fat grafting
TRANSCRIPT
Autologous Fat Grafting
Four Categories: 1. Autogenous Fat Grafting2. Dermis-Fat Grafting3. Free Fat Flaps4. Fat Injection
Micro lipo injection Lipostructure Autologous fat filler
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History of Fat Injection
1893 Franz Neuber First to use fat injectionTransferred small piece of upper arm fat to build up the face of a patient whose cheek had large pit caused by a tubercular inflammation of the bone
1896 Silex Claimed good cosmetic results in treatment of periorbital scars with grafted fat
1908 Eugene Hollander
First described a technique for using a needle & syringe to transplant fatty tissue
1926 Conrad Millar Described infiltration of fat through metal cannula as a substitute for the subcutaneous injection of paraffin & Vaseline
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1983 Chajhir & Benzaquen
Described injecting suctioned fat into the face
1986 Illiouz & Teimourian
Described injecting fat into iatrogenic liposuction deformities
1990 Sydney R.Coleman
Developed the method of reliable Fat injection
Stressed on Respect for handling tissues, and on basic sound surgical techniques
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Evolution of the Technique of Fat Injection
Autogenous fat transplantation in humans was reported as early as the late 1800s
Fat Injection developed as an “off-shoot” of Liposuction - 1980’s
But it was disappointing for many years: Reabsorption to great extent, unpredictable out-
come
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Perseverance of Plastic Surgeons: 1995 onwards – autologous fat injection became
a reliable technique Contribution of Sydney R.Coleman
Latest in the evolution tree: Tissue culture technique
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Surgical AnatomyHarvest site
Three levels of fat: Two layers of Subcutaneous fat
Superficial layer
Deep layer –“The target layer- for harvesting fat”
Third: Visceral layer
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Surgical AnatomyRecipient site
Face: Five distinct tissue layers Skin Subcutaneous fibro-
adipose tissue Superficial musculo-
aponeurotic system (SMAS)
Loose areolar tissue (spaces & retaining ligaments)
Parotid-massetric fascia & Periosteum
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Soft tissue spaces in face Preseptal, Prezygomatic, Masticator & Oral cavity
spaces Within the forth layer – between ligaments Allow gliding movements of above facial muscles They become more apparent with aging laxity The facial nerves & vessels traverse through the
walls, but do not enter the spaces
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Aging Face
The effects of aging are the summation of the interplay of factors that occur in all five anatomical layers of soft tissue & in the bone
Attenuation of the retaining ligaments at all levels Reduces quality of fixation of the soft tissue layers
Volume loss (more common in the mid cheek), due to Displacement of the soft tissue Atrophy of soft tissues & of the facial skeleton
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Based on “Auto-graft” Principle
Graft of fat cells harvested from patient’s one site to fill in the depressions (natural or post-traumatic) at the other site
Fraction of Fat graft which “takes” - becomes a living part of the body
Though results will deteriorate as the these tissues age
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Indications
Aesthetic Facial Augmentation
Facial atrophy
Facial Rejuvenation Ageing face
Augmentation of Breast Hand dorsum
Restorative / Reconstructive Correction of the “Under-
corrected” Liposuctioned areas
Filling of depressed zones resulting from injury
Correcting the wasting after Triple therapy for HIV+ patients
Augmentation of Vocal cord palsy Penis
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Facial augmentation / rejuvenation: M/C indication Includes:
Facial atrophy Filling & smoothing wrinkles Restoration of the “fullness” of ageing face In complement to certain Neck & Face Lifts Effacement of the nasolabial folds Augmentation of the lips, malar region &
cheeksdr sumer yadav , mch plastic
surgery, [email protected]
Breast Augmentation, Lumpectomy, Asymmetry, Mastectomy Injection into
subcutaneous & pre-pectoral plane Not into the breast tissue
Multiple sessions might be required In conjunction with Pre-expansion technique
If not done properly may lead to Unsatisfactory results because of fibrosis & calcifications
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Post-liposuction depressions’ correction: abdominal wall, flanks, buttocks, back, or thighs
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Correction of depressions or fatty deficits due to Lipodystrophy syndromes and atrophic areas HIV Diabetes Dermatomyositis Chronic malnutrition / anorexia nervosa Genetics, diet, alcohol, tobacco
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Augmentation of the paralyzed vocal cord In cases of Unilateral cord palsies May require secondary procedures
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Preparation
Patient selection Clinical examination, medical history Patient's lifestyle, expectations, h/o prior aesthetic
procedures Thorough discussion with patient about
Planned procedure Expected out come Post operative course Need of multiple sessions
Photography For 3-D examination purpose & Comparison Records
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The Technique
Should be Sophisticated & Thoroughly planned Amount of fat needed Levels in which to be placed
Respect for handling extremely delicate “fat tissue” Fat must survive various insults outside he body e.g.
Mechanical Barometric Chemical
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Strict aseptic precautions: Slightest of infection can ruin the desired results
Quickness: Shorter the time gap between harvesting & re-
implantation – better the chances of fat cell survival
Team approach – when dealing with Large volume fat injection
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The Procedure
Steps:1. Harvesting
Selection of harvesting sites & Planning incisions Anesthesia & Infiltration technique Suction
2. Processing & Refinement Centrifugation / Sedimentation
3. Re-implantation Injection (of the refined, concentrated fat)
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Step-1Harvesting
Harvesting sites: Should be convenient for access & Enhance patient’s contour
Most common: Abdomen Gluteal region Medial thighs
Others: Suprapubic area, anterior or lateral thighs, knees, lower
back, hips, sacrum
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Harvesting (cont’d)
Access incisions should be planned in: Crease lines, previous scars, stretch marks, or hirsute areas
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Harvesting (cont’d)
Anesthesia Local – most common Spinal, Epidural or General
For removal of larger volumes When multiple sites are used for harvesting
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Harvesting (cont’d)
Dry technique: Rarely used
Wet technique (1:1::Injectant:Fat harvested) Choice of Infiltration solution depends upon: The donor areas & on the projected volume of fat to be
removed: Small volume / LA: 0.5% Lidocaine + Ringer lactate
solution with 1:200,000 epinephrine Large volume / GA: Ringer lactate solution with 1:400,000
epinephrine
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Super-wet & Tumescent techniques ( Injectanct to harvest ratio >1)
Discouraged here (in contrast to liposuction )
Disrupt the parcel of fat cells & decrease survival
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Harvesting (cont’d)
Suction: Two-holed blunt Coleman harvesting cannula 10cc Luer-Lok syringe Combination of
Minimal negative pressure by slowly withdrawing the plunger (creating 1-2ml of space
in the syringe barrel) Gentle curetting action
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Harvesting (cont’d) Coleman harvesting cannula
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Results: Impact of Harvesting techniques
Less suction pressure– More viable adipocytes
Hand-held syringe method – Less trauma to adipocytes
Smaller gauze syringes –Avoid clumping & to ease in re-injection
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Step-2Processing & Refinement
Syringe with harvested fat Cannula disconnected Capped with “Luer-Lok plug” Placed in centrifuge
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Processing & Refinement (cont’d) Separation techniques:
Sedimentation (Force:1g)
Centrifugation High speed 3000rpm for
3 minutes (Force:3-5g)
Manual (Force:1-2g)
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The material separates in 3 layers: Top – oil (decanted) Middle – the fat cells (to be injected) Bottom – blood, injectant solution (to be drained)
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Transference: Refined & concentrated fat to 1-3ml Luer-Lok syringe
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Step-3Re-implantation
The most challenging part
Should be placed in such a way so as to encourage uniform survival, stability, & integration Small pockets Adequately spaced
To maximize the “surface area” of contactdr sumer yadav , mch plastic
surgery, [email protected]
Anesthesia: Local, Regional, General
Advisable to use: Epinephrine solution
In face- to minimize injection into vessels Blunt tipped Coleman cannula
To minimize damage to blood vessels & resulting ecchymosis or hematomas
Natural tissue planes
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Instruments’ set: Different from harvesting set
Smaller gauze (17 or 18 G) One holed cannula
For varying sites varied cannula Diameter, Length, Shape, Curves
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The procedure: Stab incisions:
1-2mm (No.11 blade) Cannula inserted & advanced:
Into appropriate plane Injection of the fat:
During withdrawal through the tissues Fat deposited as fractions of a milliliter, like peas in a pod Every next injection into a new plane / layer Sequentially
from deep to superficial layer multiple passes in a 3-D manner
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Injection volume per withdrawal Face: 0.1ml Eyelids: 0.02 – 0.03ml Breast: 1-2ml
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Injection Techniques
Mapping Technique Linear threading Fanning Cross hatching
Reverse-liposuction Technique
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Fate of Fat
Phenomenon of Variable resorption
With fat grafting, anywhere from 10% to 90% of the fat may be absorbed by the body
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Theories: Host replacement theory – Billings & May
Lipid in transplanted cells taken up by histiocytes which eventually replace the fat cells
Cell survival theory – Peer Transplanted fat cell survive, if vascularised; and histiocytes
remove, & not replace, non vascularised fat cells
Stem cell theory - Billings & May: Under nourished fat cells either necrose; or return to more
primitive cellular state Pre-adipocyte
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Post-op care
Aimed at: Minimizing swelling of the
recipient tissues (2-4 weeks)
Stabilizing the area to avoid migration
Attained by: Elevation Cold therapy Light touch (Encourage
lymphatic drainage) External pressure with
elastic tape
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Final results
Assessment at 3-6 months
Many patients may need more than one treatment - usually 3-6 months after the first one
The benefits of fat grafting can last anywhere from 3 months to 3 years, and probably more
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Complications
Aesthetic: Under correction
Not enough material Resorption
Over correction More difficult to solve
Irregularities Asymmetry
Others: Edema Infection Migration Perforation Necrosis
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Site-specific complications
Face: Embolism of Internal carotid artery / Middle
cerebral artery (Retrograde) Blindness Stroke Aphasia Skin necrosis
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Breast augmentation: Liponecrotic psuedocyst with calcifications
Groin defect correction: Cyst formation
Penile augmentation Mushroom shaped penis
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Donor site complications Edema Infection Seroma Hematoma Skin necrosis Fat embolism Perforation
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Comparison with other Fillers
Advantages Natural Biocompatible, Non
immunogenic Large volume
augmentation Cheaper
Disadvantages Unreliable resorption Donor needed for harvest
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Results Depend Upon
Biologic boundaries
Othersurgery
Patient age
Recipientsite
Injection Technique
Processing& Storage
Harvesttechnique
Harvestsite
Result
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Current researches Focus on the Cellular level
Tissue culture / stem cell technique
“Pre-adiposite” cell May be the way to achieve fat transplantation without
significant volume loss
It’s a connective tissue cell identical to fibroblast takes up lipid as it matures
Van & Roncari transplanted “pre-adiopsites” from rat epididymis into intramuscular location pad of fat developed there
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