. 1940–1944. Principles of Autologous Fat Transplantation 3 Melvin A. Shiffman

3.1 Introduction little change from weight loss or weight gain in compari- son with adipocytes with beta 1 receptors (Table 3.1). Survival of adipocytes depends on the instrumenta- The introduction of liposuction for fat reduction and tion used for harvesting and injecting the fat. Damage is body contouring has developed into transplantation of inversely related to the diameter of the instrument to the extracted fat for augmentation of defects or for cos- extract and inject fat (10). The pressure generated in metic purposes. There has been a controversy concern- injecting fat increases as a function of decreasing needle ing the manner of collecting, injecting, and cleansing diameter (from 16 to 22 gauge) (11). There is some the fat and the effectiveness of the fat transfer. Some decrease in the metabolic activity of fragments that are physicians have been disappointed with the long-term passed through 20-gauge needles or smaller (Table 3.2). results of fat transplantation. However, the size of the extracted particles is not de The process of fat transplantation has not yet been scribed. If the extraction of fat is with a cannula that is 20 standardized, and there is a need to analyze some of gauge, it is doubtful that the 20-gauge needle would the methods and results. cause damage to the adipocytes. The presence of blood in the fat injected stimulates 3.2 Fat Transplant Survival 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- Vitamin E is a necessary factor in the maintenance of fat tion of whether washing decreases the viability of frag- tissue (1) while insulin increases the metabolic activity ile adipocytes. of fat cells (2) and retards lipolysis (3–7). Hiragun et al. Campbell et al. (11) concluded that adipocyte integ- (8) theorized that insulin may induce fibroblasts to pick rity and metabolism of fat fragments subjected to up lipid lost from lipolysis and become adipocytes. mechanical manipulation by liposuction using wall suc- Skouge (3) felt that fat cells from an area of relatively tion remain intact. Illouz (12) biopsied the areas of fat poor vascularity will be more hardy, have decreased injection and found normal fat cells. metabolic needs, and increase survival. Asken (9), how- McCurdy (15) analyzed fat cell survival and con- ever, stated that the more fibrous areas, such as upper cluded that the technical factors to accomplish the goal abdomen, are not ideal for donor sites. of 40–50% transplanted adipocyte survival include: Fat characteristics may be helpful in determining which area of fat is more likely to be retained. The adi- 1. Low vascularity of donor site pocytes with alpha 2 receptors are antilipolytic with poor 2. High vascularity for recipient site response to diet and appear more likely to survive with 3. Low pressure technique of aspiration of fat 4. Filtering and washing harvested adipocytes 5. Use of ³2 mm cannula for injection to minimize M. A. Shiffman adipocyte injury Department of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302, USA 6. Multilayered deposition of fat e-mail: [email protected] 7. Overcorrection of the recipient site

M. A. Shiffman (Ed.), Autologous Fat Transfer 11 DOI: 10.1007/978-3-642-00473-5_3, © Springer-Verlag Berlin Heidelberg 2010 12 M. A. Shiffman

Table 3.1 Fat characteristics (8) • Nonfacial Alpha 2 receptors Beta 1 receptors −− Rejuvenation of the hands Lipolysis Antilypolytic Lipolytic −− Body contour defects Response to diet Poor Good −− Depressions, liposuction induced Region of fat Abdominal, trochanteric Facial, arms, −− Breast enlargement (genetic fat) upper torso −− Traumatic scars

Berdeguer (23): Clinical indications for fat trans Table 3.2 Needle size and cell survival (11) plantation Needle gauge (a) Depressed scars – face and body 16 18 20 22 1. Postsurgical Pad integrity + o − Cell morphology + + o − 2. Posttraumatic Nuclear morphology + + o − (b) Aging skin with loss of supportive tissue Fat globule + + + + 1. Glabellar furrows + = 75% or more without cell damage 2. Upper lip o = 25–75% cell damage 3. Melolabial folds − = > 75% cell damage 4. Hollow cheeks 5. Dorsal hands (c) Aesthetic enhancement Because of the problem of resorption of fat with fat 1. Cheek augmentation transplantation, 30–50% overinjection is ordinarily used 2. Chin augmentation (16–21). Asadi and Haramis (16) determined that sub- 3. Breast augmentation dermal injection is important for long-term results. 4. Leg contour surgery (d) Congenital defects 1. Hemifacial atrophy 2. Soft-tissue defects of the body 3.3 Indications for Fat Transplantation In analyzing these lists, a simpler and more useful classification can be devised: There have been two papers that relate to the indica- Indications (Shiffman) tions for autologous fat transplantation. Skouge (22): Indications for fat transplantation 1. Fill defects (a) Congenital • Facial (b) Traumatic −− Aging changes (c) Disease (acne) −− Melolabial grooves (d) Iatrogenic −− Central cheek depressions 2. Cosmetic −− Subcommissural depressions (a) Furrows (wrinkles) −− Flattened upper lip (b) Refill Lost Supportive Tissue (aging) −− Glabella (c) Enhancement −− Diffuse age-related lipoatrophy 3. Non cosmetic • Cosmetic (a) Migraine headaches, clival chordoma surgery, −− Lip augmentation congenital short palate, vocal cord paralysis, lum- −− Chin augmentation bar laminectomy, sulcus vocalis, vocal cord scar, −− Malar augmentation hemifacial atrophy, myringoplasty, eye socket • Scars reconstruction, frontal sinus fracture, temporo- −− Traumatic mandibular joint reconstruction). −− Lipoatrophy, acne −− Idiopathic lipodystrophy Some of these procedures need fat transfer to prevent −− Facial hemiatrophy scarring. 3 Principles of Autologous Fat Transplantation 13

3.4 Complications of Fat with non-smokers and actually a moderate amount of Transplantation 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 trau- Injection of small globules will prevent cyst forma- matic events such as automobile accidents or recluse tion. Johnson (24) showed that one, three, and five cc spider bites, the nasal labial furrows in aging patients. injections resulted in small cysts, but 10 cc injection Over the years, I have washed the fat, sometimes had macroscopic cyst formation. Oil cysts develop not washed the fat, added insulin, sometimes not added through the confluence of necrotic fat cells having a insulin, tried everything and currently even utilizing a lining of macrophages, and resorption may take years, 4-mm cannula to remove the fat, catching it in the ster- thus giving a false impression of a successful trans- ile in-line trap, not washing it and reapplying it utiliz- plantation (25). ing a 16-gauge fat grafting needle with a 10-mL syringe Sterility of fat retrieval and injection must be apparatus.” maintained. Fragen (29) Infection has not been reported (22). “I have found that autologous fat transplantation is Bruising, temporary swelling, and tenderness may a very effective part of my facial rejuvenation surgery, result from fat transplantation (22). provided I give the patients a detailed explanation of Teimourian (26) reported that a patient upon injec- the limited nature of the procedure and the fact that it tion of fat into the glabellar frown lines complained of is always somewhat temporary. Depending on the pain and loss of vision in one eye. There was central patient and the location to where the fat is transferred, retinal artery thrombosis, probably secondary to fat the fat survives for a variable period. I have found that particle embolism. transferring fat under skin grafts, scars, and on top of Calcifications have only been reported in fat trans- semirigid or rigid surfaces improves the viability of the plantation to the breast for augmentation. This does fat transfer. For example, if one transfers fat under the not appear to be a significant risk since the timing of skin post mastectomy, it seems to stay there and offers the appearance, the position, and the character of the some padding. Putting it under burn scars will help calcifications will indicate the etiology. increase the padding of the burn scar and make the The most important problem encountered is fat skin grafts over it more pliable and flexible. If fat is resorption. Trauma to the cells, desiccation during transferred to a lip, it seems to survive there the least, transfer, and the presence of blood are contributing because of the active nature of the lip. factors. At least an 18-gauge needle should be used to My method of transfer is very simple. I like to call reinject fat. Ersek (27) reported that very little autolo- it a closed system. Essentially what is done is the area gous fat survives but his use of a whisk in the cleansing for fat harvesting is prepped and draped and infiltrated process probably destroyed most of the fat cells. 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. 3.5 Technique of Autologous Fat If there is excess bloody tissue, then the specimen is washed in saline and again decanted. If, as is usual, Transplantation essentially pure fat is removed from the donor site, then it is maintained within the syringe with the blunt The lack of standardization of fat collection and trans- 14-gauge cannula. plantation allows a wide range of methods with varied A small stab incision is made near the site for fat results. transfer, and the blunt cannula is then placed into the Following are methods utilized by certain cosmetic donor area. Several tunnels are made with the blunt surgeons, which the author obtained by personal commu cannula so that the fat is not squeezed into the area, but nication: rather easily injected into the donor site. Then, the fat Billie (28) is transferred to the donor site. Both sites are prepared “I do have patients whose cases go back to over 10 sterilely. If the patient is under general anesthesia then years, at this point. I have had good fortune over all usually no anesthesia is used for the recipient site. If 14 M. A. Shiffman this is done under local anesthesia, a small amount of Teflon into the vocal cords. In essence, we were inject- 1% Xylocaine with adrenaline is infiltrated into either ing it through an 18-gauge needle with a very precise the lips or the glabella or whatever site we are transfer- ratchet mechanism. The results were discouraging with ring the fat to. rapid re-absorption. We felt that perhaps this was related I usually over-fill the graft site by approximately to the fact that we were injecting into a scarred area. 50%, and I tell patients that the swelling will last 3–5 At about the same time, we began injecting fat into days. I routinely do fat transferring on face lift patients. the face. My first experience with this procedure was I do somewhere around ten or more face lifts per month, to attempt to correct grooving in the cheeks that was and I would guess that 80% of those have a fat transfer caused by facial liposuction. We did not understand associated with it. the risks that were involved when liposuction was car- Untoward effects include bruising, short-term swell- ried out in this area. Many of us ended up with patients ing, occasional lumpiness, and stimulation of fever blis- who had irregularities or waviness. Again, we used the ters. The lumping has never been a problem, in that the same technique – namely aspiration with a syringe and fat can easily be compressed, even months later. Once a re-injection through the Teflon gun. Again, the results patient had a small fat cyst that was easily removed. were discouraging. It is my feeling that fat injected into the lower por- Because of these failures, we essentially abandoned tion of the nasolabial fold, the lips, and the droll lines the technique. Sometime later, we heard about suc- has a relatively short life span, with the ideal results cesses with injection of fat into the back of the hand being reached in approximately 2 weeks and slow dis- and we attempted a few cases. By this time, we had appearance over 2–4 months. In the glabella, I believe stopped using the Teflon gun and were simply aspirat- the fat will last six to more months and, in many cases, ing the fat with the syringe and transferring it to smaller over a year. I think the area nearer the nose in the syringes through a small transfer tube after which the nasolabial fold will retain fat a little better. In that area fat was injected into the back of the hand. Our tech- also the fat will last 6–8 months. Fat injected under nique included aspiration of fat with a syringe, rinsing graft sites, scars, and over other hard prominences I and straining with saline and then re-injection. Again, think lasts for many months and I have several cases both we and our patients were disappointed with the where the fat has lasted several years. The primary results. advantage of fat transfer is that it can very effectively About 3 years ago, after hearing of successes with the camouflage cosmetic defects (such as thin upper lips injection of separated fat, we were tempted to try again. with wrinkling, glabellar frown lines, drool line, etc) Several surgeons had various techniques of morselizing which are difficult to correct without other extensive the fat and injecting the fibrous portion. Often, this mate- procedures. In Palm Springs, we find many people rial was called autologous collagen, although I am not who do not want to restrict their outdoor activities, aware of any confirmation that the material was in any such as tennis and golf. These patients accept the safe, way similar to the bovine collagen that had become so though temporary, correction by fat transfer. Their popular under the trade name Zyderm. biggest complaint is that the wonderful result they get We utilized the technique recommended by Hilton is short-lived, but, until we find a safe, nonresorbable Becker of Palm Beach. Kits were available which filler which the FDA will approve, we do not have a included syringes for transferring the material through better alternative.” a progressively smaller orifice. This resulted in the Tobin (30) morselization of the material. Following this, the mate- “About 10 years ago, when liposuction surgery was rial was centrifuged and the collagenous component first introduced, we began hearing recommendations was obtained to be used for re-injection. The material for re-injection of fat. My initial experience with this was supposedly capable of being preserved by freezing procedure was to attempt to refine breast reconstruction and we attempted this as well. We probably treated cases by injecting small amounts of fat adjacent to about 25 patients with this process, carrying out multi- implants or in patients on whom other surgeons had ple injections over a period of several months. As far as carried out flap reconstructions. We initially harvested I can remember, we did not have even a single patient the fat with a syringe and reinjected it using an old, who was really pleased with the results and we have mechanical injector that was designed initially to inject since then abandoned it. 3 Principles of Autologous Fat Transplantation 15

At present, our use of injectable fat is uncommon. Uebel (38) centrifuged autologous fat at 10,000 When patients request for it, we explain the fact that rpm for 10 min in order to obtain a “fat-collagen graft.” the previous experiences have not been very positive, The centrifuged material on histologic examination but we do offer it as an option. showed cell residues, collagen fibers, and 5% intact fat Occasionally, patients request it but once again, I cells. The material is absorbed at a slow rate and main- have not seen any convincing evidence that there is any tains the contour and volume for 18–24 months. A new permanent augmentation. graft procedure is always performed to achieve a more Obviously, I am perplexed by the reports and the permanent result. literature by reputable surgeons who claim they see Chajchir et al. (35) centrifuged 1 cc of bladder fat permanent results. Until I see a series of consecutive pad from mince (both at 1,000 rpm for 5 min and 5,000 cases presented over a relatively long period of time, I rpm for 5 min) and injected it into the malar area sub- will remain unconvinced but will attempt to be open dermis. Microscopically, after 1–2 months there were minded.” 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 injection no recognized adipocytes could be found. Total 3.6 Insulin cellular damage was present in both groups. Brandow and Newman (39) found that centrifuga- Some physicians have added insulin to the fat in prepa- tion of harvested fat did not alter the microscopic ration for transplantation (12, 31, 32). The theory is structured integrity of cells. Spun and unspun samples that insulin inhibits lipolysis. were examined and were similar. Sidman (33) found that insulin decreases lipolysis. Fulton et al. (40) found that centrifuged fat, 3 min at Hiragun et al. (34) stated that theoretically insulin may 3,400 rpm, works well for small volume transfers, but induce fibroblasts to pick up the lipid lost and become not for large volume transfers into breasts, biceps, or adipocytes. buttocks. Chajchir et al. (35) found that the use of insulin did not show any positive effect on adipocyte survival during transplantation compared to fat not prepared with insulin. 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 3.7 Centrifugation sites. Fat injected with excessive pressure in the barrel of a syringe can cause sudden injections of undesired Some physicians centrifuge the adipose tissue to remove quantities of fat which will pour into recipient sites. blood products and free lipids to improve the quality of Agris (42) stated that a ratchet-type gun allows con- the fat to be injected (31, 36, 37). trolled accurate deposition of autologous fat. Each Asken (9) stated that his “method of reducing the time the trigger is pulled, 0.1 cc is deposited. material to be injected to practically pure fat is to place Neichajev (43) used a ratchet gun for free trans- the fat-filled syringe with a rubber cap (the plunger plantation of fat harvested at −0.5 atm. pressure. EH having been previously removed and kept in a sterile noted only partial resorption of the fat but with signifi- environment) into a centrifuge. The syringe is then cant improvement of the contour. spun for a few seconds at the desired rpm and the Asadi and Haramis (44) described the use of a gun serum, blood, and liquefied fat collects in the depen- with disposable 10 mL syringe for fat injection. dent part of the syringe…” Niechajev and Sevc´uk (45) utilized a special pistol Toledo (36) reported that “for facial injection we and a blunt typed cannula, with 2.3 mm internal diam- spin the full syringes for 1 min… in a manual centri- eter, to inject the fat. fuge (about 2,000 rpm), eject the unwanted solution, Berdeguer (23) used a lipotransplant gun to inject and transfer the fat…” fat into areas to be enhanced.