Reshaping faces and body through a ‘recycling’ approach by fat transfers is not necessarily a new technique. Fat grafting has been around for over 100 years but never gained much popularity until the past decade. As new techniques and research have revealed insights into how to improve the survival of fat grafts, the regenerative capabilities of the fat cell and its accompany growth factors and stem cells has become realized. But it is a very technique-sensitive procedure that is still plaqued by cell survival and volume retention issues.

In a recent published article in the March/April 2013 issue of the magazine MedEsthetics, Dr. Barry Eppley and other physicians skilled in fat transfers were interviewed about how to achieve safe and aesthetically fat grafting outcomes. On many important fat grafting issues, Dr. Eppley made the following statements.

HARVESTING FAT

‘The fact that fat is a natural and that most everyone would love to give some up does not make injectable fat grafting a completely reliable treatment method. It is important to understand that the biologic behavior of fat cells and the stem cells that accompany them is not well understood. The techniques we use are based on what we know today – and that will likely change significantly a decade from now.’

‘Fat that is being removed for transfer must be handled differently than fat that is being removed and discarded. Most doctors believe that low-pressure vacuum extraction perserves fat cell structures and improves their viability after transfer. Whether this is done through syringe extraction or a traditional liposuction machine that generates less then 720mm/HG (- 1 atm) negative pressure depends on how much fat is needed.’

PREPARING FAT FOR TRANSFER

”There are several techniques currently employed to prepare harvested fat for re-injection, all of which strive to separate the liquid fractions – blood, free lipids and injectate – from the cellular component.These include straining and washing, free-standing decanting, machine centrifugation, hand-held separation using centripetal force and low-pressure forced staining using low-micron filters. Much debate surrounds which, if any, of these offers a superior number of viable fat cells for transfer.’

INJECTING FAT

‘Placing the fat grafts into small aliquots, say 0.1cc for the face and .5cc to 2ccs for the body, is well known to allow for the best survival rates. Fat graft retention is related to how quickly the fat cells can be nourished by blood vessel ingrowth and the delivery of oxygen. Bog globs of fat are hard to get perfused, while small droplets interspersed about the tissues allow the best opportunity for nutrient perfusion.’

LONGEVITY OF RESULTS

‘The longevity of fat grafts remains a topic of debate. The retention of fat grafts, both short- and long-term, is not a completely well known issue. It is believed, and considerable experience shows, that what survives at three months after injection is what will be ‘permanent’. But whether this same fat survives five or ten years later is not precisely known, and it may depend on what specific condition is being treated.’

A NEW APPRECIATION OF FAT

‘Fat as long been reviled as the unsightly side effect of weight gain or natural genetics, but is a critical component of many of the body’s key functions. What was once thought to be a useless and unwanted tissue has ironically turned out to be a depot of regenerative material. Plastic surgery has just scratched the surface of what fat has to offer, and a whole new generation of research and clinical experience will take us much further than what we know today.’

Lipoatrophy is a well knownside effect that can occur in patients who have been treated with antoretroviral therapy for HIV. The devastating facial changes that occur with progressive loss of facial fat has a very negative impact on the quality of life for those so affected. Two basic treatment strategies  have been used for facial volume improvement including the historic use of synthetic fillers (poly-L-lactic acid, Sculptra) and, more recently, fat transfers.

Fat grafting has significant advantages over the use of any synthetic filler for a variety of aesthetic and medical conditions, including lipoatrophy. Despite the appeal of fat grafting, there are understandable concerns about how well it will work and how durable it might be. In a disease condition like facial lipoatrophy in HIV, one can not help wonder how could injected fat hold up when the underlying condition that is being treated is a fat wasting process.

In the March 2013 issue of Plastic and Reconstructive Surgery, an article was published entitled ‘ Autologous Fat Grafting and Injectable Dermal Fillers for Human Immunodeficiency Virus-Associated Facial Lipoatrophy: A Comparison of Safety, Efficacy, and Long-term Treatment Outcomes’. A literature review was done of 19 published studies which comprised 724 patients, 549 which were treated by synthetic injectable fillers and 175 by autologous fat injections. Patient satisfaction and effectiveness was similar between the two injection treatments. The use of Sculptra was associated with a reinjection rate 3X that of fat and had a subcutaneous nodule formation of 22%.

This literature review states that fat grafting was both effective in the majority of facial lipoatrophy patients and usually only required a single treatment. Where should the fat be harvested from for the procedure? The authors of this paper indicate that sites of hypertrophy such as the abdomen or the neck (buffalo hump) are convenient because they offer not only a very visible target but also treat another part of the overall syndrome.

In an accompanying discussion to this paper, two important points were brought out. First, patients need to appreciate that facial fat loss is progressive to the point that wasting of all native facial fat will eventually occur. So even though fat grafting is done, and all injected fat may even survive, postoperative facial volume may still occur to some degree. Second, donor site harvests for fat should come from non-wasting fat areas such as the mounds along the anterior mammary ridges and their corollaries on the back.

Dr. Barry Eppley

Indianapolis, Indiana

Fat grafting is done to either augment or restore soft tissue volume of the face and body areas. It can be done through one of two fat grafting techniques. These include either fat injections using concentrated graft material from a liposuction harvest or from the placement of a dermal-fat graft obtained through an open excision harvest

The following postoperative instructions for fat grafting are as follows:

1.  The discomfort from fat grafting comes almost exclusively from the harvest rather than the recipient site. Injection fat grafting uses liposuction for harvest while dermal-fat grafting uses an open incision for harvesting. Pain medications are prescribed should you need them and you should take them as directed on the label, usually 2 tablets every 3 to 4 hour as needed. Many patients only use Tylenol; or Alleve after the first few days of surgery.

2.  The liposuction donor site will usually have a circumferential wrap applied for pressure at the end of the procedure.You may take it off the next day to shower and wear as long as you need to afterwards for comfort. A dermal-fat graft harvest site incision will be covered with tapes. You may shower and get it wet the next day as well. Depending on graft size, a circumferential wrap may be used as well.

3. There are no special dressings or garments for the recipient sites for fat grafting. They may be mildly sore and temporarily bruised and swollen but no special care is needed for them afterwards.

4. Liposuction harvest and fat injections sites may have very small sutures used to close the nick incisions. They require no care afterwards. Dermal-fat grafts harvest and insertion sites will have longer incisions that may resorbable or permanent sutures placed for closure. They are usually covered with glued on tapes that will be removed one week after surgery. They also require no care.

5. You may shower 24 to 48 hours after surgery. It is alright to get any sutures or tapes wet.

6. Strenuous physical activities and working out should wait for at least two weeks after surgery. While you can not harm the result by anything you do, wait until you feel better before exerting yourself.

7. You may eat and drink whatever you like right after surgery.  Focus on liquids and soft foods for the first few days after surgery.

8.   You may return to work and any non-strenuous physical activity as soon as you would like based on your comfort level.

9.   You may drive when you feel comfortable and can react normally and are off pain medication.

10. If any donor or harvest site redness, increased tenderness, or drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of the various fat grafting procedures. The following is what Dr. Eppley discusses with his patients for these procedures. This list includes many, but not all,of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.

ALTERNATIVES 

There are alternatives to fat grafting and they change based on the reason and the face or body site that needs more volume or contour. They could include synthetic injectable fillers, allogeneic (cadaver) and xenogeneic (animal) dermis, autogenous fascia and synthetic implants.

GOALS

The goal of fat grafting in every case is to either aesthetically add or restore lost or deficient soft tissue volume in the face or body. In some reconstructive procedures, the additional goal of fat grafting is to improve tissue quality and help prevent future wound healing problems.

LIMITATIONS

The limitations of fat grafting is based on several factors including the size and availability of fat from the donor site, how much volume the recipient site can take and, most importantly, how much fat survives after transplantation.

EXPECTED OUTCOME

Expected outcomes include the following: temporary swelling  and bruising from the donor and recipient sites, temporary skin numbness from the donor and recipient sites, and months of healing and fat graft settling until the final result is seen in terms of permanent volume and contour. Healing of any fat grafting procedure is a process and the minimal amount of time to judge the result is three months and may take as long as six months to see the final retained volume and shape of the grafted face or body site(s).

RISKS

Significant complications from fat grafting are very rare but could include infection. More likely occurrences could include small nick-type scars from the harvest and injection of concentrated fat aspirates and a longer scar for the harvest and insertion of solid dermal-fat grafts. Additional risks include partial or complete loss of the fat graft, irregularities and asymmetries of the harvested and grafted areas, overcorrection vs. undercorrection of the treated areas and the unpredictability of fat grafting volume retention. While estimates are provided for percent of fat grafting survival based on Dr. Eppley’s experience, no guarantee can ever be made on how much fat will survive in any one patient. Any of these risks may require revisional surgery for improvement.

ADDITIONAL SURGERY     

Should additional surgery be required to do additional fat grafting, perform contour adjustments or  revise any harvest or graft insertion scars, these will generate additional costs.

Rhinoplasty is well known to be one, if not the most, challenging of all aesthetic plastic surgery operations. Surveys of plastic surgeons verify this historic belief and it is as true today as it was decades ago. It is one of the few plastic surgery procedures where entire educational courses and textbooks are devoted to the subject. Besides the issue that it is an operation whose results are open to heavy scrutiny given its central location on the face, it has to be done through somewhat limited access and often requires grafting materials to exhibit its best effects. How to put a nose together that will end up aesthetically pleasing has as much artistic component to it as it does hard science.  But the vexing part of rhinoplasty is the unpredictable healing process which may make what looks great on the operative table different months to years later. One of the newest aesthetic plastic surgery procedures, that is equally challenging to rhinoplasty, is that of fat grafting. Fat grafting is a very versatile procedure that can solve a large number of cosmetic and reconstructive problems, but its results are highly unpredictable. Like rhinoplasty, what looks good on the operative table may not always turn out so later. While the techniques of harvest and injection for fat grafting are far simpler than that of rhinoplasty, its unpredictability comes from a completely different healing reason. We do not yet understand the biology of fat and stems cells and how they can best respond to being transplanted. This has led to fat grafting becoming a procedure that now has its own educational courses and textbooks. Searching for improved and sustained results, much like rhinoplasty, is sure to have fat grafting becoming a focus of continual plastic surgery educational and research efforts for decades to come. Fat grafting today has become the rhinoplasty of years past…challenging, unpredictable and open to a wide number of surgical techniques and nuances.

The popularity of fat transfer by injection continues to grow due to the appeal of a natural biologic filler material for both small and large soft tissue volume needs. This interest continues to grow despite ongoing issues of inconsistency in graft take and survival. While the critical steps in fat transfer are well known, harvest, processing and injection, their exact influences on graft survival are less well understood. Each step in the process introduces variables and inconsistencies that play some role in eventual graft survival.

Because of the inconsistency in fat graft survival, the historic tendency has been to overfill or overcorrect. This technique seem logical but it results in a lot of short-term swelling and patient management issues. A fat transfer kit, Viafill (Aesthetic Factors LLC) was developed to overcome these fat transfer problems. It is based on a more efficient and self-contained method that reduces graft exposure to air, handles the graft more gently and produces more optimally-sized fat globules…all methods known to reduce fat cell death.

The viability of fat cells would seem to be better with virtually no exposure to air. Centrifuging the harvested fat at 50G for only two minutes removes unwanted liquids and cellular debris but has been shown to not damage adipocyte viability. Acquiring a collection of fat cells that are not larger than 2mm would seem to bolster survival due to quicker access to a critical oxygen supply. These three potential benefits of the Viafill system allow it to be used to the point of good fill with no need to overfill.

Complementing the Viafill kit is Viasilk cannulas. They are a disposable set of precision cannulas. Rather than using re-sterilizeable injecton cannulas, Viasilk cannulas are one-time use devices that have an internal coating that allows the fat to be passed through the cannula with minimal trauma to the cell.

Aesthetic Factors also owns Selphy, a platelet-rich fibrin matrix. When combining all three products, a comprehensive system is available to provide autologous tissue regeneration. Whether Selphyl can be an additive benefit to fat grafting to further improve survival is theoretical but is an ongoing area of clinical study.

Dr. Barry Eppley

Aging affects the entire body in very similar ways. The skin becomes wrinkled, loose and often dotted with pigmented discolorations. While much focus is understandably placed on these skin aging changes in the face, and even on the back of the hands, there are other potentially treatable areas that are overlooked. One of these is in an area that I frequently here women complain about…and it is the one that can have been heavily exposed to the sun in the past…the décolleté or breast cleavage area.

Unlike the rest of the breasts, the upper inner poles of the breast mounds and across the sternum can be exposed to heavy sun exposure particularly in those who have a history of tanning or a lot of swimsuit wear on the beach or by the pool. In theory, woman who sleep a lot of their sides or wear cleavage-enhancing bras, push the breasts closer together potentially creating cleavage wrinkles as well. Undoubtably, however, sun exposure and loss of skin elasticity and subcutaneous fat with aging are the main culprits.

An aging décolleté and cleavage area is well known and a point of disdain for some women. Many products have been used for its treatment including topical creams, chemical peels, specially-designed pillows, nighttime cleavage inserts and bras that spread the breasts apart. Medical skin care approaches have included hydration, collagen plumping creams, exfoliation through chemical peels and light laser resurfacing and pulsed light therapies for brown and red spots. While all of these have their merits, and combinations are better than either one alone, their results are usually modest.

Injectable fillers have been revolutionary in their anti-aging effects in the face and the hands, so it is logical that they be applied to the cleavage area as well. But the cleavage area is large and requires a lot of volume to have a visible effect. This is unlike the 1 or 2ccs of synthetic filler that work well in the nasolabial folds for example. For this reason, the best synthetic injectable filler for the cleavage area is Sculptra. This water-diluted mixture containing poly-lactic acid crystals adds substantial volume in a single treatment. It usually takes one or two additional injections sessions to get the maximal result that may last up to two years.

Fat injections are also a good injectable filler option because the amount of volume that can be added is virtually limitless. The cleavage area can be filled from the sternal depression upward. and out laterally over the inner breast mounds if necessary. Using 15 to 20ccs of fat can create a real ‘cleavage lift’. Fat contains stem cells which have theoretical but unproven benefits for volume-deficient wrinkled and inelastic skin. When combined with pulsed light therapies and light fractional laser treatments for the skin of the cleavage after fat grafting, a visible and sustained rejuvenative effect can be obtained.         

Dr. Barry Eppley

Indianapolis, Indiana

1.      What are the different types of fat grafting?

Fat grafting in plastic surgery in various forms has been around for over fifty years. More solid forms of fat grafts, known as dermal fat grafts, has a long history of successful use when the size of the graft is relatively small. But having to use a cut out of skin to obtain this type of fat graft, leaving a scar, relegates dermal fat grafts to more limited uses.

Liposuction is responsible for the concept of injectable fat grafting. Seeing so much liquefied fat discarded made the consideration of ‘recycling’ a logical one. Concentration of the liposuctioned fat through straining or centrifugation makes for a fat concentrate that is easily injectable. Many different methods are used to prepare this fat concentrate and there is no single method that is conclusively proven to be better than another. The discovery of high concentrations of stems in fat has led to more widespread use of this injectable approach.

2.      How is injectable fat grafting done?

Liquified fat is initially obtained by traditional liposuction. The fat is then processed to get rid of the liquid component of it (blood, fatty acids, tumescence solution)to have a high ratio of fat cells. Some do this by passing it through a fine mesh sieve, others do it by spinning it in a centrifuge. The fat concentrate is then placed into syringes for injection.

One of the unproven and potential innovations in injectable fat grafting is to mix certain agents in with the fat to help it survive better after transplantation. Currently, the most popular agent is an extract of the patients own blood known as platelet-rich plasma or PRP. The theory is that the growth factors in the platelets may help stimulate the stem cells to become new fat cells in the injected site.

3.      What is fat grafting used for?

Injectable fat grafting is used for volume fill of numerous facial areas and one specific body area, the buttocks. The locations on the face include a variety of sites from the forehead, temples, upper eyelid, cheeks, lips, chin, and sides of the face. Injecting into the buttocks is well established. Breast augmentation with fat injections is both controversial and unproven.

4.      How well does fat grafting work? Will someone else’s fat work in me?

The logic and simplicity of fat injections for numerous cosmetic applications leaves plastic surgeons optimistic about its future. Its single downside, and a significant one, is that its take is highly variable. No one can predict with any certainty how much will survive in any specific body area. It is a highly influenced by both surgical technique and unknown factors in each patient’s fat.

Certain areas of injection do seem to be more favorable such as the cheeks in the face and the buttocks in the body. One of the least successful areas, unfortunately, is that of the lips. It is known that a series of fat injections (more than one session)can increase the amount of fat which is retained.

Just like all other types of tissues, fat grafts are person specific. They will only work if it comes from you.

5.      How is fat grafting used for ‘volumetric facial rejuvenation’?

As we age, one of the effects on the face is that of volume loss or fat atrophy. While it does not affect everyone, many faces become more gaunt which also causes skin to sag. While some variations of lifting may be needed for excessively loose skin, the concept of adding volume back through fat grafting to select facial areas has become popular.

The added volume restores fullness to facial areas such as the cheeks, nasolabial folds and lips which helps to restore a more youthful look. When one is younger, fat injections may be used alone with other facial treatments (Botox, skin resurfacing) to create a non-surgical facelift or rejuvenation. In older patients, it may be combined with more conventional skin lifting procedures

Injectable facial rejuvenation can also be used when fat is lost due to medications and weight loss.

6.      Which is better for buttock enlargement, fat grafts or implants?

Both implants and fat injections are proven methods for buttock augmentation. There are numerous plastic surgery advocates on both sides of this discussion. It is not a question of whether one is better but in knowing their advantages and disadvantages.

Buttock or gluteal implants offer the advantage of a predictable result that will not ever change after surgery. There are size options that always make it possible to get an adequate result. Its disadvantages are that it is a bigger operation with a longer recovery and exposes one to all the risks of an implanted material. These include fluid collections, known as seromas, infection, implant displacement and asymmetry, and chronic pain.

Injectable fat grafting has the advantages of not being an implant, thus avoiding any implant risks, and harvesting from the donor site provides a secondary cosmetic benefit. It also has a fairly quick and comfortable recovery. Its disadvantages are that its survival is unpredictable and its best results come when multiple injection sessions are done. (which also adds to the expense)

7.      Can fat grafting be used instead of breast implants?

The interest in using a natural material for breast augmentation instead of an implant is understandably high. It certainly sounds appealing to put into a breast what is primarily composed of…fat. Although there are a few select locations around the world where this technique of breast augmentation is done, it is far from a perfected method and its long-term results are largely unproven.

One of the issues is that the survival of the fat grafts is variable so only a modest amount of fat can be injected into each breast during a single procedure. (generally only several hundred ccs) That is at the very low range of augmentation and is only comparable to the smallest of breast implants. Another concern is that some of the fat may undergo necrosis and result in areas of scar. Besides making the breast ‘lumpy’, these areas can also make the breast more difficult to evaluate for cancer.

While injectable fat grafting may one day be a good method for breast augmentation, implants continue to be create more predictable and reliable results.  

Dr. Barry Eppley

Indianapolis, Indiana

Breast reconstruction uses two fundamental approaches, prosthetic implants and expanders and autologous (your own) tissues. In some cases, a mixture of the two is done. While the type of mastectomy and the size of the opposite breast play significant roles in the selection of the reconstruction choice, the one factor that plays the biggest role is whether the breast to be reconstructed has received or is going to receive radiation.

While radiation is lethal to tumor cells, it is also harmful to normal tissues as well. A breast that has received radiation may appear normal on the outside, but once it has been injured by surgery its altered state often becomes apparent. Wounds that would normally heal may be delayed and the infection risk is higher, particularly if any prosthetic device is implanted. At the least, an irradiated breast will develop significant capsular contracture around a prosthetic device later.  Radiation produces a two-sided outcome, elimination of cancer  cells and  reduction of normal healing.

For this reason, breast reconstruction using prosthetic devices in patients who have undergone radiation is not recommended, unless there has been a muscle flap laid over the implant. That is why a recent article reporting on the use of injectable fat grafts around breast devices in irradiated wounds caught my eye. In the January 2010 issue of Plastic and Reconstructive Surgery, an article out of Spain reported on the use of fat grafting in postmastectomy breast reconstruction with expanders and prostheses in patients who have received radiotherapy. In a series of 65 prosthetic breast reconstruction patients, fat grafting was done by injection at the first stage of tissue expander placement and again at the second stage when the permanent implant replaced the expander. Their findings showed a remarkable lack of any infections, capsular contracture, and improved quality of the overlying breast skin.

Injectable fat grafting, using a patient’s own fat, continues to be a hot topic in the plastic surgery research and clinical literature. New uses and claims about what transplanted fat cells can do to the tissue beds into which they are implanted continue to appear. Consistent are the claims that new subcutaneuos tissue results and the quality of the overlying skin is improved. In theory, this seems plausible because fat is well known to contain a significant amount of stem cells. Transplanting stem cells doesn’t seem to have any downside so it seems like it should be effective.

I think this approach is very interesting and may have some real clinical value. But this article must be analyzed in the context of two important but understated elements of this article. First, all reconstructed patients were one year out from their mastectomies, known as secondary or delayed breast reconstructions. That is not the way most patients in the United States would like to have it done or actually do it. Primary reconstruction is the preferred approach which would preclude not only the technical approach of fat grafting but much of its benefits. Secondly, there was no sampling of the breast tissues so the belief that new tissue is formed and that the skin is better is a subjective and hopeful one, but not hard science.

For now, a far safer procedure that will have fewer healing complications is the use of autologous tissue in irradiated breast reconstructions. They are always a bigger operation and recovery and create a donor scar somewhere, but they have a more predictable outcome. Fat grafting may one day have an established role in breast reconstruction but it will likely be for subtotal breast defects in a delayed reconstruction role.

Dr. Barry Eppley

Indianapolis, Indiana

The gaunt face can occur in both the young and the aging. It is most commonly recognized as a part of aging for some with loss of fat in the cheeks, side of the face, and even up into the temples. But it can also occur as a natural part of one’s face even when significant aging has not yet occurred. (Abraham Lincoln is the most famous example) Known medically as facial lipoatrophy, fat replacement is a minimally invasive method for its improvement.

Fat grafting is becoming increasingly popular and is ideal for the gaunt face. Fat is harvested with a small liposuction cannula from a suitable donor site. The amount of fat needed does not usually make for a significant contour change in the donor site. So patient’s shouldn’t expect that they will be getting an equivalent liposuction result elsewhere. I usually use abdominal fat harvested from inside the belly button. There is no scientific evidence yet that supports one donor site over another in terms of fat that will survive better after transplantation.

The fat is prepared by removing loose liquids and impurities by washing and then spinning it in a centrifuge. It is then placed into syringes and injected into the desired facial areas through either the corner of the mouth, a crease in front of the ear, or within the crease of the nasolabial fold. The fat is injected in multiple small tunnels in a criss-crossing pattern if possible. The injected fat is then massaged around until it is smooth with no obvious irregularities.

Injecting fat into the face is a bit of an art form. In the gaunt face, the area below the cheek bones and into the side of the face are the most common. But other areas can be done as well including below the eyes and around the base of the nose.  The amount of injected fat is relatively small with less than 10cc in each side of the face. It can be surprising how even small volumes of fat can make a significant volumetric difference.

This procedure can comfortably be done under local anesthesia, with oral or IV sedation if desired. Whether it is done in the office or an OR suite depends on which provides the best sterility and has the required equipment for fat harvesting and preparation.

The unknown variable in this procedure for every patient is how much fat will survive. One should not expect that 100% fat survival will occur. But the lateral face and cheek area are currently thought to be the most favorable with studies reporting up to 70% retention. My experience is closer to 50% so some overfilling is always done. What one sees at three months after treatment can be expected to be retained long-term.

In older patients that may have some loose skin in the jowl or neck, it can be combined with a limited or tuck-up facelift for even better results. While the fat does add volume and can help fill some lax skin, improvement below the facial hollows must come from skin tightening. I have seen some reports which tout that the overlying skin improves after fat grafting, suggesting that the new fat somehow rejuvenates aging skin. Some clain that its is the effect of the transplanted stem cells.  I doubt that there are such effects but the underlying volume fill does stretch out the overlying skin and can give the impression of smoother skin.

Dr. Barry Eppley

Indianapolis, Indiana